I had always assumed that I would remember my first code. I don’t, but I do remember my first time coding a patient who could have been my peer. He was young and otherwise healthy. His housemates had heard a loud thud but ignored it. Later, they found him lying lifeless on the ground. He was a known heroin user.
Explore This IssueACEP Now: Vol 35 – No 07 – July 2016
In Connecticut, like in many states, prescription medications are the most common drugs of abuse.1 Prescription opioids are known gateways to heroin as patients seek stronger, cheaper, and easier-to-acquire agents. Patients addicted to opioid medication are 40 times more likely to be addicted to heroin.2 More than two-thirds of heroin addicts previously abused prescription opioids.3
One major driver of the opioid epidemic has been the proliferation of prescription pain medicine. The United States consumes nearly all (98 percent) the world’s supply of hydrocodone.4
How did this happen? In 1999, in response to popularized claims that chronic pain was undertreated at epidemic proportions, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, requiring a pain-intensity rating at all patient encounters.5 This was disseminated to the rest of the health care system two years later by The Joint Commission, which instituted pain management standards. Pharmaceutical companies seized the opportunity and aggressively campaigned, convincing physicians, patients, and regulators that opioids were safe for chronic non-cancer pain. The misinformation was so explicit that Purdue Pharma, makers of Oxycontin, eventually pled guilty to federal criminal charges.6
From 1991 to 2013, Oxycontin prescriptions skyrocketed from 76 million to nearly 207 million annually. As the prescriptions increased, so did the number of related ED visits, which more than than doubled between 2004 and 2011.7 More recently, the trend has turned lethal. Opioid-related deaths doubled in just one year, killing 5,500 in 2014.8
Well aware of these deadly trends, I initially welcomed the arrival of Connecticut’s prescription drug monitoring program (PDMP), a central database holding statewide accounts of Schedule II-V controlled substances. Signed into law in the summer of 2015, Public Act 15-198 was hailed as legislation that took “necessary and smart steps to stem prescription drug abuse and overdose deaths.”9,10
Unfortunately, the bill creates busywork for doctors, and new evidence suggests that the extra work is not making an impact. The bill mandates that practitioners check each patient’s record in the PDMP. We must check every controlled substance prescription written to last more than three days. For patients who receive prescriptions chronically, providers must recheck the PDMP every 90 days.