As I am wont to do lately, I've been thinking an awful lot about prescription drug abuse. My last shift, I saw a guy who got in two car wrecks in the space of a few hours while taking his 2mg prescription Xanax "bars" six times a day as prescribed. I saw a woman with over 300 prescriptions (each of which contained 30-120 individual pills) for opiates and benzos in the past 3 years from around 40 different doctors. Another woman lamented that she ran out of pain meds just in time for the weekend, and her primary doctor wasn't going to give her "Roxi 30's like I asked for" - street slang for oxycodone 30mg, the highest-value street drug currently on the market.
I've said it before, and I'll say it again. Prescription drug abuse in this country is a massive issue. There were over 16,000 fatal overdoses in 2010 and the number continues to rise. More people are dying from overdose than from car wrecks in some states. While I care about alcohol abuse and illicit substances to a lesser degree, I'm fixated on prescription abuse because it is preventable. One source states that the USA uses 80% of the world's opiate supply and 99% of the world's hydrocodone.
There are several issues at play. One is that no physician wants to be confrontational if they don't have to. I think ER docs do it by necessity, but primary care doctors can't afford to antagonize their patients - and thus, jeopardize their revenue stream. When someone comes in and has been on Xanax three times a day for the last 10 years, you throw up your hands and write the script plus refills.
This particular behavior needs to stop. We ER docs see the overflow from the primary care physicians, the psychiatrists, and the dentists who turn into unwilling pill mills. As long as there is no oversight, this will continue. Aside from the nebulous concept of "doing the right thing", there is no reason for any individual provider to wean patients off these meds. In fact, the opposite is true - patients would simply leave your practice and go to another provider who will give them their fix.
I believe the solution lies with the state medical licensing board. Here's my plan.
- The state board sends all physicians an alert "Your license may be in jeopardy! Statewide, physicians must come up with a plan to wean all of their patients off prescription opiate medications and benzodiazepines, unless there is a documented and valid reason to keep doing so. You have 1 year to comply."
- At the six month mark, remind physicians that they are coming up on the deadline. Give them a progress report.
- At the year, patients on chronic Xanax, Klonopin, Ativan, Valium, Percocet, Oxycodone, Vicodin etc have all had this discussion with their primary doctor "The government is cracking down on physician controlled substance licenses. Neither myself nor other physicians can prescribe controlled substances on a recurrent basis any more."
- Any physicians not playing ball get 3 notices, then lose their controlled substance license.
- The end goal is to have meds prescribed as intended, with short courses written for acutely painful or stressful episodes. Long-term opiate management would be tightly restricted to the setting of cancer, fractures, and a few other conditions. Long-term benzo use should be flat outlawed.
I'd love to hear your thoughts. Soon here I'm thinking of marching on Capitol Hill.