BMN Blog

APR 12

 

CASE STUDY

A 34-year-old male presented to a family medicine physician for chronic low back pain. The physician is comfortable prescribing opioids and has many patients on scheduled drugs. The patient has had chronic pain for many years and has undergone multiple treatments including physical therapy, steroid injections and many medications. On presentation, the patient was on Robaxin and oxycodone (four times a day). His past history is positive for hypertension and alcohol abuse, although he stated he hasn’t drank in the past year. He works as a laborer.

On exam, the patient is in moderate distress with his back pain. His vital signs and physical examination, including a detailed neurologic exam, are normal. The physician institutes OxyContin 10 mg BID for pain control and Clonazepam for muscle spasm. On a follow-up visit two weeks later, the OxyContin is increased to 20 BID.

Two days after that visit, the patient picks up his medication at a local pharmacy. The next morning, the patient is found unarousable by his roommate and declared dead at the scene by paramedics. The cause of his death is polysubstance drug overdose with evidence of oxycodone, benzodiazepines and alcohol on his toxicology screen. A lawsuit is filed against the physician.

DISCUSSION

The extent of the opioid epidemic has been well documented in both the lay- and trade-press for good reason: according to the Centers for Disease Control and Prevention (CDC) more than 33,000 people were killed in 2015 by opioids (including heroin).  Nearly half of those deaths involved a prescription opioid. 91 people die each day in this country from an opioid overdose.  While there is no evidence that the amount of pain patients are reporting has increased since 1999, the amount of opioids prescribed over that same time period has quadrupled.

Heroin use is also increasing. This is thought secondary to the ease of acquisition of this illicit substance as well as decreased price and increased potency.

What can we, as practitioners, do to protect the safety of our patients and to provide good care? While opioids can be part of an effective pain management plan, the potential for misuse can have tragic results.  The “CDC Guideline for Prescribing Opioids for Chronic Pain” issued in 2016 is intended to help primary care providers determine when, or if, to prescribe opioids for the treatment of chronic pain.  While every case deserves individual consideration, in general opioids for chronic pain should be reserved for palliative care, end-of-life comfort care and treatment of pain from cancer.  Other points to consider when opioids are, or might become, part of the treatment plan:

  • If initiating opiates, start at the lowest possible dose. If continuing a treatment plan you have inherited from another provider, consider a tapering plan.
  • Have a process in place to monitor patients who are on long-term opiates. Periodic re-assessment of the need for opiates should be documented.
  • Calculate a “Milligram Morphine Equivalent” per day for your patients on opioids. Any total over 90 mme/day may require re-consideration of the dosing amounts.
  • Use caution when other medications are involved; co-administration of a benzodiazepine can increase the chance of respiratory failure in overdose by a factor of 10.
  • Consider co-morbidities that might contribute to respiratory compromise when prescribing opioids, such as alcohol use, COPD, obesity, etc.

CASE ANALYSIS

The case revolves around the issue of responsible prescribing. Was there adequate assessment of the risk factors for accidental overdose in this patient and was the therapy appropriate for the diagnosis? Is there thorough documentation around the risks and benefits of opioids and were there attempts to wean and use alternative treatments? Were there discussions with the patient about the issues of polypharmacy and concurrent use of alcohol? Was there an opioid treatment agreement in place? If the answers to these questions are addressed in a well-documented manner that shows reasonable care, then this will be a very defensible case.

 

The guidelines from the CDC can be found here:

http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

 

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