Battling Narcotic Addiction

[MGG1848]

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[southerndoc]

This is why I think the DEA should have a national database of narcotic prescriptions that were filled. Any person with a valid DEA number should be able to check the database.

It won't eliminate 100% of abuse, but the majority of people who abuse the system for narcotics could be identified.

 

[mikecwru]

This is why I think the DEA should have a national database of narcotic prescriptions that were filled. Any person with a valid DEA number should be able to check the database.

It won't eliminate 100% of abuse, but the majority of people who abuse the system for narcotics could be identified.

A national database would not be useful so much, in that there is minimal crossing of state lines. That's not the huge problem. In Ohio, we do have a system that lets me see the prescription history for people over the past year for controlled substances. However, it's about 4-5 weeks delayed from the date you search. ie, they could have filled 200 percocet 1 week ago and you wouldn't know.

What we need is for the pharmacies to have some sort of linkage between them. It would be useful for the pharmacies to not fill prescriptions that the docs can't pick up.

Greg Henry has written about this before. His usual sentiment is that you'd want to treat 100 addicts before missing one person in true pain. I'd agree with this, albeit with a hefty dose of common sense. I usually try to give people the benefit of the doubt. He also says "You don't fix or make addicts in the ED." I absolutely DISAGREE with this. People get their addictions started in EDs all of the time. And while we may not fix the addict right there in the ED, we can probably do the ethical thing and not prescribe them narcotics for their bruise, or the even lamer "just a few," until they can see another doctor who can actually make a decision. We can also correctly identify narcotic withdrawl and offer both medical and addiction treatment.

 

[Arcan57]

Depends on where in the state your ED is located. Having trained in one state and now working in another that has two neighboring states less than a half-hour drive from the hospital, it is a problem. Plus, I think a national database would help make us more confident about treating the patient with acute pain, instead of undertreating them out of fear they may be trying to game the system.

 

[mikecwru]

Depends on where in the state your ED is located. Having trained in one state and now working in another that has two neighboring states less than a half-hour drive from the hospital, it is a problem. Plus, I think a national database would help make us more confident about treating the patient with acute pain, instead of undertreating them out of fear they may be trying to game the system.

I understand, I just think it would be more useful for the database to be accessible for pharmacies. The way phamarcies don't network is the most frustrating.

 

[southerndoc]

I understand, I just think it would be more useful for the database to be accessible for pharmacies. The way phamarcies don't network is the most frustrating.

What I propose is this: when a pharmacist fills a prescription for any controlled substance, he or she must log that prescription into the DEA database prior to the patient picking up the prescription. It should contain the drug name, strength, number dispensed, physician's name, and physician's phone number (business number of course). Patients already must show identification to pick up the script. All controlled substances will require a valid ID (state driver's license, passport, etc.). The patient must provide a social security number in order for it to be filled. The database would be searchable by pharmacists or any healthcare provider with a DEA number and could be searched by name, SSN, state ID number, etc.

 

[WerdSalid]

While I don't necessarily think that we create or heal narcotic abusers / addicts in the ED, I certainly feel that we sometimes contribute to their frequent useage of the ED by RX'ing narcotics for exacerbations of chronic pain problems. My practice has always been to treat the pain in the ED, even with IM or IV analgesics....but I will almost never refill a narcotic Rx for a chronic problem..

 

[WerdSalid]

Our ED's biggest problem right now is chronic dentalgia. Unfortunately we do not have a low cost dental clinic to whom we can refer patients. The closest dentist who accepts Medicaid is 1.5 hrs away (and likely overwhelmed from referrals). During a 24 hr shift in which I saw between 45-50 pts the other day, 9 patients had the chief complaint of 'toothache.' It is very frustrating to continually Rx PCN VK and vicodin.

 

[GeneralVeers]

sentiment is that you'd want to treat 100 addicts before missing one person in true pain. I'd agree with this, albeit with a hefty dose of common sense. I usually try to give people the benefit of the doubt. He also says "You don't fix or make addicts in the ED." I absolutely DISAGREE with this. People get their addictions started in EDs all of the time. And while we may not fix the addict right there in the ED, we can probably do the ethical thing and not prescribe them narcotics for their bruise, or the even lamer "just a few," until they can see another doctor who can actually make a decision. We can also correctly identify narcotic withdrawl and offer both medical and addiction treatment.

Treating pain is not necessarily the same as giving narcotics. There are many ways to treat pain that don't involve narcotics. For the dental pain I see if I think they are FOS they get motrin. If I think they are scamming me, but can't prove it I'll give them some Tramadol (which can actually provide very effective relief of tooth pain). If I believe they are legit and they convince me that they are in distress I'll give narcotics. To all of them I offer a dental block with marcaine.

 

[Pharmavixen]

Did you mean Toradol rather than Tramadol, General?

If you meant ketorolac, yes; I've seen it provide effective dental pain relief in my pts, who are opioid abusers receiving methadone maintenance.

And depending on the kind of pain, an NSAID may be more effective than an opioid.

In British Columbia, all pharmacies are hooked to a central database such that you fill a T#3 script and any pharmacist in the province can see it (if you present your healthcard, I think; there's some sort of limit on the access). I think we all need this kind of system. In Ontario, where I live, EDs can access all prescriptions in the province filled on Drug Benefit, which is like Medicaid. So somebody comes into your ED claiming a severe migraine can be looked up on the database, and you can see if they've been filling narc scripts all over the place.

But drs who say they need to treat 100 addicts before they turn away one pain pt are basically making excuses for enabling the illicit Oxycontin trade, which is huge.

 

[aphistis]

Treating pain is not necessarily the same as giving narcotics. There are many ways to treat pain that don't involve narcotics. For the dental pain I see if I think they are FOS they get motrin. If I think they are scamming me, but can't prove it I'll give them some Tramadol (which can actually provide very effective relief of tooth pain). If I believe they are legit and they convince me that they are in distress I'll give narcotics. To all of them I offer a dental block with marcaine.

This is the best diagnostic test anywhere for a toothache. If they're really in pain, the prospect of pain relief overrides anxiety over needles in their mouth. I'll give those people some vicodin until I can get them into the office to fix them for real.

This post brings up another point incidentally. If you're blocking the lower jaw, bupivacaine works great. Unfortunately, it's not nearly as effective at numbing maxillary teeth because it diffuses poorly through the periosteum. Other than articaine (best local anesthetic for dental use period, IMO, but I've never seen it inside the hospital) or doing a V2 nerve block with marcaine, your best bet for field-blocking maxillary teeth is regular old lido w/epi.

Finally, the EM people at my hospital already know this so you probably do too, but the dense mandibular cortical bone makes field blocks for lower teeth mostly useless (again, unless you're using articaine), so for lower teeth you have to block the inferior alveolar in the back of the mouth before it enters the mandible.

Journal of Endodontics . 2007 Sep;33(9):1021-4.
A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for maxillary infiltrations.
The purpose of this prospective, randomized, double-blind study was to evaluate the anesthetic efficacy of 1.8 mL 0.5% bupivacaine with 1:200,000 epinephrine and 1.8 mL of 2% lidocaine with 1:100,000 epinephrine in maxillary lateral incisors and first molars. Sixty-five subjects randomly received, in a double-blind manner, two infiltrations at two separate appointments, in a crossover design. The injections consisted of maxillary lateral incisor and first molar infiltrations of 1.8 mL 0.5% bupivacaine with 1:200,000 epinephrine and 1.8 mL 2% lidocaine with 1:100,000 epinephrine. In maxillary lateral incisors, bupivacaine exhibited a significantly lower anesthetic success rate (obtaining two consecutive 80 readings with the pulp tester within 10 minutes) of 78% when compared with a 97% success rate with lidocaine. In maxillary first molars, bupivacaine's onset of pulpal anesthesia (7.7 minutes) was significantly slower than lidocaine (4.3 minutes). Bupivacaine had a lower success rate than lidocaine (64% versus 82%) but there was no significant difference between the two solutions. Neither solution provided pulpal anesthesia for 1 hour.