USA: Prescription Drug Abuse

initially was written in 03/13/2017

     The healthcare providers and many healthcare organizations are worried about the abuse of prescription drugs. It did not surprise me when I received the letter directly from the office of US Surgeon General concerning the prescription drug abuse.  I am not the only one who received the letter, but all of my co-workers did receive that letter.  Dr. Murthy concerned and asked help from the healthcare providers to prevent drug abuse complications. The business insider (Brodwin, 2016) claimed that this is the first time in the US history when the US Surgeon General asked for help from the healthcare providers and the public. I am not sure if Dr. Murthy did approach the public or not if he did how he did it was not mentioned in his letter. Dr. Murthy asked for help solving an urgent healthcare crisis America facing from the drug overdose. Dr. Murthy (2016) requested all healthcare providers to take the pledge that educating ourselves treating the pain safely and effectively. Recognize the opium problem in our patients, and treating the pain as chronic disorders instead of moral failing (2016). Most of the healthcare providers agree with Dr. Murthy to save America from drug abuse. Taking the pledge is not only the solution. Each of us was taught to follow the medical ethics “Do not Harm, Respect, Autonomy”. However, we are still facing the problem because saving America is not only on hands of the healthcare professionals. But also the policymakers, public, and all health care organizations are responsible. So we should take joint action to save America from abuse of prescription drugs.

    Before we start thinking about how to control this problem, we must know how complicated and dangerous this issue is. This situation is similar to war when a person likes to know the strength and weakness of the enemies. The use of the legal and illegal drug is similar to the terrorism that creates a terror inside the human, which destroy the human soul, dignity, self-respect, social life, and of course family. We just need to know its roots, so we should cut it from the roots instead of trimming the branches.  Without proper management and planning could be wasting of the time, finance, and healthcare sources. That would only add to the healthcare cost.  

     CDC claimed 78 Americans die every day from a drug overdose that includes prescription and illegal drugs.  2014 was the year when the US hit the record of deaths with the drug overdose. Half of million people had died from drug overdose in 2000-2014. The number of written prescriptions and deaths from prescription drugs has been quadrupled since 1999 (CDC, 2016)

     Department of Health and Human Services reports 650,000 opium prescription had written every day in the United States. The drug use not only impacts the health but also impact the economic and social status. The US spent 55 billion each year related to prescription abuse cases each year. ED and inpatient care cost is 20 billion each year. In addition to this cost, CDC awarded $ 30 billion to 29 states to initiate the prescription drug monitor program. This is a very effective program where we can monitor when by whom, which drug, and how much was the quantity was prescribed. However, it shows a record of a state where the provider practices. Or the provider has given access where they practice.   The healthcare provider could not track it if a particular person fills the prescription from the neighboring states where they can drive in 15 minutes to consult the doctor and fill the prescription. The health care providers could not track out of the state prescription status. This program needs to be redesigned so the providers could at least monitor the adjoined states instead of the one state.

      Drug abuse is not the only impact on human health but also cause many other problems such as DUI, accidents, violence, stress, abuse. Finally, this leads to crime, unemployment, and finally the homeless. In the end, the person becomes the burden on the taxpayers.

     The healthcare professionals do face many challenges when to prescribe, and not to prescribe the narcotic. Sometimes they do not have any option just prescribe it instead of creating the scene in the ED or office. The healthcare professionals think easy to write a prescription than providing clarification to the hospital management or quality committee. Hospital satisfaction survey and pay for performance by many private and government agencies also contribute indirectly writing more prescriptions. Law and policies force medical providers to prescribe the narcotic and other controlled substances. The pharmaceutical companies do not have many drugs options despite some NASID and Tylenol. Many patients show up with allergies to NSAID, Tramadol, and other medications except a desirable medication. Their pain level is 10/10. What other options have left for the prescriber?

       Can it be the violation of the EMTALA when a person comes to the ED for just the use of narcotic? Can we return a person with drug seeking, behavior out of the triage area after the rapid medical examination? Can the healthcare providers make the decision on the base of their patient’s clinical condition and the professional judgment? Do all healthcare providers are on the same decision?   A patient refuses to see a particular provider on the base of failed to manage the pain or they did not get it whatever they wanted in the last visit. Another doctor will prescribe whatever patient asks for. The health care providers should have unity and similar decision-making capacity. The healthcare professional should respect the decision of his or her partner’s decision.

      This particular problem would not be solved if Dr. Murthy requested help from the healthcare professional. The entire healthcare system needs a universal policy at the national level to control the abuse of prescriptions. The root of this problem is very deep, which requires not only the pledge but also need strong decision-making policies and cooperation of all government and private healthcare organizations.  Dr. Murthy has left many unanswered questions for the healthcare providers.

     I suggest adding at least one day in a year as a narcotic free day. We do have a mother’s day, father’s day, and Yoga Day so what is the problem adding this special day. On Narc free day, the health care professionals will not prescribe any prescription, and the public or patients will not use any controlled substances.

     The healthcare providers require to continue education on pain and management.  Many providers think severe pain is a medical emergency. The Emergency Medical Treatment and Labor Act(EMTALA) is a federal law that was regulated in 1986 to provide the medical care or stabilized the medical condition anyone come to the emergency room for help despite the patients’ ability to pay or not( American College of Emergency Physician, 2016).  EMTALA does not define severe pain is as a medical emergency unless no manifestation of serious illness. EMTALA emphasizes the need of medical screening of any patients including chronic pain patients to avoid the serious underlying medical disorders, avoid impairment of bodily function, or avoid the jeopardy of somebody’s health (Dr. Bitterman, 2016). Severe pain could be related to life-threatening conditions such as ectopic pregnancy, spinal abscess, and aortic aneurysm, herniated sic with neurological deficit. Medicaid and Medicare do not say that severe pain is a medical emergency.

     However, the clinical knowledge of the practitioner plays a crucial role to determine if the pain is related to the medical emergency.  A subjective pain of 100/10 is not a medical emergency but do require medical screening. A patient with severe pain should come with some other clinical finding such hemodynamic changes or some physical findings. I doubt a patient with 100/10 would able to sit calmly, or playing on the phone. Some patients say that is a diversion from the pain that is not totally right.  After the medical screening, the health care provider could avoid the use of narcotic if the pain is not real or not severe. EMTALA law does not tell the healthcare providers to inject the patients with high doses of narcotic shots and prescribe a large amount of the narcotic pills. Every healthcare provider who works in the emergency room is pretty familiar with the EMTALA. Still, many providers continue prescribing the narcotic when not required. The private practice physicians do not have to follow the regulation of EMTAlA, so why they do prescribes 120 pills of Norco in addition to some muscle relaxant.

     The private practice physicians, pain management specialist, the pharmacist must work with the emergency room providers to solve these issues. The primary care physician must take some steps for educating their patients because the primary physicians are more close to their patients. The public must know the negative consequence of using the narcotic. Encourage family or friends to participate in their loved one if the provider thinks his patient is misusing the pain medication. DEA (Drug Enforcement Agency)) could play a significant role by tracking the providers who write the suspicious amount of prescription. This act will help to control the drug diversion in the healthcare providers. A CDC or CMS could take assist from the media spreading the word. We see many commercials on the TV for the advertisement of the new medication. I have not seen an advertisement from any private or government agencies who advertise the negative consequence of narcotic use on the health and social life. It is very easy spreading any news via modern technology and media. How about using an old-fashioned style advertisement method such as posting the flyers or mailing the flyers? A writing a letter to the health care providers is not the solutions. The health care system needs a strong structural and universal policy to fight a war against the abuse of prescription drugs.

     The healthcare professionals could not be blamed for this problem, which had occurred from prescription drug abuse. The policymakers and the public are equally responsible for this problem. The healthcare professionals are not modern drug dealers. The demand and supply have a close and strong relationship, so the healthcare providers have become the victim of rule and regulations. We do not want to ignore the patients who really need proper treatment of pain. The careful observation and spending a little time will help the providers to decide whether patients need the medication or not.

    Suboxone is a drug, which we prescribe for anti-abuse. Not all the patients on this medication are honest when they see a different healthcare provider or go to the ED. Many insurance companies do not charge for this drug. How about those patients who do not have proper insurance policies? We could give free contraceptives to prevent the teen or unwanted pregnancies. However, we could not have free anti-abuse medications or clinics. This means nobody is talking this healthcare issue seriously. 

The emergency room health care providers are under the pressure and are in dilemmas. Who should they listen or follow? They are under the pressure. The hospital administrations are also responsible. Indirectly, Press Ginny play a significant role. The patient satisfaction is more important than solving the current issues. Hospitals will not get appropriate reimbursement if the performance rate is low or not meeting the criteria for guidelines of reimbursement. Each of them thinking about the present. Are we destroying the past because of our present? Yes, the satisfaction score will decrease but only for a few months. However, eventually, it will raise. However, unity and proper communication between the ED providers, pain management specialist, and primary care provider is very crucial here. Everybody should be on the same page. There should be one goal and one policy not to write narcotic for chronic back pain without any significant radiological abnormality. Why are we writing 20-40 tablets for just ankle sprain?

     Today American healthcare system suffers from many dysfunctional policies, financial issues, latest equipment, and lack of healthcare providers. It is a right time now to take joint action. Many of us agree with Dr. Murthy but how many took the pledge yet. The solution to this problem is not that easy. It will require maximum findings, a single nationwide policy, co-operation of all stakeholders, the contributions of the healthcare providers, and awareness of the general public. This problem will not solve overnight, it may take decades to clean the system. Both private and government sectors must pay attention to the abuse of prescription drugs and take some responsibility against it.

                                           References

      American Colleges of Emergency Physicians, (2016). EMTALA.https://www.acep.org.

    Brodwin, E (2016). The surgeon general sent a worrisome letter to each American doctor.http://www.businessinsider.com/letter-surgeon-general-sent-every-doctor-on-opioids-2016-8

    Bitterman, Robert, 2016. Is “Severe Pain” considered an emergency medical condition under EMTALA? http://www.acepnow.com/article/severe-pain-considered-emergency-medical-condition-emtala.

    Center Disease control and Prevention. (2016). Addressing Prescription Drug Abuse in the United States. https://www.cdc.gov/drugoverdose/pdf/hhs

    Center for disease control and prevention. (2014)  Drug overdose deaths in the United States hit record numbers in 2014-United states, 2016. https:// http://www.cdc.gov.

    Department of Health and Human Services. (2016) The Opioid Epidemic: By the Numbers http://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf

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