Spike in medications deaths. Could it beeeeeee ……. Satan – or perhaps “The Fifth Vital Sign”

In a article to be published in the Archieves of Internal Medicine next week an alarming spike in the number of accidental deaths from prescription drug use related to “medication errors" is reported. The Article by David P. Phillips, a sociologist at the University of California, San Diego is the most recent in a series of research he has done on the subject of drug abuse, suicide, and societal trends.

“Deaths from medication mistakes at home increased from 1,132 deaths in 1983 to 12,426 in 2004. Adjusted for population growth, that amounts to an increase of more than 700 percent during that time. In contrast, there was only a 5 percent increase in fatal medication errors away from home, including hospitals, and not involving alcohol or street drugs”

"By 2004, fatal medication errors were responsible for far more years of potential life lost than were all accidents from firearms, falls, fire and flames, drowning and non-medication poisonings combined," Phillips said

So what type of medications are we primarily talking about here. You guessed it, Opioid pain medications like Methadone, Oxycodone, Vicodin, and Fentanyl. Throw in a benzo, an antidepressant, perhaps a glass of wine and out go the lights.

Similar data is being reported by the Centers for Disease Control. According to the federal Centers for Disease Control and Prevention, unintentional poisoning deaths – 95% of which are drug overdoses – increased from 12,186 in 1999 to 20,950 in 2004.

During testimony at a Senate Judiciary committee in March of 2008 Leonard J. Paulozzi, M.D., M.P.H stated


When these more specific drugs were tabulated, we found that street drugs were not behind the increase. The increase from 1999 to 2004 was driven largely by opioid analgesics, with a smaller contribution from cocaine, and essentially no contribution from heroin. The number of deaths in the narcotics category that involved prescription opioid analgesics increased from 2,900 in 1999 to at least 7,500 in 2004, an increase of 160% in just 5 years.[1] By 2004, opioid painkiller deaths numbered more than the total of deaths involving heroin and cocaine in this category.


He went on to say

All available evidence suggests that these deaths are related to the increasing use of prescription drugs, especially opioid painkillers, among people during the working years of life. A CDC study showed a correlation on the state level between usage of opioid painkillers and drug overdose death rates.[2] Perhaps because of differences in marketing or physician prescribing practices


What can be done

It is important that state prescription drug monitoring programs share data with law enforcement officials for the purpose of investigating the unlawful diversion or misuse of certain controlled substances. For example, some state prescription drug monitoring programs are administered by a law enforcement agency in conjunction with a state board of pharmacy


This recommendations falls in line with what California is implementing through the CURES program which will give providers instant online access to all scheduled drugs obtained via prescription by a patient. Law enforcement also has access to this data as needed. I recently posted about that program here

What is going on here is a direct result of politicizing medicine by the pain rights movement and the organizations (Joint Commission and others) that have mandated liberal pain management into guidelines and enforcement standards. More recently the push to promote patient satisfaction in Healthcare organizations has resulted in liberalizing of prescribing opioid medications to make patients happy. Whatever happened to do no harm? Medicine has lost its way. These numbers should serve as a wake up call and re-examination of pain management practices and the whole concept of pain as the fifth vital sign.

California takes a big step forward in fighting prescription drug abuse

In 2005 California expanded the CURES program to include all Schedule II-IV prescriptions dispensed. These medications have to be reported to the State Attorney Generals office who maintains a database of medications dispensed. This includes controlled substances directly dispensed from, Pharmacies, Doctors offices, clinics, and Emergency Departments that give out the to-go six pack of Vicodin when patients present after pharmacies are closed. Reports to the CURES program are done using a direct dispensing log that is faxed weekly to the CURES program.

Medical Providers and Pharmacist have been able to tap into this database by requesting an activity report on patients under their care. What they get is a print-out of every controlled Rx filled by the patient regardless of the source. In the past this report took several days to weeks to obtain. It was little use for the Provider who is trying to figure out if the person in front of them is filling multiple scripts from multiple sources. It worked well for ongoing care of repeat patients. I have seen it work well with some of our regular patients who return like clockwork to the ED several times a month. When confronted with the report of scripts they have filled recently and neglected to mention when listing their medications most give up knowing they have been had and you don’t see them again.

Soon the availability of activity reports will be online instantly via the California Attorney Generals web site. Instant access to a patients controlled substance prescription activity will give providers knowledge if they being lied to, used, played, to feed a habit or supply someone with an income who is reselling their meds. For those with legitimate pain conditions who are not seeking medication from multiple sources it should help them by removing the cloud of suspicion that follows them when seeking pain relief.

This effort is being funded partially by the Troy and Alana Pack Foundation founded by Bob Pack who’s 7 and 10 year old children were killed by a driver under the influence of prescription drugs obtained from multiple doctors. The Wall Street Journal recently had an article about the program.

Its about time.

A Vital Sign with concerning unintended consequences

Great post over at Aggravated Surgery Doc about the on the Downside of the 5th Vital Sign on how the PC infiltration of pain management policy caused poor patient outcomes and placed patients at higher risk. He makes valid points that political pressure has lead to more aggressive use of IV narcotic pain management instead of IM or other management thus putting patients at risk.

“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”

“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“

In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.

The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.

I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.

“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.

I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.

If this practice has not hit your ER yet, consider yourself lucky for now.