Opioid stewardship and the $90 pill
The College recently received information that a registrant had been prescribing, and a pharmacist had been dispensing, monthly dispenses of 1,440 pills of 100 mg M-Eslon and 1,400 pills of Supeudol 10 to a single patient for management of headaches. On the assumption that this amount was being consumed, it would correspond to the patient taking 48 M-Eslon 100 mg tablets and 47 Supeudol 10 mg tablets per day. This represents a morphine-equivalent daily dose of 5,500 mg. Such a high dose is never acceptable for management of chronic pain. Indeed, a dose this high suggests addiction or diversion.
Given the current street value of $90 to $100 per pill for M-Eslon 100 mg and $10 to $15 per pill for Supeudol 10, the patient was receiving drugs with a potential value of $140,000 to $165,000 per month.
Prescription drug misuse is a significant public health issue in North America. After marijuana, prescription opioids are the most commonly abused drugs in the teen and young adult populations. This group uses these drugs injudiciously as they believe that their prescribed nature makes them safe.¹ A study by the Substance Use and Mental Health Services Administration (SAMHSA) showed that for those who abuse them, 89% of prescription opioids are either directly or indirectly sourced from a physician (17% prescribed directly, 11% purchased from a friend/relative, 5% taken without permission from a friend/relative, and 56% free from a friend/relative).²
Registrants faced with the choice of whether to prescribe opioids should ask themselves the following questions:
- How well do you know the patient? Are you prescribing large amounts of complex medications to patients who are unknown to you? In such cases, it is generally reasonable to provide a very small dispense—following clinical review and once PharmaNet has been checked—with an understanding that further prescriptions will only be provided once corroborating information, including chart notes, imaging, and results of urine drug screens are received from the patient’s previous physician.
- Are you prescribing high doses of morphine equivalent per day? Doses above 100 mg morphine equivalent per day (65 mg oxycodone or 20 mg hydromorphone) put patients at a three- to five-fold increased risk of overdose. The risk is amplified if alcohol or sedatives are also ingested. Further, high dose opioids increase the risk of adverse effects including hormonal disruption, sleep disorder, GI disturbance, mood disorder, immune system dysfunction and opioid-induced hyperalgesia.
- Are you co-prescribing benzodiazepines or other sedating medications with opioids? There is no benefit in using these medications concurrently, and where they are used together, they increase the risk of morbidity from cognitive disturbance, balance disorder, mood disorder, and sleep disruption, and mortality—from CNS and respiratory depression. Simply instituting a clinical policy whereby these medications will not be co-prescribed—as a matter of patient safety—is the best option.
- Are you directing a pharmacist to dispense too much medication? As a general rule, physicians should direct the dispensing pharmacists to provide controlled medications in modest amounts of usually 50 to 100 units. Dispenses of over 200 tablets at a time are rarely warranted. A large dispense increases the risk of medication error or misuse by the patient, as they may be less mindful of the amounts they are taking when hundreds of tablets are in their possession.
- Have you considered whether this patient may be addicted? Are you legitimizing a prescription drug addiction by prescribing? Addiction is an extremely difficult disease to detect, and recognition of it generally relies on patient self-report. Patients may be less than forthcoming or in denial that they have a problem. This is especially true when they are actually misusing prescription medication, or using prescription medication to self-medicate other symptoms. Useful objective measures for assessing substance misuse include physical examination, blood work, and regular random urine drug screens.
- Is this medication being diverted in whole or part? Dispenses of medications that are too large can easily become a source of diverted medicines.
All too often the illicitly used opioids on the streets originated from a physician’s duplicate prescription. Asking the right questions before putting pen to script and practising pharmacovigilence are critical steps in addressing prescription drug misuse.
- Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national survey results on drug use, 1975–2010: volume I, secondary school students [Internet]. Ann Arbor (MI): Institute for Social Research, The University of Michigan; 2011 [cited 2014 Nov 19]. 746 p. Research Grant No.: R01 DA 01411. Supported by the National Institute on Drug Abuse, National Institutes of Health (US). Available from: http://monitoringthefuture.org/pubs/monographs/mtf-vol1_2010.pdf
- Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: summary of national findings [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2011 [cited 2014 Nov 19]. 144p. NSDUH Series No.: H-41. HHS Publication No.: (SMA) 11-4658. Available from: http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf