The best treatment for any drug overdose is prevention. Because of the national attention to the opioid epidemic and harsh statistics of deaths caused by fentanyl overdose, political, federal, state and even pharmaceutical companies have made efforts to address the problem. One strategy is to decrease the availability of prescriptions for opioids and fentanyl.
The Food and Drug administration (FDA) has produced guidelines for effective pharmacologic use of opiates, which include the identification of persons at risk, assessing a patient’s benefit vs. risk, developing and using tools to decrease risks of opiate prescription use (such as contracts for pain management and standards of required 30-day physician visits before new prescriptions can be refilled).
Prevention strategies include:
- Patient education regarding use of opiates
- Pain contract signed by patient to agree to terms of drug use
- Prescription monitoring programs to detect multiple use of pharmacies and physicians for opiates
- Detection of inappropriate prescribing of opioids
- Photo identification to pick up opioid prescriptions
- Urine toxicology screening for employees
- Safe disposal of unused opioids
- Referrals to pain and addiction specialists
- Use of semi-synthetic opioid alternatives
Patient education regarding the use of opiates—and, actually all prescription medications—is essential for them to understand the need for the drug, its side effects, and adverse effects. An additional pain contract should be included with the patient education materials, that outlines the parameters for the use of the drug. Especially when used for chronic pain management, patients should be partners with the prescriber to outline when the drug will be used and for how long.
Prescription monitoring programs include detection systems in pharmacies and the local district that identify patients who have filled a narcotic prescription. In many states, photo ID is already required for the purchase of cigarettes or alcohol and could become a beginning point to dissuade unauthorized and high-frequency prescription use.
According to the National Alliance for Model State Drug Laws, currently 85% of states require ID for narcotic prescription use. Some drugstores even run the name of a client picking up a narcotic prescription through a drug monitoring data system for alerts. The challenge is for busy pharmacists to take the time to use the monitoring system and for patients to be patient while the process is completed.
Possible “red flags” that could lead to prescription denial:
- A pain medication not previously filled the pharmacy
- A new doctor writing a prescription for the same pain medication
- A doctor writing a prescription who is not in a “reasonable geographic location” near the pharmacy
- A patient paying for a prescription in cash
- A patient seeking an early refill of a prescription
- A patient seeking an “excessive” number of pills
- A patient taking the same pain medication for more than 6 months
Another strategy includes getting prior authorization before opiates can be filled. In 2007 the FDA passed an amendment to create a patient registry for opioids. In 2012 Blue Cross Blue Shield began to require prior authorization for more than a one-month supply of opioids in a two-month period. By this simple process alone, in the state of Massachusetts the number of opioid prescriptions was decreased by more than 6,500,000 pills in one year (Boston Globe, 2016).
Safe disposal of opioids is a challenging issue because many people believe that flushing them down the toilet is appropriate, which it is not. Public education and awareness programs should include safe medication disposal such as mixing with used coffee grounds, dirt, or kitty litter and placing in a sealed container to then dispose of in the garbage. Used opioid patches should be folded in half on the sticky sides and disposed of in a sealed container in the garbage.
Several screening tools are available to help clinicians identify when a patient taking opioids may be experiencing dependence or addiction.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs” (SAMHSA, HRSA, 2016). The SBIRT model was inspired by a recommendation from the Institute of Medicine to increase community-based screening for health risk behaviors, including substance use.
SBIRT is an early and brief intervention of 15 to 30 minutes and billable to Medicare/Medicaid. The screening and referral to treatment includes a patient encounter, history, physical examination, clinical diagnosis, and plan for care specific to the concern of substance abuse other than for those patients already identified with severe substance abuse. The SBIRT screening tool can be as simple as asking several key questions of patients receiving narcotics and opioids at every doctor’s office visit.
Opioid Risk Tool
The Opioid Risk tool is another brief screening tool consisting of questions to help identify a patient at increased risk for dependence and abuse. Currently no one tool has been identified to be better than any others, nor is any one tool sufficient to identify drug behaviors of chronic pain patients using opioids (Turk et al., 2008).
Additional strategies to prevent overdose and overuse of fentanyl is to create systems of notification of awareness when a patient is using the drug inappropriately. Pharmacy notifications, Prescriber education and even identification of use during pickup are measures being implemented with varying levels of success.
The biggest problem still stems from those users of fentanyl-laced products that do not come from legal channels. Federal regulations against China have begun but with little success as manufacturers and dealers outsmart the current systems. It is alleged that most of the fentanyl arrives through legal small packages via private shipments into the U.S. mail (Herald, 2018). Tracking postal systems is costly and ineffective at present. The U.S. government announced that the DEA scheduled all fentanyl-related substances, which makes possession, manufacturing, and use of these products illegal and subject to federal prosecution (Thomas, 2017). Police forces are being trained to identify such products but training and practice take time in the ever-increasing war against even newer types of opioids.
Legal sentencing for illegal drug use of fentanyl was increased in 2016 and includes a mandatory 5-year sentence for possession of 2 grams, which is also a fatal dose. Fentanyl is odorless and colorless and generally can’t be identified within street drugs. Mandatory sentencing for heroin and other opioids has existed for more than 30 years, however legal deterrents haven’t decreased the incidence of illegal fentanyl production, delivery, or use.
Test Your Knowledge
What is the SBIRT screening tool?
- A form that assesses for risk for drug abuse.
- Screening, brief intervention, and referral to treatment.
- The intake process for admitting a patient to a rehabilitation facility.
- The history and physical assessment of patients for drug abuse.
Apply Your Knowledge
Q: In our case scenario, what steps could have been done to help the patient with safe pain relief, education, and more rapid diagnosis and treatment?
A: The answers are within the question itself: safe pain relief, education, and more rapid diagnosis and treatment. Unfortunately, there are sometimes roadblocks. Systems of health care delivery are slow at best as insurance companies largely control the speed a patient can be seen, and by whom, and which procedures will be authorized.