The Prince Effect Spotlight on the Opioid Epidemic
The following are representative cases from the CHPSO database:
A patient requested a dose of an opioid. The nurse refused as she believed it was unnecessary. The patient became irate with the nurse and physically aggressive towards her. A code gray was called.
A patient was brought into the ED unconscious. The patient’s toxicology screen was positive for opioids. According the patient’s medical history, the patient’s medication list included morphine, oxycodone, hydrocodone, lorazepam and alprazolam. Narcan was used to reverse the effects of the opioids and the patient recovered consciousness.
A patient developed an altered level of consciousness, became dizzy and nauseous. Earlier, the patient had received oxycodone, hydromorphone, and hydrocodone. The clinical team switched to non-opioid analgesics and the patient’s condition improved.
Two months ago, the singer Prince succumbed to an overdose of the painkiller fentanyl at the young age of 57. America’s addiction to prescription drugs, especially opioids, is not new and Prince’s death has certainly raised awareness to the worldwide epidemic. In 2011, 52 million Americans over the age of 12 had used prescription drugs non-medically in their lifetime. That’s the populations of California, Nevada, Oregon, and Washington combined. According to the CDC, approximately 46 people die from a painkiller overdose in the US every day, or one death every 30 minutes or so. In 2012, health care providers wrote 259 million painkiller prescriptions. That’s equivalent to every adult living in the US having their personal bottle of painkillers.
The balance clinical providers face is difficult. On one hand, they may need to use prescription medications to relieve pain and minimize suffering. On the other hand, providers are challenged to reduce overuse of opioids and recognize the adverse effects, including mortality. Opioid painkillers have become so widely available and accepted in our society, and the movement toward safe prescribing and standard treatment in hospitals is taking notice.
The Joint Commission produced a Sentinel Alert in 2012 on opioid-related drug events. The alert underscored the need to monitor patients for the potential of opioid-induced respiratory depression. Their database indicated 47 percent wrong dose medication errors of opioid-related events of which 29 percent were improper monitoring. These patients are at higher risk with higher doses, sleep apnea, morbid obesity, young age, elderly, and co-dependent on central nervous system and respiratory depressants. Ways in which to assess and manage pain among patients include:
Screen patients for respiratory depression risk factors
Assess the patient’s previous history of drug use
Conduct a full body skin assessment of patients prior to administering a new opioid. This helps to rule out whether the patient has a fentanyl patch, implanted drug delivery system, or infusion pump.
Use an individualized multimodal treatment plan to manage pain, perhaps starting with a non-narcotic.
Take precautions with patients who are new to opioids.
Consult with your pharmacy when converting from one opioid to another or changing the route of administration.
CHPSO maintains a safety report database containing events, near misses, and unsafe conditions contributed by its member organizations. We currently have about 950,000 event reports. In the database, opioids were mentioned in 62,157 medication event reports out of a total of 307,000 medication-specific events, or about 20 percent. The next most commonly mentioned drug category was benzodiazepines and nonbenzodiazepine hypnotics at 23,508 reports, about 7.5 percent. This metric highlights how frequently specific drug classes are mentioned in medication event reports. A drug may be named in the event because it was:
central to the event (e.g., opioid-induced respiratory depression),
a rescue medication (e.g., corticosteroids for an allergic reaction), or
otherwise associated with the patient, such as being in a medication list that was included in the report.
Given the gap between event reports mentioning opioids and benzodiazepines, there is an alarming trend of prescription opioid-related events. We must all recognize the significance of overuse on prescription and non-prescription opioids, as well as all other prescribed medications. Opioids certainly come with risks, however, they are also useful in relieving patient pain. The balance to achieve pain relief and reducing potential adverse events for patients is something for which we can all strive.