Who is Accountable?

This past fall we had a “drug raid” in our neighborhood. The house was right across the street from an elementary school. The police found more than 1000 prescriptive pain medications in the house. The occupants claimed they had reasons for the pain medication, including recent surgery and back pain. The case remains under investigation. The prosecutor will not only bring charges against the people with the pills but will also pursue the health care providers who supplied them with the medications.

In 2005, it was pointed out by the President of the National Center on Addiction and Substance Abuse at Columbia University that despite decreases in illegal drug use, the abuse of controlled prescription drugs—opioids, central nervous system depressants, and stimulants—has been increasing. This escalation also has brought along an increase in ED visits from people seeking more drugs.1 In 2007, 6.9 million persons aged 12 years or older used prescription-type psychotherapeutic drugs non-medically. Pain relievers were used by 5.2 million. Even though marijuana was the most commonly abused substance, pain killers came in second.2

Why does prescription opioid analgesic abuse continue to increase? Some authors have suggested the following reasons: prescriptive drugs are relatively easy to get; the purchase of illicit drugs is not closely monitored by the law; the use and abuse of prescription drugs is more socially acceptable; the purity and dosage of prescription medications are safer than illicit drugs; and these drugs can be used to assist with the withdrawal symptoms of illicit drugs.3

Dealing with patients who are drug seeking in the emergency department can be time consuming and energy draining. Running out of drugs, losing prescriptions, coming to the emergency department on the weekends because a physician is not available, reporting stolen drugs, and eliciting sympathy because of a painful disease and no medication are a few of the behaviors that may be seen. The patient who tells you that he or she is allergic to “everything” and can only use a specific medication can make it difficult to truly care.4

What can be done? Several solutions have been proposed. First, all health care providers and patients must become educated about pain and pain management. Pain management is complicated and goes beyond “pharmaceuticals.”4 Case managers could play a key role in working with patients who use the emergency department for prescription refills.

Some sort of surveillance system that assists ED personnel with prescriptive drug abuse monitoring is needed. This system could be state or locally driven, but the data must be available in real time.5 An existing system entitled Researched Abuse, Diversion and Addition-Related Surveillance (RADARS) uses three-digit ZIP codes and other detection systems such as law enforcement agencies and Poison Control Centers to identify the abuse of hydrocodone and extended-release and immediate-release oxycodone. Some systems do exist but are not universally available.3

We must recognize that in the United States we have a problem and, unfortunately, the emergency department and emergency nursing is in the middle of it. Prescription drug abuse requires a systematic approach that involves health care providers, patients, and the communities in which we live. We all are accountable.