Who to blame in fatal medication overdoses

There was news of yet another high profile death from an uncertain cause in a star with addiction history.   Media accounts included reference to the “27 club” — a lengthy list of famous artists who have perished by their own hand, often unintentionally, at the age of twenty seven.

The reality is that too many fatal overdoses responsible for the deaths of the famous and not-so-famous are from medications that were dispensed by a pharmacist in response to a physician’s legal prescription.  The Who’s Who list of “dead in their prime” celebrities in the headlines is long, many because prescription medications were determined to be the cause of death.   In our county, the medical examiner will routinely notify the physician whose prescribed medication is found at the scene of a drug related death.  It can be a sobering call to receive–as it should be.  It should cause the physician to think twice before they sign their next controlled substance prescription.

It is time for those of us who vowed to “first do no harm”  to share in the responsibility for these deaths.  Without our implicit cooperation — our prescription pads, our signatures and our willingness to please patients, especially the rich and famous, by offering up a hand full of pills for every expressed concern and complaint, there would not be so many empty pill bottles sitting next to corpses, and not so many corpses.  We prescribers, including those professionals with prescriptive authority other than physicians,  need to be accountable for the clinical decisions that place combinations of potentially lethal medications in their patients’ hands and mouths.

In the twenty years I have managed medical detox for addicted patients, I have learned how frequently physicians overprescribe for complaints of anxiety, stress, sadness, insomnia as well as the everyday pain of living in the modern world.   Too many pills per prescription, too many unquestioned refills, too many times written without regard to what another physician may have prescribed a week before, too oblivious to what recreational self medication/beverage may be routinely consumed.  Addicts know well who the easy touches are in the physician community, know exactly what they need to say and do to get the drugs they seek.  Addicts also know to rotate emergency room and pharmacy visits and how to  “borrow” from a family member’s medication supply, as well as where to buy “on the street” when all else fails.

As a prescriber, I’ve learned there are ways to responsibly prescribe chronic opiates and benzodiazepines under a patient/prescriber medication contract.  I prescribe small amounts of certain medications that I know can be a problem and never automatically allow refills.   There are never “after hours” or weekend refills.  When I am concerned about potential abuse, I say “no more”  and mean it, when it is clear the medication is no longer justified for the symptoms.  If a taper is necessary, it is done on a daily dispensing basis through a pharmacy.   I insist on random urine drug tests if I’m not sure if the patient may be self-medicating or possibly diverting the drugs I prescribe.   I check the community pharmacy database if I’m not certain I’m the only prescriber for the patient and I check the hospital medical record system for recent drug-seeking emergency room visits.  With the help of modern collaborative electronic medical record systems,  shared information about a patient’s prescriptions can prevent the tragedy of sharing the blame for a patient’s unnecessary overdose.

No prescriber wants to get the call that the medications they prescribed in good faith, in a spirit of healing and compassion, caused an overdose death.   We can do better, and before the next celebrity’s name hits the headlines, we must do better.

Emily Gibson is a family physician who blogs at Barnstorming.

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  • http://twitter.com/USMCShrink Kevin Nasky

    I agree with all your suggestions, but the collaborative electronic medical record systems and community pharmacy databases are sorely lacking in much of the country. It will certainly be easier to control this problem when all prescribers and dispensers are ‘plugged in’ to an easily-accessible database.

  • http://www.practitionersolutions.com Niamh van Meines

    I don’t believe the cause of death for the celebrity you speak of was an obvious overdose, but it would not have been a surprise. I work in hospice and palliative medicine where symptom management is a priority. I’m not sure how your recommendations would fit in this environment when we would be putting our patient’s through added discomfort when prescribing this way. There needs to be flexibility with rescue doses of pain medication and a trust relationship with the patient so that relief from suffering can be achieved. I would love to hear your recommendations when we know the person is not an addict but requires significant medicating to alleviate distress. Thanks

    • Emily Gibson

      There are clearly situations, like hospice and palliative medicine, where flexible dosing of narcotics and benzodiazepines are the routine standard of care.  This can be addressed in a medication management contract with the patient and caregivers.  I know you must be aware of the risk of diversion by family members and care givers in that setting.  In my work with addicts, they were well aware and took advantage of the plethora of medication available to terminally ill family members.

  • Joe Kosterich

    You are correct in your approach. However those who want drugs will shop around till they find a  doctor who is a well meaning “soft touch”.

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