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12 Articles in Volume 12, Issue #1
Ask the Expert: Escalating Opioids
Can Yoga and Stretching Exercises Relieve Chronic Low Back Pain?
Cortisol Screening in Chronic Pain Patients
Editor's Memo: FDA Removes Homeopathic HCG; Helps Legitimate Use In Pain Treatment
Formulation: The Four Perspectives of a Patient in Chronic Pain
Guide to Chronic Pain Assessment Tools
How to Select an In-Office Electromagnetic Field Device
Letters to the Editor: Hormone Therapies
Managing Pain in Active or Well-Controlled Systemic Lupus Erythematosus
PPM Editorial Board Examines Steps to Prevent Accidental Overdoses
Saliva Drug Screening in the Office Setting: Detection of Drug Use and Abuse
Understanding the Toxicology of Diazepam

PPM Editorial Board Examines Steps to Prevent Accidental Overdoses

Editor’s Note:
We recently surveyed our editorial board members and asked them what they recommend a busy pain practitioner do to prevent accidental overdoses.

What is your view on this topic? Let us know; please send comments to ppmeditorial@verticalhealth.com.

Be an Astute Prescriber

Peter Moskovitz, MD
Washington, DC

Use opioid pain relievers (OPRs) judiciously and according to established guidelines, but also fairly. Remember Pellegrino’s dictum: It is immoral to withhold opioids because of a fear of addiction or abuse. Balancing efficacy and safety is never easy.

Know yourself: Recognize when you are caring for a patient whose needs are beyond the scope of your practice or your ability to maintain control of the relationship. Abusive behavior feels like an affront to your professionalism and your empathy for the patient’s predicament. Your anger won’t help your patient or give the patient behavioral control.

Understand and recognize depression and suicidality. Assess regularly and refer promptly.

Understand and recognize the difference between dependence, tolerance, and abuse (personal abuse leading to overdose and abuse that takes the form of diversion). (The term “addiction” should probably be abandoned.)

  1. For dependent patients, a) have one physician write prescriptions and one pharmacy fill them; b) have an OPR storage plan that is secure; c) refill prescriptions monthly or at shorter intervals; and d) have direct contact with the patient at each refill to assess mood, affect, and state of consciousness.
  2. For tolerant patients who may be at greatest risk for accidental overdose, a) follow step 1; b) switch medications at regular intervals; c) expand multimodal therapy; and d) refer for counseling to maximize behavioral control.
  3. For abusive patients (those with a history of medication, alcohol, or “recreational” drug abuse, or when reasonable doubt about compliance exists when tolerance emerges), a) follow steps 1 and 2; b) conduct urinalysis; c) consider referral to another pain management practitioner for better behavioral control; and d) maintain regular communication with the pharmacist and check the patient’s “profile” for abuse or diversion.
  4. For patients who actively abuse OPR prescriptions (beyond the control of steps noted above), a) report abuse to the pharmacist, referring physician, other practitioners, and law enforcement; b) refer for inpatient detoxification and a program to “start over”; and c) consider discharge for noncompliance with urinalysis, which is undesirable no matter how “mad” you are at an abusive patient.

ePrescribing Is Key to Managing Prescriptions And Interactions

Greg Winterkamp
Dallas, Texas

This is a very important subject and a major issue that has been exacerbated by the growth of the pain management industry in the United States.

I believe busy pain practitioners need up-to-date information that can help them effectively prescribe for and monitor their patients. That can only happen by getting into electronic prescribing (ePrescribing), which gives doctors a very effective tool to view patient prescriptions and interactions (eg, drug–drug, other possible allergies). It also allows them to view what other doctors have prescribed for their patients. Without having access to the ePrescribing network, it is almost impossible to determine what prescriptions a patient is taking, and doctors have to rely either on what the patient tells them or on outdated prescription information. This also leads to overdoses.

Having access to the ePrescribing network also can help thwart “doctor shopping” by patients who go to different clinics as well as cross state lines to get additional “meds.” Currently, there is no effective way to monitor this across state lines. The ePrescribing network allows physicians to pull in drug formularies and, in a few months, get information on filled and refilled prescriptions back from the pharmacies electronically.

With government intervention for the adoption of electronic health record systems over the past year, ePrescribing has taken on an even more important role. Studies have shown that ePrescribing has already helped in reducing drug fatalities.

As of June 2010, the Drug Enforcement Agency (DEA) has finally allowed ePrescribing of controlled substances, which is a huge step toward better management of the prescribing of controlled substances and monitoring of patients’ dosages and interactions. Surescripts, the main company that connects pharmacies to ePrescribing companies, had to recode its computer software to allow for proper provider authentication and ensure proper chain of command in ePrescribing controlled substances. That work has been finalized and was slowly getting rolled out in the last quarter of 2011 by states. This is crucial to all pain doctors because they do so much of the controlled substance prescribing. (It is important to note that many, if not most, pain doctors are still not ePrescribing!)
Editor’s Note: Mr. Winterkamp is CEO/President of Addison Health Systems, Inc, which markets an electronic medical record system.

Ask Patients to Document And Safeguard Opioids

Raleigh-Durham, North Carolina

No matter how careful a physician may be, there is not much that can be done to help a patient who uses opioids inappropriately. The patient may take his opioid appropriately and doze off. Upon awakening, unsure if he already took his medication, he may take a second dose in order to help himself sleep or perform some activity. The bottom line is that patients are human, and even the best-treated patients (or untreated people) can forget if they’ve taken a pill and take another one in an effort to be compliant, but accidents happen, most frequently—fortunately—not fatal.

On the other hand, when grandma has a bottle of acetaminophen and hydrocodone (Vicodin) in her medicine cabinet or dad has some oxycodone (OxyContin) given to him for a failed back syndrome, there is typically nothing to stop a teenager (or anyone) who wants to “take some” (steal) and use them indiscriminately. These are the individuals who may die of an “accidental overdose”; that is, they didn’t try to kill themselves; they just wanted to get high.

For these reasons, I do two things with my patients to go a step further to prevent opioid drug stealing: I ask them to obtain a small safe—a single gun safe is sufficient (and not too expensive)—and always keep their medications in it. As long as the combination is not common knowledge, that can help.

I also tell my patients to keep a notebook and write down the time they take every pill, and further ask them to consult that notebook before they take every pill so they don’t accidentally take too much medication in a short period of time.

I also suggest putting their medications in an individual travel pill holder with multiple plastic sections that they can use to lay out their pills and mark the sections according to the time the pills are to be taken.

Although it is relatively easy to make suggestions, everything depends on patient follow-through—that is, doing what they are asked to do. There is nothing a physician can do except make clear from the initial meeting that he or she means business—when the physician asks that something be done, the patient must be able to follow through; if not, the physician and patient must discuss it before the patient leaves the office and determine a mutually agreed-upon solution. (Patient: “I can’t afford to buy a gun safe on my social security.” Physician: “How about a place you can hide your medications where it is easy for you to access, but very hard for someone else to find them?”)

Physicians can try mightily to help patients avoid accidental medication overdoses, but it is the patient who must follow through with the physician’s recommendations; physicians may recommend, but they can’t demand.

The doctor, however, must document his or her discussion regarding ways to try to prevent patients from accidentally overdosing, including his or her recommendations and the patients’ stated agreement (or not).

Leverage Trust in the Patient–Physician Relationship

Joseph Ruane, DO
Columbus, Ohio

One thing you can do is leverage the trusting relationship you have developed in prescribing long-term pain care for your patients. Ask if they know what acetaminophen is and where it is found, including in their pain medication. Look them in the eye and tell them that if they consume excess alcohol, take more medication than they are supposed to, or self-medicate without your knowledge, the consequences can be dire. Ask them to call before they take more than the prescribed dose if their pain is out of control. You can never prevent intentional abuse, but these simple interactions can help prevent accidents.

“Share the Risk Model” Can Unite Healthcare Professionals

Joseph Shurman, MD
La Jolla, California

Follow the Share the Risk Model. If a physician does not have access to outside specialists, he or she can use the Emerging Solutions in Pain Website (www.emergingsolutionsinpain.com). (The Share the Risk Model was a catalyst for Emerging Solutions in Pain.) The Website has various tools a physician can use.

The October 2006 issue of Practical Pain Management featured an article on the Share the Risk Model1:

“The goal [of the Share the Risk Model] has been to unite physicians and other healthcare professionals who treat chronic pain in the San Diego area. It is axiomatic that patients with chronic and intractable pain are among the most complex and difficult to treat in all of medicine. They invariably have multiple and often esoteric somatic problems, predictably complicated by layers of social and emotional stress, or by concurrent anxiety and personality disorders. In recognition of these realities, the Share the Risk Model’s fundamental premise is that no physician—no matter how well educated, confident, compassionate, committed, or meticulous—can adequately meet all the needs of the patients with chronic and intractable pain. Instead, the model calls for a multidisciplinary team approach to treat the chronic pain patient.

In the application of the Share the Risk Model, using any part of the model is better than being out in the community alone. Documentation is important but outside consultation, if possible, should be part of your risk management program. The Share the Risk Model continues to expand and offer assistance for both physicians and patients in the treatment of chronic pain.”


  1. Shurman J, Sack J, Shurman G, Schnierow B, Gabriel C. Share the Risk Model. Pract Pain Manage. 2006;6(7):10-20.

Administer Adequate Dosing, Then Taper Subsequent Doses

Elmer G. Pinzon, MD, MPH
Knoxville, Tennessee

For acute severe pain, the drug regimen should be equal to the task of alleviating the pain immediately. This philosophy of aggressive dosing (ie, “descending the ladder”) has gained acceptance partially because too often, fears of addiction and respiratory depression have led to too-timid dosing of narcotics. Otherwise stated, a dose that is felt to be adequate should be administered, and the subsequent doses are slightly tapered down until the pain threshold is discovered. Then the dose is adjusted just slightly upward to alleviate the pain on an “around-the-clock” basis without overdosing. This system should lead to lower maintenance doses because the patient is rapidly, rather than gradually, brought into the realm of comfort.

As with all aggressive treatment regimens, the clinician should be diligent in monitoring side effects, especially because the opioids have central nervous system–depressant activity. Significant sedation will present itself at narcotic levels above the pain threshold. The ideal dose will be achieved if sedation is not significant and pain control is maintained. Sedation later in therapy may be an indication of an accumulation toxicity effect. Respiratory depression also is a fear of many clinicians who administer potent doses of narcotics, although significant respiratory depression is not common in pain patients receiving narcotic treatments. It appears that if the opioid is not causing clouded thought processes, risk for respiratory depression is minimal. It has been demonstrated that “around-the-clock” pain medication administration provides superior analgesia compared with “as needed” or PRN administration. Not allowing the pain symptoms to recur causes less mental and physical trauma and actually can lead to less medication use with better pain control. Pain memory (when the patient begins to feel pain and anticipates continued pain distress) can be eliminated when the pain control pharmacotherapy is regularly scheduled.

Follow the 10 Commandments Of Preventing Opioid Overdoses

Pierre LeRoy, MD, FACS
Newark, Delaware

The 10 commandments to help manage the epidemic of overdoses of opioid pain relievers are:

  1. Close patient supervision; for example, 1-month follow-up consultations
  2. Develop a patient profile, if possible, for dependency tendencies, such as smoking and alcohol use
  3. Refer to counseling services upon suspicion of dependency
  4. Limit dosages and dispensing quantities
  5. Educate the patient on the dangers of opioid consumption
  6. Educate the patient on undesirable side effects, such as constipation, lassitude, and depression
  7. Educate the patient concerning the development of drug tolerances
  8. Refer the patient promptly for comorbidities to other specialists
  9. Consult with pharmacies on medical concerns
  10. Advise and request close family supervision
Last updated on: February 15, 2012
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