Our relentless chase for statistics in the 21st century has driven us to be bigger higher and better than our compatriots, whether locally, nationally or worldwide. While we strive to achieve higher percentages compared to other developed countries, some numbers being high is not a good thing. Let’s take the consumption of opiates in the United States. We are host to around 4 percent of the world population and yet, we consume over two thirds of the total supply of legally prescribed opiates in the world. Our gradual albeit steadily growing dependence on quick and optimal relief of pain, while in general, a noble goal has led us towards a slippery slope of easy fixes and at times, unreasonable expectations. Pain, remains one of the most enigmatic and unpredictable domains of medical science. As opposed to a symptom (as expressed by the patient), which can be substantiated with a sign (elicited by the practitioner), level of pain remains entirely subjective. While a thorough and observant clinical exam may be able help confirm or question one’s level of discomfort, various factors cloud that judgement. Individual pain thresholds, i-e, an individual’s pain tolerance may vary widely from on to another, so does the impact of psychosocial determinants. For example, an engaged and content individual may push aside a certain level of discomfort in a much more effective manner compared to someone who is, due to life circumstances, already looking at the glass as half empty. Our brave men and women serving the military, fire departments, police and other emergency services are trained to push through pain and discomfort in order to save others and achieve their goals. Who can forget Aron Ralston, cutting his own arm off and escape the 800 pound boulder to save his life. We have all seen athletes, pumped full of adrenaline push through severe pain and continue playing; Donavon McNabb running on a broken leg, Ben Roethlisberger, throwing deep balls with a dislocated shoulder and of course, Tiger Woods, winning the US open with stress fractures and torn ACL, however, ordinary humans like us, under normal circumstances, may not be able to withstand such extremes without help. Over the years, our patient centered approach taught us that any amount of pain is unacceptable and we need to address it aggressively as well as effectively. This approach, while humane, focused on the unilateral treatment of pain, but ignored the aspect that required us to stress on patient education. Patients wanted resolution of pain and wanted it fast; health care providers, pushed under increased workload and increasing bureaucracy of our healthcare system began to find it easier to prescribe medications that achieved this. The end result was a culture of quick fixes, which is not limited to pain but also to any other symptom. We want our weight- lost, cough,-gone, our sore throat soothed, blood sugar and pressure optimized with the flick of a magic wand or, a pill, magic or not. Quick Fix culture of medicine has overwhelmed the emergency rooms and led to an increasing crop of Urgent Care Facilities in every block, even in pharmacies and grocery stores. The conglomerate culture of medicine is looking for every competitive advantage in the communities. While ready access to healthcare is a dire need and fulfilled by this culture change, it has also lead to an inevitable dilution in the quality of care. Patients see it as an opportunity to receive prompt access to care, leading to a quick resolution of the problem, but also leads to reduced continuity of care and adequate management of chronic condition such as diabetes, high blood pressure etc. Result is the rampant escalation in opiate consumption and antibiotic resistant bacteria resulting in public health nightmares.
Treatment of pain is at the top of the list of such needs and has led to a slippery slope that is increasingly difficult to reverse. Opiate abuse and overdose remains a major public health hazard as legally prescribed drugs end up in the black market, street corners or at clandestine meetings around shoddy bars. According to CDC data, in 2014, almost 2 million Americans abused or were dependent on prescription opioids and, more than 14,000 people died from overdoses involving prescription opioids.
Opioid prescribing continues to fuel the epidemic. Approximately 80 percent of the global opioid supply is consumed in the United States. At least half of all U.S. opioid overdose deaths involve a prescription opioid and these numbers have quadrupled since 1999 leading to 165,000 deaths. There were 2732 deaths during 2014 in Pennsylvania alone, which constitutes one of the largest numbers among all states after California and Ohio.
Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients. They are designed to monitor this information for suspected abuse or diversion (i.e., channeling drugs into illegal use), and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help prescribers and pharmacists identify patients at high-risk who would benefit from early interventions. As of now, 49 states are participating in these programs.
PDMPs continue to be among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk. Additional research is needed to evaluate PDMP practices and policies to identify best practices.
Under this program, all dispensers are required by law to collect and submit information to the PDMP about each dispensing of a controlled substance prescription drug within 72 hours. The PDMP stores the information in a secure database and makes it available to healthcare professionals and others as authorized by law. As part of good clinical practice, the Department of Health recommends that healthcare professionals check the system every time before a controlled substance(s) is prescribed or dispensed.
The onus of this falls on all of us. While, healthcare providers need to take the charge and engage in active education regarding a culture of responsible consumption and ill effects of not only opiates, but also other medications of major public health concern such as antibiotics, the public needs to be vigilant about their own healthcare needs and the responsible ways to achieve a level of wellness that is safe and is built on the principles of preventive medicine. Only with this partnership and full engagement of our lawmakers will we be able to lay the foundations of a responsible culture, which is responsible, high value and focused on our collective wellness as a nation.