After the Overdose

aaaaaaaaaaaaaaaaaaaaaaaaaaapic

 

 

 

 

 
I just read an astounding and completely believable study in a recent issue of the Annals of Internal Medicine. [1]

This study, done by Dr. Larochelle and associates at Boston University Medical Center, did a retrospective study of prescription opioid overdoses. They looked at patients who were being prescribed opioids long-term for non-cancer pain who had a non-fatal overdose. The study lasted from May 2000 until December 2012, and included over twenty-eight hundred patients. All of these patients had commercial insurance, and were between 18 to 65 years old.

This study found that after having a non-fatal overdose, 91% of these patients resumed getting prescription opioids, and that 70% got them from the same doctor.

The lead author said he was shocked to find so many survivors continue to be prescribed opioids after having an overdose from these very opioids. He had hoped after a near-fatal experience, prescribers would do something different to address pain, in order to prevent future overdose.(https://hereandnow.wbur.org/2016/01/13/opioid-prescriptions-after-overdosing)

From other studies, we know that the best predictor of a future overdose is a past overdose, which is why I ask every patient entering the opioid treatment program (OTP) if he has ever had an overdose.

The author of this study postulated that with our fragmented healthcare system, the prescribers may not have known the patient had an overdose. Not knowing about any problems, the doctor continued to prescribe opioids.

I have no problem envisioning how this happens.

Not long ago, one of my opioid treatment program (OTP) patients missed two days of dosing. Per our protocol, her counselor called her on the first day she missed dosing. The patient told her counselor that she had been admitted to the hospital for trouble breathing, and was being treated for asthma.

Also per out protocol, we request hospital records for every patient of ours who gets admitted to the hospital, and our patient gave permission for this.

When I got the records four days later, imagine my surprise when I read that she had respiratory failure due to an overdose. Her drug screen at the hospital was positive for methadone and also benzodiazepines, and indeed she was now positive for benzos at the OTP too. This information lead to a drastic change in this patient’s treatment plan.

If we had not called to see where our patient was, she could have returned in several days and not told us about her hospital admission.

Our local hospital did not call our OTP to tell us our patient was hospitalized with an overdose. Indeed, they didn’t call to tell us she was in the hospital. To my patient’s credit, she did tell them she was a patient of ours, since it was recorded in her hospital record.

When our patients are admitted to the hospital for medical reasons, the admitting doctors continue to prescribe the usual dose of methadone, and I am happy about that, but they don’t call us to confirm the dose. They take the patient’s word for what the dose has been, instead of making a quick phone call. I worry that someday, one of our patients, in a misguided effort to feel an opioid effect, will tell his hospital doctor he’s been dosing at a higher dose than he actually is, and catastrophe could ensue.

In contrast, the big teaching hospital an hour away, which is where our patients go when they are really sick, routinely calls to confirm each patient’s dose.

The Larochelle study seems to indicate there’s a lack of communication in other medical communities as well. Emergency department physicians may administer Narcan and revive a patient, but no one thinks to take the next essential step: call that patient’s prescriber about the drug overdose.

We can’t assume the patient, now revived from a near-death experience, will tell her doctor about what happened. If that patient has an addiction, she might keep quiet about prescription mishaps, fearing her supply of opioids may be cut off.

Family members might tell the prescribers, and that’s very helpful, but often patients are told the doctor can’t release any information. That is true, but the family can certainly give information to the doctor.

I know hospitals and emergency departments are busy. Healthcare professionals are all busy. We are being asked to do more and more in less and less time. But this is a communication issue, and it need not be a physician- to- physician communication. A nurse or even a social worker from the hospital could call or fax valuable information quickly. Privacy laws can be blamed for some lack of communication, but there are exceptions in life-threatening situations.

And please, let’s make medical records readable. Even when I finally get local emergency department records about one of my patients, I have a hard time deciphering them. I’ll admit to being a bit of a Luddite when it comes to electronic medical records, but partly because most electronic records are not all that helpful.

For example, on our local emergency department records, I quickly can find the results for Ebola screening (it’s on the first page, at the top), but often I am left scratching my head about what the doctor’s final diagnosis and treatment plan was for the patient.

We’ve got to fix this communication problem. It’s great when an overdose is treated and prevented. But let’s do just a little more, and communicate to the prescriber of the overdose medications.

It is life and death.

  1. Ann Intern Med. 2016;164(1):1-9. doi:10.7326/M15-0038
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8 responses to this post.

  1. Posted by logirl27 on January 23, 2016 at 3:15 pm

    The problem is that this is a slippery slope. Sure, it seems obvious you want prescribers to know of a patient who had a near-fatal overdose and adjust their medications accordingly (more likely they’d cut them off cold-turkey and tell them to get lost), but once you start interfering in the judgement of doctors through regulation, you further constrain them, and they are *already* constrained by health insurance providers and governments.

    So, we have to be careful to let doctors do their thing w/o unnecessary constraints — and maybe have DIFFERENT opinions from the majority, for example — something I know you have had from time to time.

    The one thing I am sure of is that very few (as-in statistically 0) doctors want to intentionally do harm to their patient. It’s their Hippocratic oath (the inverse). However, the way they can help patients should be left up to them, since it is them who knows the patient. For instance, maybe in every case cited in this study, had the prescription not been available, off-the-street drugs would have been used instead, and perhaps they would have fatally overdosed sooner. You never know, so don’t want to draw conclusions from studies like this that do NOT prove any type of causality.

    Reply

    • Posted by logirl27 on January 23, 2016 at 3:19 pm

      And I agree on communicating to confirm doses ;p. I have never been able to lie myself, terrible at it, and always assumed I’d be caught.. but if addicts knew many didn’t confirm, they may up their dose to what they think it should be. Of course, it’s also possible they are in pain from something else and need a dose escalation. Anyway, I do think that’s a minor symptom of the communication issue you site. Where I again disagree is on the breadth of communication. For instance, I can foresee a situation where a single doctor had some errant diagnosis of a patient, and that diagnosis follows that patient forever. Sometimes it’s good to not have a tainted history and get fresh eyes on your health. There was a funny Seinfeld episode about this (the AMA in that case).

      Reply

    • I don’t advocate additional regulation, just better communication. I think a doctor should be informed if a patient nearly died from a medication that doctor prescribed.

      Reply

  2. It’s absolutely insane. I was having a conversation about this with Alan Wartenberg and Sharon Dembinski a few days back. I’m glad you are raising awareness on this issue. You would think they would at LEAST send them home with naloxone and make sure a close family member or friend that lives with them is trained in how to use it — IF they’re going to continue prescribing opioids. Are we in the twilight zone?

    Reply

    • Posted by stephen Bain on January 24, 2016 at 5:17 am

      why may I ask,from my way of thinking what are they to do.take some street drugs,i new Zealand the gp as a rule don’t know a lot about drugs so is naloxone going to stop pain.???? na, well iv been on methadone for 30 years but it does nil for pain.

      Reply

  3. The nature of addictive disorders, and the shame, manipulation and secrecy that surrounds it, necessitates consistent and thorough communication between all healthcare providers, working for that patient’s health needs. I agree with Dr. Burson, any SUDS patient requires that the facility remain in constant contact with any other healthcare provider. Those of us who are chemically dependent, do not always tell the truth or work to our own health advantage. We are masters of manipulating the system, given the chance. The system is responsible for a seamless communication so that this tendency for the disease to decide, does not lead to more unnecessary deaths. Dead people don’t ever find recovery.

    Reply

  4. Posted by Andrew Angelos on January 25, 2016 at 1:40 am

    Medical record sharing should be paramount. Between doctors anyway. I have a personal friend that has overdosed and had to be resuscitated three times in the last two years while in a suboxone program. The doctor either never knew or if he did didn’t change anything or say anything. On one hand is say why is this person in a program. Kick him out so someone who wants to try a program can get in. On the other hand isn’t he way better off on suboxone and doing other stuff only some of the time instead of always. I personally believe the most vournerable time Is when someone has been out for a few days and then gets a script. Whatever the dosage or amount. Because the mind of an addict ( at least my mind does ) tells us to th and get high cause it’s been a few days.

    Reply

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