Misuse, Abuse, and Diversion

Many physicians are concerned about prescribing high doses of long-term opiates because of the potential for misuse, abuse, and diversion. After talking to many patients, I think opiates are a little different than many other medications because patients think they can manage their dose without physician input. If a patient takes her blood pressure at home and it's elevated, she isn't likely to take an additional lisinopril or metoprolol. But if a patient has an exacerbation of his back pain, he might pop an extra oxycodone to tide him through. Misuse of drugs like this can lead to early refills, running out of pills, and physician distress.

Why do we get distressed? Because worse than misuse - which can hopefully be cleared up with better education and communication between the physician and patient - we worry about abuse and diversion. Because opiates have a euphoric effect, patients can take them for non-medical reasons, for the "high." This gives these medications a street value, and some people divert drugs by selling medications intended only for themselves. Not only can abuse and diversion be medically dangerous and physically harmful, but it's illegal. Worry about prescription drug abuse erodes patient-doctor trust. It piques the curiosity of the DEA and contributes to a massive societal problem. 

There are tools we have to flag aberrant behaviors. We use urine drug screens and check to see what prescriptions are filled, who wrote them, where they are filled, how many tablets were given, and how many were used. The majority of patients are reliable, using their medications appropriately, and pose no problems. But there's always the fear that one patient will get us in trouble, and with our licenses on the line, it's no wonder that chronic opiate use scares us. Furthermore, recent epidemiology studies show that as opiate prescription rises, opiate related emergency visits and deaths continue to rise. This is a big problem with health care in the U.S.