Author: 
Roneet Lev, MD FACEP

Road Map to Prevention

As an emergency physician, it is my job to keep people alive. If someone dies during my shift, it's considered a failure. I never get used to it. Looking though medical examiner’s reports, it was page after page and prescription after prescription of failures, and those are the death diaries.  By studying why people died from an accidental prescription overdose we can learn about the red flags and create prevention strategies. San Diego death diary research looked at every such death and traced every prescription, pill, physician, and pharmacy. The data is a road map for prevention.

But first, you must understand the reason for the opioid epidemic.  In 1999-2000 several prescribing “speed bumps” were removed from the medical community and regulations were put in place that pushed physicians to prescribe opioids. Add to that conflicting education about prescribing, and physicians became another victim of the epidemic. We need to place back some “speed bumps.”

It's not just opioids.  The death diaries teach us that most people die of a cocktail of medications. Opioids and benzodiazepines together are deadly. Mixing Benadryl or sleeping pills with opioids is dangerous. Central nervous system depressants are addictive, so even at appropriate opioid dosing, drugs can be fatal. Benzodiazepines are the new opioids. Approximately six percent of U.S. adults use benzodiazepines and there has been a five-fold increase in deaths between 2001 and 2014. 

The population at-risk are the chronic users – 69 percent of deaths were in people who were on the same exact medication for three consecutive months. Doctor shoppers are not the majority of overdoses. They received more than 50 percent of all the prescriptions, but were only 28 percent of deaths.

The 2016 data is 116 deaths a day from opioids. We have a ways to go.

We can curtail the medical supply of the epidemic in just a few years if we drastically change prescribing practices and reimburse patients for non-addictive alternatives for pain management. This will help to stop a new generation of Americans from getting hooked on opioids in the first place. We know what the problem medications are – we know the problem combinations. We need to go back to prevention basics and reduce access and availability through changes in prescribing and reimbursement practices, as well as educate the public about the huge risks involved in the misuse of opioid drugs.

Do people die from marijuana? Yes. In the Emergency Department we experienced an 830 percent increase in marijuana poisonings in the past 10 years. The reason people think no one dies from marijuana is that medical examiners and coroners are not reporting this data. The complex pharmacokinetics of marijuana is an excuse not to consider THC in deaths.  The San Diego Medical Examiner's office found over 400 deaths a year in people who tested positive for THC - a one-year old baby, a 15-year-old, suicides, homicides, drugged drivers, and many cardiac deaths. Deaths from all drugs went up 56 percent in the past 10 years and THC positive deaths went up 64 percent. We cannot afford to ignore this correlation.

Here are a few ideas to explore:

  • Limit prescriptions to safe dosages and combinations
  • Consider alternatives to opioids for chronic pain
  • Stop heavy financial incentives for high patient satisfaction scores - this fuels the epidemic and hospitals may chose economics over safe prescribing
  • Predict and prevent deaths by using analytics and restricting access for people at risk
  • Your privacy should not kill you - MAT programs should enter data to PDMP
  • Have a naloxone kit near every AED machine
  • Make naloxone over-the-counter
  • Mandate medical examiner and coroners to report THC positive cases
  • Create a dashboard of marijuana deaths, similar to opioids
  • Connect all emergency department with shared care plans for complex patients
  • Medical community and law enforcement collaboration with overdose alerts - similar to the flu alerts

Dr. Lev will be presenting at this year’s Mid-Year Training Institute, Death Diaries - Prescription and Marijuana, on Tuesday morning in the Sun Ballroom A. This presentation is for all audiences, particularly for coalitions looking to partner with the medical community.