A 55-year-old male calls an ambulance complaining of severe low back pain. He says he tried to transport himself to the hospital, but his pain is so severe he cannot stand, let alone drive. The patient reports the back pain is from a car accident several years ago. You examine him and find no visible evidence of injury; CSM is intact. The patient has no other medical problems, but he is allergic to ibuprofen and Toradol. He rates his pain a 10, sharp and constant, and is unable to find a position of comfort. He has already tried ice, heat packs, stretching. He says, "What I really need is some morphine. Can you give me something for the pain?"
Pain is the most common patient complaint, and patients' desire for pain relief often supercedes their desire to identify and resolve the cause of pain. Drug-seeking most commonly involves pain medications. Hydrocodone, a Schedule Two analgesic that is widely prescribed for the treatment of pain, is the most widely abused prescription medication in the United States. ED visits for hydrocodone abuse have increased 500% since 1990.1
Research shows that pain is undertreated in all healthcare settings, including prehospital care. Patients are the best judge of their own pain. Pain control, not the cause of the pain, is their primary concern. The pain management paradox is the caregiver's desire to relieve pain and comfort the patient weighed against the fear of being fooled by a drug-seeker, creating addiction or being investigated for improper use of pain medications.1 The opening case study included many assessment clues that may have caused you to question the patient's motives.
According to the DEA, diversion of prescription drugs is a significant drug enforcement problem. It includes physicians who sell prescriptions to drug dealers or abusers; pharmacists who falsify records and subsequently sell the drugs; employees who steal from inventory; prescription forgers; and individuals who commit armed robbery of pharmacies and drug distributors.2
In the prehospital setting, it is difficult to determine if the patient is tolerant, dependent or addicted to a controlled prescription medication. Being aware of the differences can help resolve the pain paradox.3
As an emergency responder, you are well aware of the pervasive abuse of drugs and alcohol. Many EMS calls are caused by drug, alcohol or tobacco use. Impaired drivers cause motor vehicle accidents, intoxicated spouses injure family members, and a host of medical problems are secondary to drug, alcohol and tobacco abuse. The most commonly abused prescription drugs are opioid analgesics, sedative-hypnotics and stimulants.1 Fortunately, most patients who use these medications use them as directed by their prescribing physician.1
The Controlled Substances Act of 1970 is federal legislation that strictly controls drugs based on their potential for abuse. Schedule One drugs have the highest potential for abuse.4
Other commonly abused prescription medications include benzodiazepines like Valium, stimulants, barbiturates and other sedative-hypnotic agents. Only ALS-level providers carry and administer a limited number of controlled prescription medications.1
Controlled prescription medications that are abused share several characteristics:1
- Psychoactive effects that create a high, which gives them street value
- Habit-forming, which creates a state of dependence when taken for a long enough time
- Predictable dose and concentration
- Cost less and are more easily obtained than other addictive substances.
Prescription drugs that produce a high are more reinforcing to the user if the drug:1,5
- Has rapid onset of action
- Has high potency
- Has brief duration of action
- Has high purity
- Is water-soluble for IV use or has high volatility to vaporize for smoking.
How many medications do you carry that meet these criteria?