By John Palmer
A new report from medical liability insurer Coverys takes a close look at the growing epidemic of opioid addictions and the high-severity injuries, including death, that the problem causes every year.
In addition to the thousands of deaths each year impacting patients, friends, and family members, the problem has been a staggering issue for first responders and hospital personnel as they struggle to prevent and contain the epidemic—even as the incidence of opioid drug diversion in hospitals continues to rise.
Healthcare providers in U.S. hospitals bear the brunt of the epidemic as they deal with the medical consequences of opioid addiction. From 1999 to 2017, Coverys says, more than 700,000 people died as a result of the opioid epidemic and the number of opioid-related overdoses grew sixfold.
“The opioid epidemic in the United States has become pervasive throughout our communities and addressing it has proven to be very challenging,” the report concludes.
That doesn’t even begin to cover the costs of the epidemic. According to 2019 statistics from the National Institute on Drug Abuse, the total cost of prescription opioid misuse in the United States is estimated to be more than $78 billion per year.
Some of the major findings in the report included the following:
- Half of all opioid-related cases examined in the report involved a high-severity patient injury, including death
- 41% of claims cited errors in the screening and prescribing stage of the pain management processes, followed by 30% of claims citing errors in the monitoring and management stage
- Of those claims citing errors in the screening and prescribing stage, more than 50% of the patients involved had either psychiatric or substance abuse history
- The top opioid drugs involved in these events were fentanyl (22%), followed by Dilaudid® (19%), Percocet® (13%), and morphine (13%)
- Opioids were often prescribed to patients who already have complex medical regimens; the top drugs prescribed with opioids were anti-anxiety (29%), antidepressants (24%), muscle relaxants (13%), and NSAID medications (13%)
The study, titled “Red Signal Report: Opioids,” was released in November 2019 and is the latest in the series of reports that explores the increased risk and liability brought on by several patient safety issues in healthcare, while offering suggestions on how to improve.
This is the fifth report in the company’s “Dose of Insight” series, which has previously explored medication error, errors in the ED, diagnostic accuracy, and obstetrics.
The report analyzes five years of closed opioid-related malpractice claims from 165 patient events to identify the major risk factors, warning signs, and safety vulnerabilities within the pain management process. Additionally, it addresses evidence-based risk recommendations and practice changes offered to improve patient safety and reduce malpractice exposure to opioid-prescribing clinicians.
“A dramatic increase in opioid use over the past several decades has led to an epidemic of addiction and high-severity injuries,” according to a Coverys press release. “This growing tragedy is taking thousands of lives each year and is impacting patients, family members, and clinicians. This latest report focuses on the specific steps that relate to active pain management and associated risks that can contribute to opioid dependence and persistent use.”
The report is co-authored by Ann Burke, senior director of risk management for Coverys; Sharon Gilmore, senior risk specialist; Ann Lambrecht, senior risk specialist; Maryann Small, director of data governance & business analytics; and Anthony Zheng, data analyst.
“Although many patients are able to use opioids without any issues, a national epidemic of opioid misuse is taking place and having a very significant impact on the lives of patients,” the report concludes. “The potential to become addicted—from either short-term or long-term use—is very real and can be attributed to a host of factors.”
One of the biggest factors Coverys found leading to problems with opioids involved the screening and prescribing process. More than half of the opioid events studied found that prescription of opioids didn’t start with a thorough history of the patient’s history with addiction or behavioral issues.
“This is the most critical step in the process and where—if close attention is not paid—overprescribing practices can sometimes begin,” the report states. “Coverys data show that over 50% of the patients involved in these events had either a psychiatric or substance abuse history. It is well established that the relationship between mental health disorders and opioid addiction is bi-directional. Additionally, chronic use of opioids has been linked to an increased risk for depression.”
While opioid addiction is often prejudicially blamed on the patient who decides to keep going with the medication, the reality is that physicians often make errors in prescribing, leading to accidental deaths.
For example, one case that Coverys followed included a patient who saw a new physician for an office visit while taking oxycodone; unaware of the existing prescription, the physician prescribed hydrocodone, and the patient died two weeks later. Another case involved a chronic pain patient who was given a fentanyl patch for 50 micrograms (mcg), which was increased to 200 mcg over four months. That increase was too high, and the patient was found dead 15 days later.
Among some of the prescribing recommendations Coverys offers are the following:
- Educate patients about using opioids to manage pain, particularly with regard to the risks of addiction. Carefully describe the risks and benefits. Provide information on the safe storage and disposal of opioid medications.
- Assess the risk of pregnancy for all women of childbearing age. Avoid prescribing opioids to pregnant women.
- Avoid concurrently prescribing opioids and benzodiazepines or other sedative hypnotic medications. Exercise extreme caution when prescribing opioids to patients who are already using benzodiazepines or other sedative hypnotic medications.
- Exercise extreme caution when prescribing opioids to patients who have comorbid conditions that may increase their risk for an adverse outcome.
- Consider conducting a patient urine or blood screen that is specific for opioids and illicit drugs prior to prescribing opioids.
The second largest factor leading to problems with opioids had to do with monitoring and management of patients who are on long-term opioid therapy, as well as the tapering and discontinuance process, to make sure patients don’t continue to rely on opioids longer than necessary. The Coverys study found that 30% of patients suffered issues from lack of proper management.
“This step is essential to making sure that patients do not ‘fall through the cracks’ of a busy clinic, engage in follow-up visits, and are regularly assessed to determine that the opioid therapy is still effective,” the report concludes. “These programs help to identify patients who are potentially abusing opioids, as well as physicians who are overprescribing them.”
Coverys recommends using CDC guidelines to help adopt protocols for monitoring and managing patients given opioids for chronic pain, including the following:
- Evaluate the effectiveness of opioid treatment within one to four weeks of initiating the therapy
- Consider obtaining a pain management consult at a specified point of time in the opioid therapy
- Consider conducting a patient urine or blood screen that is specific for opioids and illicit drugs at each patient visit and, perhaps on a random basis, prior to continuing prescribing opioids
- Perform random pill or patch counts at each patient visit
- Document the rationale for increasing dosages to 50 mg/day or greater
- Avoid increasing dosages to 90 mg/day or more unless carefully justified
- Monitor patients for opioid-related adverse outcomes
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.