Pubdate: Sun, 02 Jul 2017
Source: Baltimore Sun (MD)
Copyright: 2017 The Baltimore Sun Company
Author: David Myles


Even for seasoned health care workers, it can be unnerving to hear
"emergency in the parking lot" over the loudspeaker. There, we found
an 18-year-old man lying lifeless on the asphalt and not breathing.
Before I could utter the words, an astute nurse immediately ordered
that the patient be given Naloxone as she correctly recognized that
this patient was suffering from an opioid overdose. Soon, the patient
began to breathe spontaneously, effectively coming back to life.

This story could be used to celebrate the marvels of medicine and the
skill of our health care workforce. However, this story does not have
a happy ending.

Shortly after waking from his opioid-induced coma and realizing where
he was, the man literally ran out of the emergency department. While I
do not know for certain what prompted him to abruptly leave against
medical advice, I have a suspicion. He admitted that he did not have
insurance and did not want his parents to have to cover the cost of
the visit; he could not qualify under his parents' plan because he was
not in enrolled in school and had moved out of his parents' home.

This unfortunate situation is a common occurrence where I work in
rural Maryland, and it is a shameful reminder of the inadequacy of
current efforts to reform our country's system of health care. Health
insurance that is unaffordable does little to address access to care
and does nothing to address the skyrocketing price of prescription
medications. The price of Naloxone (the medication that saved my
patient's life) has increased by 500 percent over the past two years.
Fortunately for residents in Maryland, Vermont and California,
legislators in those states passed laws to address prescription
medication price increases. However, a federal approach is necessary
to ensure all Americans can afford life-saving medications.

Even as a pediatrician, I share some of the blame for the drug abuse
epidemic that is now the leading cause of death for people under 50
years old. A significant percentage of those who are now addicted to
opioids obtained their first dose from a physician. This is a function
of how we are trained. I recently completed my residency training in
pediatrics here in Baltimore, where I was often taught -- erroneously
- -- that children's pain is undermanaged. To combat this
misinformation, Massachusetts now mandates that all physicians
applying for or renewing a medical license must complete at least
three hours of training on evidence-based opioid prescribing practices.

Hospitals trying to increase their patient satisfaction scores are
also partly to blame. That a patient's pain level is included as a
vital sign (which traditionally includes temperature, pulse, blood
pressure, respiratory rate and blood oxygenation) implies that it must
be expeditiously addressed and managed. As a physician, I am
instructed to treat a patient's pain within a certain time period.
Such metrics can set up perverse incentives to over treat certain
types of pain. These criteria should be re-examined in light of the
current epidemic.

I and my physician colleagues should do a better job of managing
expectations of the level of pain that a patient may have given their
specific medical condition. We can also give patients and families a
variety of options. This could include initially prescribing
non-narcotic pain medications and, if pain is still not optimally
managed, then consider prescribing a narcotic. Massachusetts has
passed legislation limiting the number of days that opioids can be
prescribed in some instances. Maryland tried to pass similar

Although my 18-year-old patient lived through his most recent trip to
the emergency department, there is no guarantee that he will be as
fortunate the next time. Prescribing opioids responsibly could at
least help ensure that there are fewer people in his position.

David Myles is a pediatrician, fellow of the American Academy of
Pediatrics (AAP) and a member of AAP's Committee on State Government
Affairs; his email is  ---
MAP posted-by: Matt