The manner in which EMPs write prescriptions can have direct impact on medication diversion. In the ED, prescriptions are more commonly written for opioid pain medications than for sedatives or stimulants. While addressing pain adequately is important, it is often appropriate to prescribe lower-potency opioids or even nonnarcotic pain relievers. EMPs should limit the total number of pills specified in proportion to the immediate diagnosis, and refills should not be provided—if for no other reason than to encourage timely follow-up.
Delayed-release opioids, because they lack the protective measures built into delayed-release stimulants, should be avoided in the ED for treatment of acute pain; research is under way to develop oxycodone in viscous gel form that is immune to injection.22 In other efforts, opioids are being combined with the antagonist naloxone to blunt the opioids' immediate euphoric effects.20 Writing out the number of pills on hand-written prescriptions and using watermark paper for computer-generated prescriptions can also diminish forgery and diversion.
Patient Education
Educating patients—especially teenagers—about the potential for drug tolerance, dependence, and abuse plays an integral role in combating this problem. With most diverted prescription psychotherapeutic medications coming from family or friends, convincing parents to safeguard prescriptions in the household is critical. A huge discrepancy exists between what parents perceive about their children's prescription drug use and what actually occurs. Although 21% of teenagers admit to using prescription pain medications for their psychotherapeutic effects, only 1% of parents consider it "extremely likely" or "very likely" that their child has done so.23
When parents actively address this important issue—teaching their children about the dangers of drug and prescription drug abuse—these practices can be reduced by nearly half.23 Impressing on parents the importance of their role in preventing prescription drug abuse may be the single most important way for EMPs to further the cause.
Resources for Concerned Clinicians
The DEA and the FDA rely on a complex set of databases to monitor prescription drug abuse. The Drug Abuse Warning Network (DAWN)24 and the NSDUH,8 administered by the Department of Health and Human Services, are two examples. DAWN is a public health surveillance system that monitors drug-related visits to hospital EDs through chart review and drug-related deaths investigated by medical examiners and coroners. By joining DAWN, EDs can gain access to real-time data and receive payments to participate in data collection.24 NSDUH gathers data by administering in-home, face-to-face questionnaires to a representative sample of the population. Both programs publish reports on the Internet and make findings available to the general public.8,24
Also in the arena of prescription drug abuse monitoring is an industry-initiated database known as RADARS (Researched Abuse, Diversion and Addiction-Related Surveillance), developed by Purdue Pharma to address diversion and abuse of OxyContin®. RADARS' goal is to develop proactive, timely, geographically sensitive methods to detect abuse and diversion of OxyContin and other scheduled prescription medications.25 This program acquires high-quality data from drug abuse experts, law enforcement agencies, and regional Poison Control Centers, covering more than 80% of the nation's zip codes. Regionally specific risk-minimization strategies are RADARS' next goal.
Conclusion
Clinicians who provide emergency care are in a position to slow, or even reverse, the escalating misuse of prescription medications by teenage patients. Primary care providers, too, are called on to keep abreast of emerging reports on this trend, to reconsider how they write prescriptions for psychotherapeutic agents, and to be vigilant to the signs of abuse in their adolescent patients.