I am going to begin this column with a personal story.
My grandson needed to have his wisdom teeth extracted. Gunnar delayed this for around 3 years, and neither he nor I really like surgical procedures. Finally, it was time to have his wisdom teeth removed. We were referred by our dentist to an oral surgeon that I truly consider "top notch" in our geographic area. Gunnar made the decision to have his wisdom teeth extraction with a local anesthetic. I took him to the oral surgeon and waited for him while he had the procedure done. All four of his wisdom teeth were extracted in about 45 minutes. When we had first entered the practice that morning, the nurse had requested information on the pharmacy that we used. I had provided her this information. When the procedure was completed, I was allowed back to see Gunnar and to also review his discharge instructions. I told the nurse that I guess I will have to put ice packs on his face to prevent and reduce swelling. She stated that I would not have to do that as the surgeon did not have to drill into the jaw bone. She stated that his wisdom teeth were down far enough that extraction without drilling was done. Swelling only results if drilling into the jaw bone occurs. This was really great news. She further advised that two prescriptions had been called into our pharmacy and that we should retrieve these prescriptions on our way home.
I stopped by the pharmacy and picked up the two prescriptions as directed. One was for Zithromax, and the other was for Vicodin. Gunnar questioned as to what the prescriptions were. I advised him that he would be taking the antibiotic and that he would try Motrin for pain before taking any Vicodin and that I would keep the Vicodin and he would have to see me if he needed a Vicodin tablet. During the next week, Gunnar only required three doses of Motrin for pain relief. He never needed a Vicodin tablet.
I pondered why would Vicodin be prescribed in the first place? The only plausible reason that I could think of was that the oral surgeon did not want to be bothered to prescribe something if Motrin did not control the pain. I then thought to myself, "I wonder if patients are getting dependent on Vicodin by one prescription of 15 tablets?"
A few months ago, I was doing a history and physical examination on a 24-year-old patient being admitted for opiate dependency to the residential treatment center that I practice at. I always question my patients about what led to their chemical dependency. This patient told me that Vicodin, when prescribed for extraction of his wisdom teeth, led to his problem with opiates and now heroin. I asked him where he resided, and it was in the same geographic area that I reside in. My next question is, who prescribed the Vicodin when you had your wisdom teeth extracted? His response was the same oral surgeon that had prescribed my grandsons'. I thought to myself that this provider is getting patients dependent on opiates without even realizing it.
When one really contemplates this entire scenario, it is certainly understandable as to the nature and severity of the prescription opioid epidemic that exists in ours and other countries.
Secondary to this epidemic, New Jersey (the Garden State) has had 21 pieces of legislation in various stages of progression to address, curtail, and prevent this epidemic.
In July 2015, Governor Chris Christie, governor of New Jersey, signed a bill (New Jersey Legislature, 2014) that expands the scope and strictness of the state's prescription monitoring program (PMP).
The bill also revises current provisions that delineate the types of access to the PMP that are made available to various parties seeking information. Specifically, the bill would require the division to automatically register pharmacists and practitioners to participate in the prescription monitoring program as part of their registration to dispense controlled angerous substances. The division must provide online access to prescription monitoring information to practitioners and pharmacists for purposes of providing health care to their patients or verifying information with respect to a patient or a prescriber. (Bill S-1998. Retrieved from http://www.njleg.state.nj.us/2014/Bills/S2000/1998_I1.HTM)
As noted above, the bill requires by law that all licensed practitioners and pharmacists register for access to the state's PMP. This is done when such providers initially register or renew their Controlled Dangerous Substance license in New Jersey.
The PMP was designed to be used to track patients who are abusing their prescriptions by seeking drugs from multiple doctors and practitioners. It also requires licensed practitioners to check the PMP when patients return for a second refill on medication. Senator Joseph Vitale (D-Middlesex County) was the primary sponsor of this piece of legislation.
It is practice in New Jersey that, when a patient requires a second refill on Schedule II medications, they must come in for an in-person office visit. Aligning the PMP with that practice makes total sense as the program needs to be accessed before prescribing the second prescription.
As prescription opioids are oftentimes the gateway to heroin use, this bill does not address that crisis. According to the CDC (2015), it should be noted that New Jersey ranks 45th in the nation in terms of opioid prescriptions written per person. Also of interest is that the state's heroin overdose death rate is more than triple the national average. Please refer to the graph above:
This bill is one more piece of legislation in New Jersey implemented in an effort to reduce the opioid epidemic and the death rate from opioids in the Garden State.
The take-home message to me, as a nurse practitioner, is to be extremely cautious when prescribing opioids for pain management. I hope that that is the message for anyone who prescribes opioids for pain management. I am probably preaching to the choir as the vast majority of individuals reading this article most likely work in the field of addictions and prescribe opioids very judiciously.
This specific piece of legislation in New Jersey has been presented as New Jersey serves as a microcosm of what is occurring in most states and their efforts to combat this growing epidemic. One needs to assess their own state and certainly support legislative efforts to control this growing epidemic.
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