Indeed, determining proper dosing, especially when combining short- and long-acting painkillers, is at the heart of the problem. It can take many hours for long-acting narcotics like methadone and the fentanyl patch to be broken down by the body. In Mable Mosley's case, the doctor prescribed the second and third, higher-dose fentanyl patches while other opioid drugs were still active in her system, and before the first and second patches had run their full 72-hour course.
"It's like shooting an ant with an elephant gun," claimed Paul Doering, a University of Florida pharmacy professor who was retained as an expert by Alvie Mosley's attorney, Patrick Dekle. (The hospital declined to comment.) The rise in overprescribing coincides with a fundamental shift in how health care practitioners think about pain.
"The pendulum has swung now to where there's a push nationally that patients should be pain-free," says Allen Vaida, a pharmacist and executive vice president of the Institute for Safe Medication Practices. "And that's a good thing, but it has also led to a situation where patients go to the hospital for a procedure, or to the ER or to a doctor's office, and they're put on unnecessarily high doses of pain medications."
Patients then might go home with one or more prescriptions for painkillers, not fully realizing what they're taking. "They seem okay when they leave," says Vaida, "but when they get home, they may take another oral tablet and go to bed and not wake up."
The Food and Drug Administration's approval of newer and more concentrated pain medications has only compounded the problem. "We've seen a lot of overdoses with the transdermal fentanyl patch," says Vaida. "They're very potent [80 times stronger than morphine, according to the Drug Enforcement Administration], and they're not being prescribed for the correct patients."
The fentanyl patch has been recalled multiple times for product defects since its 1996 debut. And in 2005 the FDA gave it a black-box warning label — the strictest kind — noting the risk of accidental fatal overdose.
Still, the patches are safe, says the FDA, when prescribed to the proper patients — those who have been taking daily opioid medications for chronic pain. But not for patients like Mable Mosley, who are not taking opioids, or for those experiencing acute pain following surgery, or for headache sufferers, or for those with mild or occasional pain, as numerous reports to the FDA have indicated.