En español | In May 2008, Mable Mosley, then 68, arrived in the emergency room of west Florida's Brandon Region al Hospital, complaining of neck and shoulder pain. Her husband, Alvie, a retired construction worker, stayed by his wife's side as a doctor examined her.
Illustration by Alex Eben Meyer
On a scale of 0 to 10, Mable's pain reached a level 8, so the ER doctor prescribed three pain medications: Toradol, morphine sulfate, and Dilaudid. Mable's pain dropped to a 1, but later that day she was admitted to the hospital by her primary care physician, who ordered a 50-microgram Duragesic fentanyl patch, a powerful, extended-release narcotic absorbed through the skin. This was followed the next day by a higher, 75-microgram fentanyl patch, and then the next day by a 100-microgram patch and Neurontin, a nonnarcotic drug used to treat pain caused by nerve injury. "I'm not saying she wasn't hurting real bad. She was," recalls Alvie. "But after getting the first medications in the ER, she felt much better."
At midnight on her third day in the hospital, Mable Mosley stopped breathing; she was resuscitated but died several days later. To a grief-stricken Alvie, the cause of his wife's death seemed obvious: An overdose of pain medications killed her. A year and a half after her death, he filed a wrongful-death lawsuit against the hospital, the pharmacists, and the doctors who had treated her.
From 1999 through 2007, the number of unintentional overdose deaths from prescription opioid painkillers — such as oxycodone, hydrocodone, methadone, and the fentanyl patch — more than tripled, according to the Centers for Disease Control and Prevention. In fact, these painkillers have now surpassed heroin and cocaine as the leading cause of fatal overdoses.
That's not to say every prescription painkiller is bad; quite the opposite. "When prescribed appropriately and taken as directed, these drugs ease great suffering in patients with other wise severe chronic and postoperative pain," says Robert J. Friedman, M.D., a neurologist and pain specialist at the Palm Beach–based Headache & Pain Center. But take too many painkillers, or combine them with potent sedatives — as actor Heath Ledger did in 2008 — and they can be fatal.
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.
So how do you manage your pain, while still staying safe?
Before leaving the ER, hospital, or doctor's office, ask questions.
What is the name of the medication? How much should I take (dosage and strength)? Is it a long- or short-acting drug? (Long-acting painkillers — including the fentanyl patch, methadone, and morphine sulfate — are typically prescribed for patients who require around-the-clock pain relief.)
Take the medication only as prescribed.
"What often happens is that when a pain medicine isn't working fast enough, people will take another pill," says Vaida. Or they forget they've already taken a pill and take another, or they put on a second patch, unaware that the first one is still stuck somewhere on their body.
Be cautious when first taking a new medication.
Many fatal overdoses happen when people have just started taking pain medication, when their bodies aren't used to it.
Ask your pharmacist about the risk of drug interactions.
Methadone can be fatal when used with certain antidepressants, antibiotics, cardiac medicines, and alcohol. Doctors also advise getting all of your medications from the same pharmacy, which can track possible drug interactions.
Never take someone else's painkillers.
A dose prescribed for one person can be fatal to another, particularly if that second person is taking other medications.
Keep a pain/medication diary.
Write down when you take your medicine, how much you take, and what your pain levels are. This will help you and your doctor track how well your medications are working.
In 2010, Alvie Mosley settled his lawsuit against the doctors who treated his wife, leaving the case against the hospital and pharmacists pending. "Mable didn't need all that medication," Alvie says. "There's just no excuse for it."
You may also like: How to create a personal medication record.
Dosage source: modified from FDA prescribing information.