Ability to Drive a Critical Concern in Opiate Prescribing

PHOENIX, Arizona — With substantial focus in opiate prescribing on balancing pain management while preventing addiction or abuse, attention is lacking in another critical area that can put patients and the public at risk for harm, and clinicians at risk for liability: patients driving under the influence of medications.

Gerald M. Aronoff, MD, discussed the issue during a keynote talk on the subject presented here at the American Academy of Pain Medicine (AAPM) 30th Annual Meeting.

"The biggest deficiency that I have seen as I review records involves this issue of not monitoring safety in terms of patients driving or returning to work," said Dr. Aronoff, who is the medical director of Carolina Pain Associates, Charlotte, North Carolina, and a past president of the AAPM.

"Driving is a complex task and when we write patients prescriptions for these drugs we need to document in our charts the assessment of risks before we send them out on the highway."

A recent study underscored the increasing gravity of the problem, showing a troubling increase in traffic safety risks associated with the use of an array of medications, including antipsychotics, anxiolytics, hypnotics, antidepressants, and sedatives, Dr. Aronoff noted.

The study showed the risk was particularly high with the use of benzodiazepines, which increased the risk for crashes by as much as 50%.

"Over the last decade we have seen an increase in accidents when opiates were involved, and the ones I am most concerned about are benzodiazepines," Dr. Aronoff said.

"[Clinicians] need to recognize that even if they are not the ones writing the benzodiazepine prescription, the patient may be getting these drugs from somewhere else. This can put not only the patient, but you, the prescriber, at risk."

The concerns of liability are being further exacerbated by the likely increase in drivers under the influence of marijuana as recreational use laws loosen in places such as Washington and Colorado.

"I am concerned about this because, let's say a patient you have prescribed opioids or some other medication for is involved in a deadly accident and that patient is charged with vehicular homicide," he said.

"The authorities do a urine drug screen and not only do they find THC [tetrahydrocannabinol] or cocaine or something, but they also detect the drugs you, the clinician, have prescribed. What they may say is, 'How do we know it was the marijuana that caused the impairment and not the drug?' That's just not an acceptable risk for me."

One way to avoid the risk is to simply refuse to write a prescription if the patient tests positive for marijuana use, Dr. Aronoff suggested.

"I will not risk my medical license because someone wants to use recreational marijuana," he said.

The decision can be a tough one when the marijuana use is for medical purposes — specifically for pain — but Dr. Aronoff suggested strongly considering the potential driving consequences even in those situations.

"With medical marijuana, I urge [clinicians] to rethink the whole issue of where they stand on medicinal or recreational marijuana — not the issue of whether it helps cancer or noncancer pain. We know it does — that's not the issue. The issue is the potential for people getting injured in motor vehicle accidents."

Physicians further have the responsibility to monitor the patient's alertness, document the measures in the medical chart in detail, and inform the local Department of Motor Vehicles if they feel a patient constitutes an impaired driver, Dr. Aronoff said. He noted that in prescribing opiates, he will even take proactive measures to assess a patient's motor responses.

"If that patient is out on the road and someone in front of them slams on their brakes, you want to make sure the patient is alert enough to be able to react quickly and stop in time," he said.

"So in addition to taking a mental status evaluation, what I will do is toss a light, soft ball at them when they are sitting across the desk and not expecting it, and in the event that they don't respond or the ball winds up hitting them in the head or something, I will dictate that the patient is advised to leave their car at the hospital and have someone take them home."

"I may change medications or decrease their dose, but I don't do nothing because I think [the test] demonstrates that someone may be at an increased risk."

Physicians should keep in mind that patients at particular risk may not be those who are receiving stable doses of medications but those who take them only intermittently.

"That's when you're more likely to see some psychomotor impairment, compared to patients taking sustained acting drugs on a fixed schedule," he noted.

Classes of medications to use particular caution with include sedating tricyclic antidepressants, sedating antihistamines and muscle relaxers, and particularly anxiolytics.

"Caution should especially be used with long-acting benzodiazepines, more than the short-acting ones, and in combination with other drugs," Dr. Aronoff said. "These are often implicated not only in driving and work injuries but in wrongful death cases."

Liability Extensive

According to Joshua B. Murphy, JD, the liability physicians can face in relation to prescribing is indeed extensive, and can even reach to a third party harmed in an incident.

"A physician can be held liable for injuries caused by the impairing effects of medications prescribed by the physician, including marijuana," said Murphy, associate chief legal officer with the Mayo Clinic in Rochester, Minnesota.

"The physician may be liable to the patient or to a third party if the patient is in a car accident caused by the impairing effects of the medication prescribed by the physician," he told Medscape Medical News.

"The physician may be liable if he/she prescribed a medication or combination of medications that was inappropriate for the patient, and even if the medications were appropriate for the patient, the physician may be liable if he/she did not appropriately warn the patient of the side effects and risks associated with the medication."

And with such high stakes, any extra efforts or time in monitoring and documenting patient mental status with opioid prescribing are worthwhile investments, Dr. Aronoff emphasized.

"We need to heavily monitor these potent drugs we are prescribing," he said.

"We can use them medicinally, but their use can be a double-edged sword. I urge physicians to aggressively and proactively treat pain, but to do it cautiously with recognition of the unintended consequences of driving."

Dr. Aronoff has disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 30th Annual Meeting. Presented March 8, 2014.

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Cite this: Ability to Drive a Critical Concern in Opiate Prescribing - Medscape - Mar 17, 2014.