As there are many more states and providers across the country focusing on the epidemic of opioid abuse and addiction concerns, there can be some utility in recognizing patterns that exist within your own zip code. “Each community chooses its opioid.  Within a 60-mile radius of where I have worked, patients have told me that ‘only idiots’ abuse any opioid other than ‘fill in the blank.’  Heroin, oxycodone, meperidine, hydromorphone, fentanyl, dextromethorphan- they all have been abused, but usually only one is abused in any given community. This is primarily due to control of the drug scene by one gang or another.  If opioids do have to be prescribed, limit dosing to three to four days maximum because follow-up for persistent pain is essential.”  ACEP Now, Feb 2015, Vol.34, Number 2, p. 7.  This is a fairly consistent experience for many providers, particularly so in emergency departments.  However, there is some variability related to what might be considered controlling factors for the supply of the drugs in any given area, largely due to the type of setting, whether inner city, suburban, small community or rural hospitals. Interestingly, many providers are unaware of how truly savvy many patients are when their motivation is to obtain prescriptions for pain medication.

Over the years I have realized that many patients have a far deeper knowledge of the providers in my catchment area than I do.  They have come to learn provider’s personality traits, practice patterns and habits to the extent that contrived relationships are established.  These relationships perpetuate atypical prescribing patterns of controlled substances. This crosses over into several different practice environments, from EDs to PCPs, psychiatrists, dentists and pain centers, generally within the same zip code or within neighboring towns.  As a result, one of the easiest and most realistic ways to consistently control the aberration in prescribing and dispensing medications of abuse is not governed or respected with uniformity.  “Doctors in some states seem to wield a freer hand issuing prescriptions for powerful narcotic medications, leading to wide variations in narcotic drug use among states.”  HealthDay, July 1, 2014, Prescriptions for Powerful Painkillers Vary Widely Among States: CDC.  “The bottom line is we’re not seeing consistent, effective, appropriate prescribing of painkillers across the nation, and this is a problem because of the deaths that result.”  Dr. Tom Frieden, director of the CDC, as cited in HealthDay, July 1, 2014, Prescriptions for Powerful Painkillers Vary Widely Among States: CDC

Having recurrent themes of patients overdosing on prescribed medications who return sometimes within days or weeks of their overdose with yet another overdose due to having had their prescriptions refilled with one to three month supplies of controlled meds is absurd. Concerted efforts involving prescribers must be a shared vision and mission.  This is highly effective in reducing unnecessary deaths and addiction patterns.  “The declines in Florida deaths linked to specific prescription painkillers-oxycodone, methadone, and hydrocodone- paralleled declines in prescribing rates for those drugs.”  HealthDay, July 1, 2014, Prescriptions for Powerful Painkillers Vary Widely Among States: CDC

While so many will continue to be impacted by this epidemic, providers everywhere must be consistent and mindful of their prescribing patterns.  Additionally, external and universally accepted controls should be considered to limit the amount of medication that can be prescribed from specific specialties, for designated conditions, and by location.

Lukas Kolm, MD, MPH

Please send your comments or questions to or post a comment below.



Right on Lukas. Makes a person wonder about the degree of laziness, ignorance or worse, complicity, of script writers...sad to say.