PRN, Pro Re Nata
Is it "Help When Needed Most" or "The trap door to confusion and the passport to misuse and addiction..."?
According to the US Department of Health and Human Services, some 42 million Americans, roughly 20% of the population have used prescription drugs for non-medical purposes. Opiates, hypnotics, anxiolytics, sedatives, CNS stimulants, and depressants are the most frequently misused agents. The National Center for Health Statististics reports that over 50% of an estimated 400,000 accident-related injuries are prescription drug related. Misuse and addiction to prescription drugs is at an epidemic proportion and an alarming public health concern. An internet search for "prescription drug misuse, abuse, and addiction" locates an estimated 500,000 pieces of information. Misprescribing and over prescribing are the 2nd most common cause of disciplinary actions against physicians and the 3rd most common cause of professional liability claims. Similar to other public health threats when left unattended by the medical community, this phenomenon has resulted in the development of self-help organizations, such as AddictionByPrescription.com, by individuals and groups who have lost hope and confidence in medicine. The problem of prescription drug abuse, misuse, and addiction is rather multifaceted, complex, and multi-stakeholder, including the drug, the manufacturer, the patient and their unrecognized and untreated addictive psychopathology, the doctor, the nurse, the health care administrator, the pharmacist, and not least, the socioeconomic interest groups involved in drug acquisition, distribution, and employment of individuals feeding off this destructive industry.
The nonverbal communication of PRN instructions generally suggests that the physician is aware of a particular symptom in the patient and has knowledge about a possible remedy. He or she, however, conveys to the patient that they will not be there nor do they know when the symptom might strike and be severe enough to warrant suppression. As a result, the physician gives a PRN instruction suggesting, "I know this medication may relieve your symptoms... you take it when you think you need it... " This is the passport to misuse and addiction to medications of abuse.
Availability, accessibility, and lack of structure and schedule for "using" are among the cardinal and necessary elements for addiction to alcohol and drugs. Prescription fraud, walkie talkie doctor shoppers, and lack of concise medical instructions, along with casual accountability for left over or unused CNS-acting prescription drugs at institutions, hospitals, pharmacies, and nursing homes, are among the primary reasons for prescription drug abuse and addiction among health care professionals and diversion of prescription drugs into the communities. PRN instruction and access to CNS-acting medications is the gateway to abuse, misuse, and addiction.
Physicians provide countless medical instructions to the patients who most follow them word for word and step by step based on the confidence and trust they place in their physician. These instructions, be they procedural in nature or actionable are invariably backed by the hard science behind them, as it pertains to instructions for medications: time of onset, duration of action, half life and bioavailability, pharmacodynamics and pharmacokinetics of medications guide the physician to render the appropriate instructions. It is unlikely that a physician would order a PRN antiobiotic or for that matter a PRN antiviral medication. Even in the case of insulin dependent diabetics, the PRN usage and administration of insulin is preceded by measurements of blood and urine glucose. Similarly, in the case of intractable pain and fever, we employ measurable objectives and limiting parameters for PRN administration of analgesics and antipyretics. Manufacturers of medications with abuse and addictive potentials advise against prolonged use of these medications and warn of the potential of misuse and addiction. Except for scheduled maintenance usage of legend medications for pain and other symptoms in progressive malignant conditions where maintenance therapy might be appropriate, the customary standard for usage of these medications calls for short term, i.e., only a few weeks, and sufficient scheduled dosages to suppress the target symptom until a more permanent and safer alternative is established. PRN instruction of legend medications in a hospital setting is usually left to the discretion of an educated and skilled nurse who in collaboration with the physician is supposed to use objective measures to evaluate the necessity for a single PRN administration. Maybe we should use the same reasoning for judicious use of the medications of abuse. The only PRN instruction I give to my patients is an emergency room visit or phone calls for Unscheduled Follow Up Visits.
K. Shams, MD
Executive Medical Director
Okaloosa NeuroPsychiatric Center
