Prescription drug abuse - Partners in Healthcare Education

4healtheducation.com

Prescription drug abuse - Partners in Healthcare Education

Clinician CE LESSONClinician CE LESSONdiffered from the overall population and fromyoung adults. While boys reported significantlygreater use of, abuse of and dependence onmarijuana in that age bracket, younger girls(ages 12 to 17 years) exceeded boys in theirnonmedical use of psychotherapeutics. 25In another study, instead of looking at hardnumbers regarding gender differences, researchersinstead examined the reasons andmotivations for misuse and abuse of prescriptionmedications by gender. Interestingly, theiranalysis showed that drug misuse by womenis motivated more by emotional issues andpsychological distress, while in men this behaviorusually stems from problematic socialand behavioral problems. 26ElderlyWhile the elderly may not be the largestdemographic in the prescription drug abusearena, people ages 65 years and older accountfor more than one-third of total outpatientspending on prescription medications in theUnited States. 27 There are a number of factorsat play here. The elderly often have multiplemedical issues and may have multiple prescribers,which can lead to overlapping orredundant prescriptions. Furthermore, thereoften is a higher incidence of chronic pain inthis population when opioids may be used.In many cases, prescription drug abuse in thispopulation may start out as prescription drugmisuse. As stated earlier, misuse may arisefrom a combination of the patient’s inabilityto read or understand dosing directions, cognitivedecline that comes with aging and/or complicated drug-taking regimens (e.g.,“Was that four pills two times per day or twopills four times per day?”). Other factors thatmay inadvertently contribute to the processinclude: 1) rationalization and denial amongfamily members, peers or care providers (e.g.,“They’re old, and they’re in pain; it’s OK”);2) abuse can be masked by the myth that drug— not alcohol — addiction is a disease of theyoung; or 3) the symptoms of drug abuse, suchas forgetfulness, irritability, increased stumblingor falls, may be dismissed as the person“just getting old.” Regardless of whetheror not misuse becomes abuse, the high ratesof co-morbid illnesses in older populations,age-related changes in drug metabolism andthe potential for drug interactions may makeany of these practices more dangerous than inyounger populations.Figure 1Rates of prescription painkiller sales, deaths and substance abuse treatment admissions (1999-2010)Source: National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS)of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009Co-morbid mental health conditionsAccording to the Substance Abuse and MentalHealth Services Administration, more than8.9 million people in the United States have cooccurringor co-morbid disorders; that is, theyhave both a mental or psychiatric disorder anda substance use disorder. 28 With easier accessto and greater availability of psychotherapeuticdrugs, it stands to reason that this populationalso may be at higher risk for prescriptiondrug abuse. Indeed, most drugs of abuse,whether illicit or prescription, affect brain regionsand/or have mechanisms of action similarto those we use therapeutically for treatingpsychiatric disorders. It’s the “chemical imbalance”concept and therein lies the rationale forself-administration. People will find the substanceor substances that make them feel goodor feel better, that either correct or mask the“chemical imbalance.” Unfortunately, whenundertaken without the guidance and monitoringof a healthcare professional, it can rapidlybecome a downward spiral.WHY HAS THERE BEEN AN INCREASEIN PRESCRIPTION DRUG ABUSE?There are four interrelated components thatplay into the prescription drug abuse process:availability of the drug, characteristics of thedrug, patient factors and prescriber behaviors. 29Drug availabilityIn many regards, the prescription drug abuseissue comes down to the basic economic principlesof supply and demand. Let’s start with thedemand side. Essentially there are three thingsthat occurred over the past decade that may beresponsible for increased demand. Rememberthat about 10 years ago, methamphetamineand 3,4-methylenedioxymethamphetamine(i.e., MDMA or ecstasy) were among the hottestdrugs for recreational use or abuse. First,MDMA primarily was manufactured in Europeand exported to the United States. Following9/11, with an increase in surveillance on imports,that avenue dried up for a while. Second,establishing tighter regulations on the “starting”materials for synthesizing methamphetamine— namely limits on pseudoephedrinepurchases and the removal of phenylpropanolaminefrom the market — led to diminished“meth” availability. The third possible factorthat was occurring simultaneously and mayhave played a role in increasing demand was achange in health care’s view of managing pain,sleep and behavioral/learning disorders. Inparticular, we adopted a more aggressive, yetappropriate, approach to treating pain in thiscountry, as well as insomnia, ADHD and others.With that has come a greater demand forpsychotherapeutic agents and a disproportionateincrease in the availability of these drugs inthe supply chain. This also has led to increaseddiversion into the hands of abusers.Regarding the supply side, production quotasfor prescription opioids and stimulantshave risen steadily for the past two decades,as has the number of prescriptions written forthose drugs. Prescriptions dispensed for opioidshave increased threefold in the last twodecades, while those for stimulants have increasedmore than tenfold. It stands to reasonthat the more “pills” available in the home,the greater the potential for misuse or abuseby either the patient or others who have accessto those medications. To give this some realworldperspective, according to the IMS Institutefor Healthcare Informatics, 131 millionprescriptions for hydrocodone were dispensedin 2010. 30 If one assumes conservatively 30 tabletsper prescription, that represents roughly4 billion tablets that were out in circulation in2010. And that’s just of hydrocodone.Figure 1 shows a direct correlation betweenthe availability of prescription opioids andtwo markers of abuse: overdose deaths andsubstance abuse treatment admissions. 31Once drugs are out of the pharmacy andinto the home medicine cabinet or kitchendrawer, it becomes a free-for-all. Anyone hasaccess to them: spouses, children, friends, relativesand visitors. In fact, 40% of 12th-gradersreported that painkillers were “fairly” or“very” easy to get, and more than half said thesame thing for stimulants. 32Drug characteristicsObviously, a particular drug’s characteristicsplay a major role in its potential for abuse.Those that have the potential to be “rewarding”(i.e., feel good, feel better) are those thatenhance dopaminergic transmission in specificregions of the brain (i.e., nucleus accumbens)or those that produce “disinhibition” throughenhancement of the inhibitory neurotransmittergamma-amino butyric acid, or GABA. 33,34Those that affect dopamine include the opioidsand the stimulants, and generally fall into DrugEnforcement Administration schedules II or III,while the anxiolytics and sedatives (i.e., benzodiazepinesand z-hypnotics) affect GABA andfall into schedule IV. 35 A key pharmacologicalconsideration about drugs of abuse is thatwhile the concentration, or how much of thedrug gets into the brain, may be important, itis how fast it gets there that correlates with increasedabuse potential — the faster, the better.This is why route of administration playsa role in the abuse potential of any individualdrug (intravenous > smoked > inhaled > immediaterelease > slow release). Drugs thatcan be crushed and/or made soluble and administeredby a faster route have greater potentialfor abuse. Therein lies the rationale forproducing “tamper-resistant” drugs. However,“tamper-resistant” does not equate with“abuse-resistant;” they still can be taken orallyin higher-than-prescribed doses, although theyare less likely to be altered to produce a greater“drug-rewarding” experience. 36Patient characteristicsThere basically are two types of prescriptiondrug abusers: those who obtain drugs directlyfrom the healthcare system — prescriber topharmacy — for their own personal use or tosell to others for financial gain, and those whoobtain them secondarily from the prescriptionTable 1Various methods that may be used to obtainprescription drugs for purposes of abuse 22• “Doctor shopping” (i.e., seeing more than onephysician for the same prescription)• Receiving drugs from friends or relatives• Forged, stolen or counterfeit prescriptions• Acquiring prescription drugs via the Internetwithout a physician visit• Buying drugs from patients leaving clinics• Feigning legitimate illness (e.g., sports injuries,anxiety) to obtain a prescription• Purchasing from a drug dealer• Theft from pharmacies or homes, including familymembers taking someone else’s drugs from amedicine cabinetrecipient. The former uses various methods,including doctor shopping, forging or stealingprescriptions, or feigning legitimate illness(e.g., sports injuries or anxiety) to obtain theirdrugs. Those that obtain drugs secondarilytypically get access to the drugs by requesting,buying or stealing drugs that already are inthe hands of a patient and outside the controlof the pharmacy. Table 1 outlines additionalmethods that may be used to obtain prescriptiondrugs for purposes of abuse. For example,nearly two-thirds (64%) of teenagers who haveabused prescription drugs reported receiving,buying or stealing them from friends or relatives;almost half (46%) said they got prescriptionpain relievers for free from a relative orfriend; another 9% said they bought pain relieversfrom a friend or relative, while 5% tookthe drugs without asking. 32 Again, the reasonsfor the nonmedical use of prescription drugsvary with the individual and can range fromthe use of the drugs for occasional recreationalpurposes to dependence, substance abuse disorderor addiction.Prescriber characteristicsPrescribers can have a significant influencewith regard to prescribing controlled substances— in particular, pain relievers. For example,an advanced practice clinician who is uncomfortablewith prescribing opioids due to personalbiases, inadequate training or the regulatoryburden associated with these prescriptions, maynot treat or may under-treat a legitimate painpatient. 37 This can increase the possibility thatthe patient will seek an additional, or multiple,provider(s) or seek out nonmedical sources foropioids in order to self-medicate their pain.Conversely, a clinician may appropriately treatpain with aggressive use of opioids; but in turn,this places more opioids into circulation, with agreater possibility for diversion or a greater riskfor the patient to develop dependency and furtherabuse. Indeed, over the past decade, in anattempt to better treat patient pain, providershave dramatically increased their rate of opioidprescribing for pain-related visits. Unfortunately,patients who abuse opioids have learnedhow to exploit this new sensitivity. There alsois a third scenario that has become recognized.Where there is a demand and money involved,there is the potential for indiscriminate prescribingof controlled substances. Not to diminishthe legitimate benefits of “pain clinics,” butthe for-profit pain clinic, or “pill mill,” phenomenonhas exploded over the last three or fouryears as more providers recognized there is bigmoney to be made in what has been an unregulatedindustry. 38 The issue generally had beenoverlooked until recently as states begin to craftlaws that toughen oversight of pain clinics andwho operates them.DANGERS OF PRESCRIPTION DRUG ABUSEAs stated in the introduction, the numberof deaths associated with unintentional overdosesfrom prescription drugs have increasedroughly fivefold since 1990 and now are secondonly to motor vehicle crash deaths amongleading causes of unintentional injury death in2007 in the United States. 39,40In 2007, there were 27,658 unintentionaldrug overdose deaths. 39 That translates intoone death every 19 minutes. Again, to putthat into perspective, in the time it takes tocomplete this CE activity, about six peoplewill have died from an unintentional drugoverdose. It is important to recognize that the27,658 overdose deaths represent the total ofboth prescription drugs and illicit drugs likeheroin and cocaine.The number of deaths that can be attributeddirectly to prescription opioid analgesics in2007 was approximately 12,000, which still ismore than the combined total of heroin andcocaine deaths. In fact, the number of deathsinvolving opioid analgesics was 1.9 times thenumber involving cocaine, and 5.4 times thenumber involving heroin. 40 More recent datafrom 2008 reported that prescription painkilleroverdoses killed nearly 15,000 people, suggestingthat the problem is getting worse. 39While the mortality data is dramatic, it doesnot portray the even greater morbidity associatedwith prescription drug abuse and overdoses.For every overdose death due to opioid analgesics,the problem is multiplied by other incidentsthat burden the public health system. Inthat regard, it has been suggested that for everyoverdose-related death from opioids, there arenine abuse treatment admissions, 35 emergencydepartment visits for abuse or misuse, and 161people who suffer from abuse/dependence. 2Treatment data from emergency departmentvisits can highlight this morbidity and can beaccessed more quickly than mortality data. Asit turns out, ED visits for the nonmedical use ofprescription and over-the-counter drugs noware comparable to ED visits for use of illicitdrugs like heroin and cocaine. 40A 2010 report from SAMHSA’s Drug AbuseWarning Network showed that the estimatednumber of ED visits for nonmedical use ofopioid analgesics increased 111% from 2004to 2008 (from 144,600 to 305,900 visits), withthe biggest increase (29%) occurring duringthe most recent year, 2007-2008. 41 The highestnumbers of ED visits were recorded for oxycodone,hydrocodone and methadone, all ofwhich showed statistically significant increasesduring the five-year period. The estimatednumber of ED visits involving nonmedicaluse of benzodiazepines increased 89% duringthe same five years (from 143,500 to 271,700visits) and again more dramatically (23%) inthe most recent year of the analysis. Notably,results from 2008 indicated that in additionto the large increase in visits compared with2004, peak visit rates for both opioids and benzodiazepinesappear to have shifted into the3 • MARCH/APRIL 2012 DSNCOLLABORATIVECARE.COM DSNCOLLABORATIVECARE.COM MARCH/APRIL 2012 • 4


Clinician CE LESSONClinician CE LESSONyounger age groups (i.e., 21 to 24 years from 30to 34 years for opioids, and 25 to 29 years from35 to 44 years for benzodiazepines).Beyond the mortality data, these findingsindicate substantial, increasing morbidity andshifting use patterns associated with the nonmedicaluse of prescription drugs in the UnitedStates, despite recent efforts to control the problem.Stronger measures to reduce the diversionof prescription drugs to nonmedical purposesare warranted.Table 2Prescribers’ responsibilities 42• Clinicians have a legal and ethical responsibility to upholdthe law and to help protect society from drug abuse.• Clinicians have a professional responsibility toprescribe controlled substances appropriately, guardingagainst abuse while ensuring that patients havemedication available when they need it.• Clinicians have a personal responsibility to protect theirpractice from becoming an easy target for drug diversion.Clinicians must become aware of the potentialsituations where drug diversion can occur and safeguardsthat can be enacted to prevent this diversion.Table 3Common characteristics of the drug abuser 42• Unusual behavior in the waiting room• Assertive personality, often demanding immediate action• Unusual appearance — extremes of either slovenlinessor being over-dressed• May show unusual knowledge of controlled substancesand/or gives medical history with textbook symptomsOR may give evasive or vague answers to questionsregarding medical history• Reluctant or unwilling to provide reference information.Usually has no regular doctor and often no health insurance• Often will request a specifi c controlled drug and isreluctant to try a different drug• Generally has no interest in diagnosis — fails to keepappointments for further diagnostic tests or refuses tosee another practitioner for consultation• May exaggerate medical problems and/or simulatesymptoms• May exhibit mood disturbances, suicidal thoughts,lack of impulse control, thought disorders and/orsexual dysfunction• Cutaneous signs of drug abuse — skin tracks andrelated scars on the neck, axilla, forearm, wrist, foot andankle. Such marks usually are multiple, hyper-pigmentedand linear. New lesions may be infl amed. Shows signs of“pop” scars from subcutaneous injections.THE ADVANCED PRACTICE CLINICIAN’S ROLEIN DRUG ABUSE PREVENTIONAdvanced practice clinicians who can writea prescription for controlled medications, suchas those discussed in this lesson, have a professional,personal, legal and societal responsibilityto try to prevent the abuse and diversion ofsuch drugs. 42 Prescribers’ responsibilities arefurther outlined in Table 2. Within this framework,this responsibility would, at minimum,include proper and adequate patient assessment;appropriate drug selection; educatingthe patient, as well as selected individuals“in-the-loop,” such as family members; andcommunicating with other health professionalswhere appropriate. Additionally, theprescriber needs to continually monitor thepatient’s response to treatment, as well asmaintain clear and accurate records and protectagainst the potential for theft or alterationof prescriptions. 43 Although much of the literaturepertaining to reducing prescription drugabuse is focused on opioid analgesics, all ofthese principles hold true for prescribing psychotherapeuticsin general, such as stimulants,tranquilizers and sedatives.Patient assessmentWith respect to patient assessment, whendone properly and thoroughly, a comprehensiveassessment can help prescribers identifypatients who might be seeking prescriptions forrecreational, self-treatment or other nonmedicaldrug-taking behavior. Table 3 outlines commoncharacteristics of the drug abuser, while Table4 highlights common behaviors and methodsused by drug-seeking patients. 42 As discussedearlier, risk of prescription drug misuse andabuse varies from one individual to another;however, certain demographics are known tohave higher risk, including adolescents andyoung adults, patients with existing mentaldisorders and chronic pain patients. 44-46 A thoroughhistory may shed some light on a patient’scurrent and past substance misuse and abuseof alcohol, illicit drugs or prescription medications.This is where maintaining accurate notesand records on patients helps. Obviously, newTable 4Behaviors and methods often usedby drug-seeking patients 42• Must be seen right away• Wants an appointment toward end of offi ce hours• Calls or comes in after regular hours• States he/she is traveling through town, visiting friendsor relatives (not a permanent resident)• Feigns physical problems, such as abdominal or backpain, kidney stone or migraine headache in an effort toobtain narcotic drugs• Feigns psychological problems — such as anxiety,insomnia, fatigue or depression — in an effort toobtain stimulants or depressants• States that specifi c non-narcotic analgesics do notwork or that he/she is allergic to them• Contends to be a patient of a practitioner whocurrently is unavailable or will not give the name ofa primary or reference physician• States that a prescription has been lost or stolen andneeds replacing• Deceives the practitioner, such as by requesting refi llsmore often than originally prescribed• Pressures the practitioner by eliciting sympathy orguilt or by direct threats• Uses a child or an elderly person when seekingmethylphenidate or pain medicationpatients may require greater scrutiny and theadvanced practice clinician should strive todetermine who provided medical care in thepast, including the types of drug(s) that wereprescribed, and for what conditions or indications.One place to turn is prescription drugmonitoring programs, or PDMPs. Both nationaland local PDMPs have been formed (see page 6)to help detect suspicious patterns of drug use,particularly controlled-substance use. 47 Wherethese programs exist, they may be useful foridentifying other providers who have or still areprescribing for that patient, as well as patienthistories of filling certain prescriptions. Medicalrecords from current or past providers shouldbe sought and reviewed — after obtaining patientconsent — if reasonable, before controlledmedications are prescribed.Communicating with the patientThe informed consent process can be a usefultool for educating patients on the risks andbenefits of drug therapy with controlled medications.48 Establishing realistic expectationsfor therapy is critical and may help reduce apatient’s drive to “self-medicate” beyond thetreatment plan. The NP should recognize, andpatients should be guided to understand, thatrestoration of function is the goal, rather thancomplete relief of symptoms when using manymedications, including controlled drugs. Additionally,such discussions should include areview of the potential risks for drug misuseand abuse. Issues that should be addressed includeethical and legal obligations for the patientand advanced practice clinician; the potentialfor drug-related cognitive impairmentand/or physical injury; adverse effects causedby interactions with other drugs, includingalcohol; and the risk of accidental overdose.Additionally, for women of child-bearing age,it is imperative to review the implications ofbecoming pregnant while taking selectedcontrolled substances and the adverse effectsthat can cause obstetrical complications, aswell as detrimental effects on the fetus with inutero exposure. 49Patients also should be informed at the timea controlled drug is prescribed that it is illegalto sell, give away or otherwise share the medicationwith others, including family members.Furthermore, talking with patients about thesafe storage and disposal of medications shouldbe part of the overall plan to help prevent useor diversion by others in the household. Agood resource for information regarding disposalis the local pharmacist. Advanced practiceclinicians may be able to direct a patient toprescription take-back events in their communityor mail-back programs. If such take-backmethods are not available, patients should beinstructed to follow any disposal instructionson the medication label and not to flush themedications down the toilet unless the patientinformation instructs them to. If patients aren’table to use a take-back method, advise them toremove the drugs from their original containers;crush them and mix them with an undesirablesubstance, such as coffee grounds or kittylitter; and then put them in a sealable bag orcan. This will help make them less desirable tochildren, teens, pets or those trying to obtaindrugs for the purpose of misuse or abuse. 50,51Another area where the advanced practiceclinician can play an important role is in educatingparents about prescription drug abuse inschool-aged children. Alerting them to the highprevalence of teenage prescription drug abuseand to keeping better tabs on medications in thehome is a start. Teaching parents the signs of intoxicationwith psychotherapeutic medications,as well as the side effects that may arise fromfrequent use (i.e., constipation from opioids, irritabilityor insomnia from stimulants), also maybe helpful in identifying and averting chronicabuse and its sequalae in the teen population.Drug contracts and treatment agreementsA growing number of primary care clinicianshave taken to using the written treatmentagreements that have been widely used in thepast in pain specialty practices. These agreements,or “drug contracts,” spell out the obligationsof both the provider and patient whenprescribing and using controlled drugs. 52,53 Theuse of opioid agreements is endorsed by theFederation of State Medical Boards and is writteninto code in most state pain managementpolicies. The language of these agreementsmay come across as accusatorial, mistrustfuland confrontational by both patients and primarycare providers; however, rather than apunitive, accusing document, the agreementsimply can outline the pain problem, the medicine,dosage, number of pills, refill interval andhow much time is needed for refills to be done.Other language can be added, adapted, writtenin later and adjusted according to the patient,refer to Table 5. Although time-consuming anduncomfortable, primary care should includeTable 5Suggested provisions of drug contracts 48• Agreement to obtain prescriptions for a class ofcontrolled medication from only one clinician and,preferably, from one designated pharmacy. Identifyingthe specifi ed pharmacy in the document is helpful.• Agreement to take the medication only as prescribed,with options provided that allow the patient to makesome adjustments in response to changes in symptoms.• Acknowledgment that patients are responsible forarranging refi lls during regular offi ce hours. They mustplan ahead and not require medication refi lls duringweekends or clinician vacation periods.• Agreement that the patient will stop taking all othercontrolled medications of that type, unless explicitlytold to continue them.• Agreement that violation of the terms of the agreementmay result in discontinuation of the controlled medication.these agreements, and clinicians can add thisneeded option to their treatment plans. 54PrescriptionsThe proper and accurate writing of individualprescriptions, as well as “protecting”the prescription pad from theft is critical. Anyprescriber should treat prescription pads asthey would their own personal checkbook,including keeping prescription pads in theirpossession when they actively are using them,not leaving them “unattended” and storingsurplus pads in a locked drawer, safe or otherappropriate area. It also is essential to reportany prescription pad theft to local pharmacies,as well as the State Board of Pharmacy. 55Although there are opposing views on thesubject, it is recommended that advancedpractice clinicians should not preprint DEAnumbers on forms in order to make it moredifficult for stolen forms to be used. Ideally,prescription forms should be made tamperresistant— that is, printed on paper that showsany erasures or ink removers. As with all prescriptions,clear writing is essential. Spellingout the quantity to be dispensed, in additionto the numeric figure, may limit tampering.The prescription order should specify both themilligram dose along with the volume of solutionto be taken at any given time for oralliquids, and should specify the concentrationto be used. Regardless, forgers often beginwith a legitimate prescription order, whichcan be either photocopied and altered or usedas a template to design and print prescriptionsfrom a computer. It goes without sayingthat limiting the number of refills allowsthe advanced practice clinician to monitor thepatient’s response periodically, which is particularlyimportant during long-term therapy.Requests for early refills are a warning sign ofdrug misuse or abuse. Drugs sometimes are legitimatelylost or accidentally destroyed, butmultiple requests for early refills should betreated as evidence of aberrant medication useand handled accordingly.DocumentationThe importance of accurate and up-to-datedocumentation cannot be over-emphasized.PRACTICE POINTSHaving a complete medical record protects boththe advanced practice clinician and patient. Advancedpractice clinicians need to know andunderstand laws and regulatory requirements.In the United States, the Board of Medical Licensureor the Board of Pharmacy — or theirequivalent — in each state can provide informationabout the relevant56, 57requirements.Prescription drug monitoring programsBoth national and local PDMPs have beenformed to attempt to detect suspicious patternsof drug use, particularly controlled substanceuse. 47 The National Alliance for Model StateDrug Laws, or NAMSDL, reports on its websitethat, as of January 2012, there are PDMPsoperational in 40 of the 50 states. An additionaleight states have enacted legislation, but it isnot yet operational. 50 National and/or localPDMP participation may provide further opportunityto identify and minimize any potentialabuse, misuse, diversion or fraud involvingprescription drugs. PDMPs seek to identifyprescribers and patients at risk for both addictionand diversion, and provide for methods ofprofession and law enforcement intervention.Advanced practice clinicians’ participation insuch programs may further help to reduce thespread of prescription drug abuse. As the designand requirements of state programs maydiffer, nurse practitioners are directed to theDEA or NAMSDL for further information on50, 58their state-specific requirements.CONCLUSIONPrescription drug abuse undoubtedly is anepidemic and has been increasing at an alarmingrate. The abuse of psychotherapeutics —including opioid pain relievers, tranquilizers,stimulants and sedatives — poses the biggestthreat. Advanced practice clinicians can playan important role in reducing prescriptiondrug abuse through proper and adequate patientassessment, appropriate drug selection,patient education on proper use, storage anddisposal of controlled medications, open communicationwith other allied healthcare professionals,responsible monitoring and recordkeeping, and protecting against the potentialfor theft or alteration of prescriptions.• Prescription drug abuse is the intentional use of a medication without a prescription for nonmedical purposesor in any manner other than as it was prescribed, and it has reached epidemic levels in the United States.• Psychotherapeutics — including opioid pain relievers, tranquilizers, stimulants and sedatives — currentlyare the most abused prescription drugs.• Advanced practice clinicians should make themselves aware of behaviors and methods often used bydrug-seeking patients, so that they may identify patients that may be of concern.• Advanced practice clinicians can play an important role in reducing prescription drug abuse through properpatient assessment, appropriate drug selection, patient education, open communication with other alliedhealthcare professionals, responsible monitoring and record keeping, and protecting against the potentialfor theft or alteration of prescriptions.5 • MARCH/APRIL 2012 DSNCOLLABORATIVECARE.COM DSNCOLLABORATIVECARE.COM MARCH/APRIL 2012 • 6


Clinician CE LESSONClinician CE LESSON1 National Institute on Drug Abuse. Prescription Drugs: Abuse and Addiction. Available at: http://m.drugabuse.gov/sites/default/fi les/rrprescription.pdf. Accessed Feb. 16, 2012. 2 Centersfor Disease Control and Prevention. Public Health Grand Rounds: Are Drug Overdoses a Public Health Problem? Available at: http://www.cdc.gov/about/grand-rounds/archives/2011/pdfs/PHGRRx17Feb2011.pdf. Accessed Feb. 15, 2012. 3 Topics in Brief: Prescription Drug Abuse. NIDA. December 2011. Available at: http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse. Accessed Feb 15, 2012. 4 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC. 5 Graham,AW, Schultz, TK, Mayo-Smith, MF, et al (Eds). Principles of Addiction Medicine. 3rd ed. American Society of Addiction Medicine, Inc., Chevy Chase, MD 2003. 6 Substance Abuse and MentalHealth Services Administration, Results from the 2009 National Survey on Drug Use and Health: Summary of National Findings. Available at: http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm. Accessed Feb. 15, 2012. 7 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use andHealth: Summary of National Findings. Available at: http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm. Accessed Feb. 15, 2012. 8 Kuehn, B. Opioid Prescriptions Soar.Journal of the American Medical Association. 2007; 297(3):249-51. 9 Rannazzisi, J. DEA offi ce of Diversion Control. U.S. Department of Education Offi ce of Safe and Drug Free SchoolsPresentation. “The National Pharmaceutical Situation Report.” August 2009. 10 Drug Enforcement Agency Offi ce of Diversion Control. Drugs and Chemicals of Concern. Available at: http://www.deadiversion.usdoj.gov/drugs_concern.htm. Accessed Feb. 16, 2012. 11 National Institute on Drug Abuse. NIDA for Teens. Available at: http://teens.drugabuse.gov. Accessed Feb. 16,2012. 12 Prescription for Peril: How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs. December 2007. Available at: http://www.insurancefraud.org/downloads/drugDiversion.pdf. Accessed Feb. 16, 2012. 13 National Drug Intelligence Center. National Drug Threat Assessment 2009. December 2008. Document ID: 2008-Q0317-005. Washington,DC: U.S. Department of Justice. www.usdoj.gov/ndic/pubs31/31379/index.htm. 14 University of Michigan Institute for Social Research. “Monitoring the Future: National Results of AdolescentDrug Use.” Available at: http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf. Accessed Feb. 16, 2012. 15 National Institute on Drug Abuse. “Selected PrescriptionDrugs with Potential for Abuse.” Available at: http://www.whitehousedrugpolicy.gov/drugfact/prescrptn_drgs/rx_ff.html. Accessed Feb. 16, 2012. 16 Benzodiazepine abuse treatmentadmissions have tripled from 1998 to 2008. SAMHSA News Release. http://www.samhsa.gov/newsroom/advisories/1106082530.aspx. Accessed Feb. 15, 2012. 17 Drug EnforcementAgency Offi ce of Diversion Control. Drugs and Chemicals of Concern: Dextromethorphan. Available at: http://www.deadiversion.usdoj.gov/drugs_concern/dextro_m/dextro_m.htm. AccessedFeb. 15, 2012. 18 Substance Abuse and Mental Health Services Administration. “Non-Medical use and Abuse: Prescription-type and Over-the-Counter Drugs.” Available at: http://www.oas.samhsa.gov/prescription.htm. Accessed Feb. 16, 2012. 19 Generation Rx: national study confi rms abuse of prescription and over-the-counter drugs. Partnership for a Drug-Free America.May 15, 2006. Available at: www.drugfree.org/portal/drugissue/research/teens_2005/Generation_Rx_Study_Confi rms_Abuse_of_Prescription. Accessed Feb. 15, 2012. 20 Prescriptiondrug abuse prevention. Offi ce of National Drug Control Policy. Available at: www.whitehousedrugpolicy.gov/drugfact/prescr_drg_abuse.html. Accessed Feb. 15, 2012. 21 Youth RiskBehavior Surveillance — United States, 2009 Morbidity and Mortality Weekly Report June 4, 2010 / Vol. 59. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Accessed Feb. 15,2012. 22 Fact Sheet: Prescription Drug Abuse - a DEA Focus. Available at: http://www.justice.gov/dea/concern/prescription_drug_fact_sheet.html. Accessed Feb. 15, 2012. 23 Offi ce ofNational Drug Control Policy. The Abuse of Prescription and Over-the-Counter Drugs. September 2007. Available at: www.theantidrug.com/pdfs/resources/teen-rx/Prescription_Abuse_brochure.pdf. Accessed Feb. 15, 2012. 24 Highlights of the National Institute on Drug Abuse’s 2011 Monitoring the Future Survey. Available at: http://m.drugabuse.gov/sites/default/fi les/pdf/mtfhighlights11.pdf. Accessed Feb. 15, 2012. 25 Cotto JH et al. Gender effects on drug use, abuse, and dependence: A special analysis of results from the national survey on drug use andhealth. Gender Medicine. 2010;7(5):402–413. 26 Nauert R. (2010). Risk for Prescription Drug Abuse Varies by Gender. Psych Central. Available at: http://psychcentral.com/news/2010/04/28/risk-for-prescription-drug-abuse-varies-by-gender/13249.html. Accessed Feb. 14, 2012. 27 Simoni-Wastilla L and Keri Yang H. Psychoactive drug abuse in older adults. The AmericanJournal of Geriatric Pharmacotherapy. 4(4):380-394, 2006. 28 Why do drug use disorders often co-occur with other mental illnesses? Comorbidity: Addiction and Other Mental Illnesses,NIDA: Research Reports. Available at: http://www.drugabuse.gov/publications/research-reports/comorbidity-addiction-other-mental-illnesses/why-do-drug-use-disorders-often-co-occurother-men.Accessed Feb. 14, 2012. 29 Parran T. Prescription drug abuse. A question of balance. Med Clin North Am. 1997;81(4):967. 30 The use of medicines in the United States: reviewof 2010. IMS Health.com; 2011. Available at: http://www.imshealth.com/deployedfi les/imshealth/Global/Content/IMS%20Institute/Static%20File/IHII_UseOfMed_report.pdf. Accessed Feb.14, 2012. 31 Offi ce of National Drug Control Policy. The Abuse of Prescription and Over-the-Counter Drugs. September 2007. Available at: www.theantidrug.com/pdfs/resources/teen-rx/Prescription_Abuse_brochure.pdf. Accessed Feb. 14, 2012. 32 National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the DrugEnforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009. Available at: http://www.cdc.gov/vitalsigns/PainkillerOverdoses/. Accessed Feb. 14, 2012. 33Nestler EJ. “Is There A Common Molecular Pathway For Addiction?” Nature Neuroscience. 2005;8(11):1445–1449. 34 Licata SC and Rowlett JK. Abuse and dependence liability ofbenzodiazepine-type drugs: GABA(A) receptor modulation and beyond. Pharmacology Biochemistry Behavior. 2008; 90(1):74–89. 35 Drug Enforcement Agency Controlled Substances -CSA Schedule. Available at: http://www.deadiversion.usdoj.gov/schedules/orangebook/e_cs_sched.pdf. Accessed Feb. 14, 2012. 36 Coleman JJ, Bensinger et al., Can drug design inhibitabuse? Journal Psychoactive Drugs. 2005;37(4):343. 37 Gilson AM and Kreis PG. The burden of the nonmedical use of prescription opioid analgesics. Pain Medicine. 2009;10 Suppl 2:S89.38 States target prescriptions by ‘pill mills’. USA Today. Available at: http://www.usatoday.com/news/nation/story/2011-10-13/pill-mill-drug-traffi cking/50896242/1. Accessed Feb. 14, 2012.39 Prescription Painkiller Overdoses in the US. CDC Vital Signs, Nov 2011. Available at: http://www.cdc.gov/vitalsigns/PainkillerOverdoses. Accessed Feb. 14, 2012. 40 Centers for DiseaseControl and Prevention. Unintentional Drug Poisoning in the United States. CDC Data Brief, July 2010. Available at: http://www.cdc.gov/HomeandRecreationalSafety/pdf/poison-issue-brief.pdf. Accessed Feb. 14, 2012. 41 Cai R, Crane E, Poneleit K, Paulozzi L. Emergency department visits involving nonmedical use of selected prescription drugs in the United States, 2004–2008. Journal Pain Palliative Care Pharmacotherapeutics. 2010;24(3):293–297. 42 Don’t Be Scammed By A Drug Abuser, DEA, USDOJ, December, 1999. Available at: http://www.deadiversion.usdoj.gov/pubs/brochures/drugabuser.htm. Accessed Feb. 20, 2012. 43 Database of State Statutes, Regulations, and Other Offi cial Government Policies Available at: http://www.painpolicy.wisc.edu/matrix.htm. Accessed Feb. 20, 2012. 44 Liebschutz JM st al., Clinical factors associated with prescription drug use disorder in urban primary care patients withchronic pain. J Pain. 2010;11(11):1047. 45 McCabe SE. et al. Motives for nonmedical use of prescription opioids among high school seniors in the United States: self-treatment and beyond.Arch Pediatr Adolesc Med. 2009;163(8):739. 46 Turk DC et al., Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain. 2008;24(6):497.47 Burke J. “RX Abuse 2011 – Moving Forward.” February 2011. Available at: http://www.pharmacytimes.com/publications/issue/2011/February2011/DrugDiversion-0211. Accessed Feb. 17,2012. 48 Wilford, Bonnie B., et al., Prescription drug abuse and addiction: Prevention, identifi cation, and management; Up-to-Date, 2012. Available at: http://www.uptodate.com/contents/prescription-drug-abuse-and-addiction-prevention-identifi cation-and-management?source=search_result&search=prescription+drug+abuse&selectedTitle=2%7E10. Accessed Feb. 21,2012 49 Dattel BJ, Substance abuse in pregnancy. Semin Perinatol. 1990;14(2):179. 50 Status of State Prescription Drug Monitoring Program. The National Alliance for Model State DrugLaws. January 2012. Available at: http://www.namsdl.org/documents/StatusofStates011112.pdf. Accessed Mar. 2, 2012. 51 U.S. Food and Drug Administration. How to Dispose of UnusedMedications. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm. Accessed Feb. 17, 2012. 52 Adams NJ, Plane MB, Fleming MF, et al. Opioids and thetreatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22:791-796 53 Arnold RM et al. Opioid contracts in chronic nonmalignant pain management: objectivesand uncertainties. Am J Med. 2006;119(4):292. 54 McCarberg, Bill H. Opioid Contracts in Primary Care. Medscape Neurology. 11/16/2009. Available at: http://www.medscape.com/viewarticle/711659. Accessed Feb. 21, 2012. 55 Compliance Tips -Alabama Board of Pharmacy. Available at: www.albop.com/compliance_tips.html. Accessed Feb. 21, 2012 56 AmericanMedical Association Links to State Medical Boards. Available at: http://www.ama-assn.org/ama/pub/education-careers/becoming-physician/medical-licensure/state-medical-boards.page.Accessed Feb.y 21, 2012 57 National Association of Boards of Pharmacy. Available at: http://www.nabp.net/boards-of-pharmacy/. Accessed Feb. 21, 2012 58 Drug Enforcement Agency.“State Prescription Drug Monitoring Programs.” Updated July 2010. Available at: http://www.deadiversion.usdoj.gov/faq/rx_monitor. Accessed Feb. 17, 2012.Successful completion of “Prescription DrugAbuse: From bad to worse” is accredited for1 hour of continuing education credit, of which0.75 hour is considered pharmacology credit.To obtain credit, answer the following questionsand complete the evaluation online atDSNCollaborativeCare.com.1. Prescription drug abuse is:a. The intentional use of a medicationwithout a prescription or in a way otherthan as it was prescribedb. The unintentional use of a medicationin a manner other than how it wasprescribedc. A maladaptive pattern with recurrentand significant adverse effects, such asfailing to fulfill major role obligations,legal problems, physically hazardoususe or interpersonal problemsd. All of the above2. Which of the following prescriptionmedications are most commonly abusedand misused?a. Tranquilizers, opioids and steroidsb. Opioids, tranquilizers, stimulantsand sedativesc. Opioids, stimulants and steroidsd. Opioids, stimulants and antifungals3. The number of deaths associated withunintentional overdoses from prescriptiondrugs is the ________ leading cause ofunintentional injury death in the UnitedStates, according to 2007 data.a. Secondb. Thirdc. Fourthd. 10thLearning Assessment4. Which of the following accounts for aboutthree-quarters of total prescription drugsabused and may be more likely to producemorbidity and mortality?a. Benzodiazepinesb. Sedativesc. Opioidsd. Stimulants5. According to the “2010 National Surveyon Drug Use and Health,” approximatelyhow many people in the United Stateswere current users of psychotherapeuticdrugs taken nonmedically?a. 1 millionb. 3 millionc. 5 milliond. 7 million6. Which of the following is being used inincreasing amounts for “performanceenhancing”effects among students believingthat the use will increase grade pointaverages and test scores?a. Diazepamb. Hydrocodonec. Oxycodoned. Methylphenidate7. Among the central nervous systemdepressants, _____________ are by far themost commonly abused drugs.a. Barbituratesb. Benzodiazepinesc. Opioidsd. All of the above8. Prescription drug misuse by women ismotivated most by which of the following?a. Behavioral problemsb. Emotional issues and psychologicaldistressc. Social problemsd. A and C9. Both national and local prescription drugmonitoring programs have been formed to:a. Attempt to detect suspicious patternsof drug use, particularly controlledsubstanceuseb. Identify prescribers and patients at riskfor both addiction and diversion, andprovide for methods of profession andlaw enforcement interventionc. Lower prescription drug costsd. A and B10. Which of the following behaviors ormethods may be used by drug-seekingpatients?a. Patient might feign psychologicalproblems — such as anxiety, insomnia,fatigue or depression — in an effort toobtain stimulants or depressants.b. Patient might state that specific nonnarcoticanalgesics do not work or thathe/she is allergic to them.c. Patient might state that a prescriptionhas been lost or stolen and needs replacing.d. B & Ce. All of the above7 • MARCH/APRIL 2012 DSNCOLLABORATIVECARE.COMDSNCOLLABORATIVECARE.COM MARCH/APRIL 2012 • 8

More magazines by this user
Similar magazines