Controlled Substances in Primary Care: An Overview of the Issues, Challenges and Management Strategies Jeff Reiter, PhD, ABPP

Learning Objectives List the controlled substances commonly encountered in primary care patients Understand the terminology and clinical phenomena of controlled substances Explain the challenges posed by long term use of controlled substances Detail strategies for addressing the challenges in primary care 2-3:00

Terminology and Basics “Tolerance” is either: Need for incr’d dosage to achieve effect, or Diminished effect from the same dosage “Dependence” is a state of adaptation evidenced by drug-specific withdrawal Normal w/ prolonged use; does not=addiction “Withdrawal” occurs w/ abrupt d/c of drug Potentially fatal in benzos Controlled/Sustained release preferred

Terminology and Basics Addiction (substance dependence) is > 3: Tolerance Withdrawal/Dependence Heavier use than intended or prescribed Unsuccessful efforts to decrease use Much time spent obtaining or using Adverse effect on important activities Cont’d desire for meds despite problems Medication “misuse” (see next slide)

Terminology and Basics “Misuse” is use of a medication for other than its intended purpose Diversion (selling, giving away), recreation, use for a problem it was not prescribed for “Pseudoaddiction” is dramatic pain behavior sometimes seen w/ severe pain Often confused with addiction “Long-term” use is > 3 consecutive months

Controlled Substances: Opioids Oxycodone (Oxycontin) Hydrocodone (Vicodin) Codeine Fentanyl Methadone (Dolophine) Morphine (Roxanol) Morphine sulfate, controlled release (MS Contin) 5:00

Controlled Substances: Opioids Aka narcotics, opiates Generally prescribed for: Postsurgical pain relief Management of acute or chronic pain Relief of coughs and diarrhea Potential tolerance, dependence, abuse SE: sedation, GI sx, depression (death) May lead to hyperalgesia, incr’d pain flares

Controlled Substances: Opioids Withdrawal characteristics: Flu-like symptoms are common Muscle aches, runny nose, sweating, diarrhea, stomach cramps, nausea, vomiting Yawning, anxiety Very uncomfortable but not life-threatening May be treated with meds for nausea and diarrhea, and clonidine for other symptoms Buprenorphine may help; can be used long term Methadone may be used long term

Controlled Substances: Benzodiazepines Diazepam (Valium) Alprazolam (Xanax) Clonazepam (Klonopin) Lorazepam (Ativan) Temazepam (Restoril) Chlordiazepoxide hydrochloride (Librium)

Controlled Substances: Benzodiazepines Benzos are “CNS Depressants” which also includes Barbiturates Generally prescribed for: Anxiety disorders Acute stress Sleep disorders Anesthesia (at high doses) Detox from alcohol Muscle spasms, restless legs

Controlled Substances: Benzodiazepines Potential SE: Psychomotor slowing, drowsiness, confusion Depression Heavy alcohol use usually involved in deaths Potential tolerance, dependence, abuse Withdrawal characteristics: Anxiety is the primary symptom Seizure and death can occur No medication treatments

Controlled Substances: Stimulants Methylphenidate Ritalin (SR, LA) Concerta Methylin (ER) Metadate ER, CD Focalin (XR) Dextroamphetamine (Dexedrine) Amphetamine-Dextroamphetamine Adderall (XR) Lisdexamfetamine (Vyvanse)

Controlled Substances: Stimulants Mostly prescribed for ADHD Less commonly for narcolepsy, depression Potential SE: Decreased appetite Insomnia HA, stomachache Irritability Weight loss/growth suppression Paranoia, seizure, CV failure with high dose

Controlled Substances: Stimulants Potential for dependence, abuse Withdrawal characteristics: Irritability, anxiety Depression Sleep increase or decrease Increased appetite No medication treatments for withdrawal

Summary of Problems Tolerance, eventually reaching ceiling Dependence, leading to withdrawal In opioids and benzos Addiction Misuse and Diversion Lack of long-term effectiveness Side effects Hyperalgesia, Incr’d pain flares (opiates)

A Major Public Health Problem Opioids: Poisoning (90% drugs) second only to MVA as cause of accidental death Deaths doubled from 1999-2006 (37,000 per yr) Driven largely by 4-fold increase in opioid Rx Benzos: 80% of abuse is polydrug Enhance effects of opiates, etoh; alleviate w/drwl Stimulants: fewest reports of abuse 2006: 750,000 of 6.5 M Rx drug abuse cases

Management Strategies: Screen for Risk of Abuse Commonly used paper-and-pencil screens SOAPP ORT Review old records Thorough evaluation? Problems w/ past Drs? Inconsistent history? Substance use hx Urine drug screen at initial visit—matches hx? I WILL GIVE AN OVERVIEW, THEN SUMMARIZE SPECIFIC BHC CONTRIBUTIONS AT THE END

Management Strategies: Screen for Risk of Abuse Aberrant behaviors past or present? Changed Drs to get meds Use of etoh, drugs (+ meds) for sx relief Use of meds for other than intended purpose Refusal of non-medication programs, e.g. PT Refusal of long-acting meds Refusal of non-controlled substances (e.g., NSAID, SSRI, strattera) Prior Dr(s) refused to prescribe

Management Strategies: Monitor Use Use long-acting meds Avoid prn use of opioids Regular UDS At refill and other visits Problems: Illicit drugs Non-prescribed meds Absence of prescribed meds Establish functional goals and track

Management Strategies: Monitor Use Develop and use Controlled Substance Agreement (CSA) Purposes of a CSA Decrease: abuse/diversion, self-dosing, urgent pt calls, conflicts w/ staff, early RF Increase: discussion about meds issues, PCP satisfaction Components of a helpful agreement Education, conditions for refill, functional goals! Important to use routinely (not after a problem is suspected)

Management Strategies: Augment and Organize Care Offer individual BH visits For chronic pain, anxiety, ADHD, etc. For drug problems Offer group BH visits Consider requiring attendance Allows BH to follow more easily than 1:1 BH assistance with patient-PCP conflicts BH teaches PCPs behavioral strategies

Management Strategies: Augment and Organize Care Assist in development of clinical pathway For example: Require old records, workup, risk assessment before giving meds Pts w/ acceptable risk complete CSA, functional goals Required attendance at BH group Or other ancillary treatment, e.g. PT Provide refills at the group UDS at every visit Annual evaluation of progress, CSA renewal

Management Strategies: Summarizing the BH Role Assess risk of abusing meds Gather history, review old records Evaluate (e.g., ADHD, anxiety vs mania) Offer behavioral assistance 1:1 interventions Group visits for anxiety, chronic pain Help for drug abuse, dependence Monitor (complete CSA; measure progress) Assist in pathway development

THANK YOU! I HOPE YOU ENJOYED THIS COURSE Jeff Reiter, PhD, ABPP 1:45