Center for Professional Health Proper Prescribing Practices: Prevention, Pitfalls and Challenges Charlene M. Dewey, M.D., M.Ed., FACP William H. Swiggart, M.S., L.P.C./MHSP Co-Directors, Center for Professional Health Vanderbilt University School of Medicine Nashville, TN Washington Hospital March 22 & 23, 2011

Center for Professional Health Goals The purpose of this session is to outline proper prescribing practices to help residents and practicing physicians avoid misprescribing practices that could harm patients or break rules resulting in loss of licensure. Participants will learn: 1.The rules of proper prescribing (based on the BME and the DEA) as well as internal and external factors that result in risky prescribing behaviors. 2.How SBIRT can help identify patients with substance use issues.

Center for Professional Health Objectives Upon completing the training, participants should be able to: 1.Self-identify personal risk factors and categories for misprescribing. 2.Identify at least 3 theories why physicians misprescribe. 3.List the 12 steps to trouble and discuss ways to improve practice behavior. 4.Discuss basic statistics around CPD abuse. 5.Define the difference between pseudoaddiction and addiction. 6.List components of SBIRT. 7.Reflect on current practices and determine improvements for proper prescribing practices.

Center for Professional Health Agenda 1.Introduction 2.Theories 3.Medical Board/DEA 4.Cases 5.Q&A 6.Summary

Center for Professional Health Ground Rules Everyone's opinion counts Respectful Interactive discussion All questions allowed – time at the end Time Flexible

Center for Professional Health Introduction The story of the Starbuck’s Manager

Center for Professional Health Introduction “To write a prescription is easy, but to come to an understanding with people is hard.” ~Franz Kafka A Country Doctor,1919

Center for Professional Health Introduction “It is not what you prescribe, but rather how well you manage the patient's care, and document that care in legible form, that is important.” ~Released by the Minnesota BME 1990, adapted by both the North Carolina and TN BME

Center for Professional Health Theories: Why Physicians Misprescribe Controlled Substances : –Family of origin –Core personality –Patient types –Pharmacological knowledge –Professional practice system

Center for Professional Health Misprescribing Definition: Prescribing scheduled drugs in quantities and frequency inappropriate for the patient’s complaint or illness. E.g.: –Known alcoholic or drug addict –Large quantities/frequent intervals –Family members –For trivial complaints

Center for Professional Health Twelve Steps to Trouble

Center for Professional Health Step 1 Ignore your pharmacist and don’t return his/her calls.

Center for Professional Health Step 1 - Lesson 1.Listen to your pharmacist. They are a good source of information about drug seeking patients. A major cause of reports by pharmacists to the BME is poor collegial relations between the pharmacist and the physician.

Center for Professional Health Step 2 If the BME sends an investigator to audit your charts for scheduled drug prescriptions, be rude and uncooperative.

Center for Professional Health Step 2 - Lesson 2.Cooperate: Hostility will only come back to haunt you. The investigator is only there to follow- up on a complaint about your prescribing scheduled drugs for certain patients. Your best defense is a well-documented chart and cooperation with the investigator.

Center for Professional Health Step 3 Schedule large numbers of patients daily.

Center for Professional Health Step 3 - Lesson 3.Know your limits. Working long hours for months or years with a daily commitment to a large number of patients greatly increases burnout and the chance of a medical error. The CME faculty is constantly amazed that physicians put themselves under severe pressure to see large numbers of patients. The investigator of their records cites them for poor or non- existent documentation.

Center for Professional Health Step 4 Keep your prescription pads in plain view and accessible at all times.

Center for Professional Health Step 4 - Lesson 4.Secure your prescription pad and DEA number: You are responsible for your DEA number and prescription pad. Drug seeking patients are constantly on the lookout for unattended pads.

Center for Professional Health Step 5 Pretend addiction doesn’t exist.

Center for Professional Health Step 5 - Lesson 5.Address Addiction: Chemical dependency is a disease, which responds to treatment. Early brief interventions have shown to be effective and saves health care dollars.

Center for Professional Health Step 6 Never say no to any request for Schedule II Drugs from a patient or colleague.

Center for Professional Health Step 6 - Lesson 6.It’s OK to say NO: It is important to document the need for Schedule II drugs in the patient’s chart. Never prescribe for a colleague or family member.

Center for Professional Health Step 7 Never refer your patients to a pain clinic or suggest any non-narcotic solutions for chronic pain management.

Center for Professional Health Step 7 - Lesson 7.Refer when appropriate: Pain clinics can be very helpful, though not always easy to access. Ask for their recommendations in writing and include them in the medical record.

Center for Professional Health Step 8 Rarely write anything in your chart that is legible or might explain why you are prescribing narcotics or benzodiazepines for a patient for years.

Center for Professional Health Step 8 - Lesson 8.Document: It is imperative that you document your plan for the patient and that it is legible. You will be unable to defend yourself if the investigator cannot read your writing or documentation is absent. This is the most frequent cause for an investigator reporting to the BME that the physician should be cited for inadequate prescribing practices.

Center for Professional Health Step 9 Do not have any written office policy regarding Schedule II drug refills, pain contracts, lost medication, or phone in prescriptions.

Center for Professional Health Step 9 - Lesson 9.Develop standards in your practice: Clearly defined written policies and pain contracts regarding schedule drugs, etc. save time and energy.

Center for Professional Health Step 10 Ignore family members concerns by not returning their phone calls or if you happen to speak to them remind them you are the doctor and unable to discuss potential addiction in their loved ones.

Center for Professional Health Step 10 - Lesson 10.Include families if appropriate: Family members can be important allies, especially when addiction is involved.

Center for Professional Health Step 11 Remain isolated from your peers and never ask for help.

Center for Professional Health Step 11 - Lesson 11.Keep up to date: Becoming uninformed about addictive potential of certain drugs is a major cause of medical error. Recent examples are OxyContin (oxycodone HCL) and Ultram (tramadol).

Center for Professional Health Step 12 Focus on the negative aspects of medicine today such as managed care and the loss of income.

Center for Professional Health Step 12 - Lesson 12.Focus on self-care: Malpractice suits and medical errors often occur in times of stress. Proper self-care is an important way to avoid these errors. Remember why you went into medicine!

Center for Professional Health Demographics

Center for Professional Health Course Demographics Total N = 771 Ave Age: 51 Male = 88% Female = 11% Medical School Graduation Year Jan – Nov % 5% 10% 26% 31% 22% 2%

Center for Professional Health Jan – Nov Total N = 771 Practice Type

Center for Professional Health Jan – Nov % 7% N = % 7% 8% 3% 16% Specialty Types

Center for Professional Health Categories of Misprescribing 1.Dated – Fails to keep current 2.Disabled – failed judgment due to impairment 3.Duped – fails to detect deception 4.Dishonest – personal or financial gain 5.Dismayed – Rx as quick fix due to time limits 6.Dysfunctional – finds it hard to say NO

Center for Professional Health Test Your Knowledge Dr “V” is a young physician out of residency training for three years. She attended a US medical school with a heavy focus on academics and research, scored well on her family practice board exams and has had no academic difficulty. She is opening a solo practice in rural Louisiana. She has experimented with marijuana while in college but has not used any since then. She drinks 1-2 glasses of wine in a week with dinners. She had a father who was an alcoholic and her mother suffered with depression for many years.

Center for Professional Health Test Your Knowledge Dr. V’s demographic that is most associated with misprescribing is which of the following? 1)Her female gender 2)Her experimentation with marijuana 3)Her risk of alcoholism 4)Her board scores 5)Her rural, solo practice 6)Her choice of family practice 7)Her consumption of ETOH 8)Her training in a US medical school 9)I don’t know

Center for Professional Health Test Your Knowledge From the list below select the two theories most consistent with why physicians misprescribe controlled substances. a)Family of origin and professional practice systems b)Type of medical school attended and patient types c)Residency training location and US vs. foreign training programs d)Gender of the patient and knowledge of pharmacology e)I don’t know

Center for Professional Health Test Your Knowledge Dr X is on the last patient of the day. He is trying to get to his daughter’s symphony performance. The last walk-in patient complains of back pain after he lifted a dresser while moving 10 days ago. The pain is improved but still bothering him especially at night. The patient asks for Percocet by name. Dr X did not have time to ask about other pain control or complete a full back and neurological exam. Dr X provides a prescription for Percocet, dispense #15 tabs with no refills before leaving the clinic.

Center for Professional Health Test Your Knowledge This physician has misprescribed due to being: a)Duped b)Dishonest c)Dismayed d)Dated e)Disabled f)I don’t know

Center for Professional Health Controlled Prescription Drugs

Center for Professional Health Controlled Prescription Drugs The problem: –Substance abuse, including controlled prescription medication, is the nation's number one health problem affecting millions of individuals. 4 –Rate of controlled prescription drug (CPD) abuse - ~ doubled from 7.8 mil to 15.1 mil in last decade ( ) 2 –Adults >18 is up by 81% Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC National Survey on Drug Abuse and Health, SAMHSA

Center for Professional Health Controlled Prescription Drugs New drug users of prescription opioids = 2.4 million –Marijuana (2.1 million); Cocaine (1.0 million) Total use is > those abusing cocaine, hallucinogens, heroin, and inhalants combined! “the most commonly used illicit substance.” DEA Practitioners Manual 2006 ed.; Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005.

Center for Professional Health Controlled Prescription Drugs More “new users” tried opioids for non- medical reasons in the past year than any other illicit drug CDC: –Opioid prescription painkillers cause more drug overdose deaths than cocaine and heroin combined –Increased ER visits –Increased accidental deaths –Health care costs = millions of dollars annually DEA Practitioners Manual 2006 ed.; Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC National Survey on Drug Abuse and Health, SAMHSA

Center for Professional Health Controlled Prescription Drugs Rate has nearly tripled in the teenage population 2 Children aged are abusing CPD more than adults at a rate estimated at 212% vs. adults Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC National Survey on Drug Abuse and Health, SAMHSA

Center for Professional Health Statistics on Illicit Opioid Use Americans = 4.6% of world’s population –Use 66% of world’s illicit drugs –Use 80% of global opioid supply –Use 99% of global hydrocodone supply 2006 National Survey on Drug Abuse and Health, SAMHSA

Center for Professional Health Controlled Prescription Drugs Prescription drug diversion is simply the deflection of prescription drugs from medical sources into the illegal market. 18 Physicians remain the #1 provider of CPD Sources: doctor shopping illegal internet pharmacies drug theft prescription forgery illicit prescribing by physicians family members U.S. Department of Justice, Drug Enforcement Administration, Prescription Accountability Resource Guide, September 1998, (5 January 2004).

Center for Professional Health Controlled Prescription Drugs Up to 43% of physicians DO NOT ask about CPD abuse in patient's history Only 19% received any MS training - identify diversion Only 40% received training on identifying CPD abuse and addiction 5 “Confrontational Phobia”- a term used to describe physicians’ reluctance to say “no” to a patient, thus making physicians an “easy target for manipulation.” 5 Bollinger et al, 2005

Center for Professional Health Test Your Knowledge The majority of scheduled drugs that find their way to the street get there by physician prescribing practices. a)True b)False c)I don’t know The majority of controlled drugs on the street are obtained from family and friends from previous prescriptions. a)True b)False c)I don’t know

Center for Professional Health The DEA & Medical Boards What is the difference between the medical boards and the DEA?

Center for Professional Health Controlled Substances Act (CSA) CSA 1970: DEA assigned legal authority for the regulation of controlled substances (illicit and licit) Responsibility is two-fold: 1.The prevention, detection, and investigation of the diversion of controlled substances from legitimate channels 2.Ensuring that adequate supplies are available to meet legitimate domestic medical, scientific, and industrial needs

Center for Professional Health Controlled Substances Act (CSA) Monitors: –Diversion to Illicit Use  Self  Others –Maintenance of addictions –Iatrogenic addictions Five (5) schedules

Center for Professional Health Controlled Substances Act (CSA) Must be registered Registration can be suspended or revoked by the Attorney General upon a finding that the registrant: falsified any application filed been convicted of a felony had State license or registration suspended, revoked, or denied by competent State authority committed acts as would render his registration inconsistent with the public interest been excluded (or directed to be excluded) from participation in a program pursuant to section 1320a- 7(a) of title 42.

Center for Professional Health Test Your Knowledge 1.What constitutes schedule I or other schedules assignments for drugs? 2.Identify the schedule for each of the following: Marijuana; morphine; heroin; codeine; LSD; opium; amphetamine; cocaine; hydrocodone 3.How often do you renew your DEA registration and what happens if you move? 4.Which schedules can be refilled? 5.Can scheduled II prescriptions be faxed? DEA Practitioner’s Manual 2006; pg. 5-6 & 9-11 & 21-22

Center for Professional Health Answers Q1: What constitutes schedule I or other schedules assignments for drugs? Schedule I: no accepted medical use in the US; therefore, cannot be prescribed, administered or dispensed for medical use; no evidence of safety; high potential for abuse Schedule II-V: some accepted medical use and can be prescribed, administered, or dispensed for medical use; High potential for abuse; descending order (II > III > IV >V) DEA Practitioner’s Manual 2006; pg. 5-6

Center for Professional Health Answer Q1 : (cont.) Schedule III: –<15mg of hydrocodone (Vicodin® & Lortab®) –<90mg of codeine Schedule IV: –narcotics (propoxyphene) & benzodiazepines Schedule V: –<200mg of codeine/100 ml or g (Robitussin AC® & Phenergan with codeine®) DEA Practitioner’s Manual 2006; pg. 5-6

Center for Professional Health Answer Q2: Identify the schedule for each of the following drugs. Schedule I: –Marijuana –Heroin –LSD Schedule II: –Marinol (Dronabinol) - medical marijuana –Morphine –Codeine (II-V) –Opium –Amphetamine –Cocaine –Hydrocodone (II-III) DEA Practitioner’s Manual 2006; pg. 5-6

Center for Professional Health Answer Q3: How often do you renew your DEA and what happens if you move? Renew DEA registration q3 years –Sent 45 days prior to expiration –Sent to address on file; will not be forwarded –If you don’t receive it w/in 30 days, call Relocating: modify application on- DEA Practitioner’s Manual 2006; pg. 9-11

Center for Professional Health Answer Q4: Which schedules can be refilled? Schedules III-IV can be refilled on the prescription –Up to 5 times w/in 6 mo Scheduled II: –Refilling a prescription for a controlled substance listed in schedule II is prohibited (Title 21 US Code $ 829(a)) –No federal timeline of must be filled from signing –No federal limit on quantity; some states limit to 30 day supply DEA Practitioner’s Manual 2006; pg

Center for Professional Health Answer Q5: Can scheduled II prescriptions be faxed? Expedite filling: –Schedule II prescriptions can be faxed but pharmacist cannot dispensed until they have original Rx. Emergencies: –MD may call in schedule II by telephone –Amount limited to treat during the emergency period –Original written/signed must be presented to the pharmacist w/in 7 days –Pharmacy MUST notify DEA if Rx is not received DEA Practitioner’s Manual 2006; pg

Center for Professional Health Test Your Knowledge A patient from one of your colleagues calls on a Saturday night complaining of pain in his abdomen. He says that Dr “P” who usually sees him is out of town. He would like some lortabs (hydrocodone/ acetaminophen) 10/500 mg because he has taken this before. His pain is diffuse and he has chronic constipation. It started this morning and he has not taken anything for it. He has hypertension, diabetes and coronary artery disease. He denies fevers, chills, nausea or vomiting. He denies blood in the stool or changes in stool patterns. He states that Dr “P” usually gives him about sixty tabs when he has these “flair ups.” You are covering for the weekend and are not familiar with Dr “P”.

Center for Professional Health Test Your Knowledge What is the most appropriate statement for this gentleman at this time? a)I am uncomfortable managing this disorder at this time. You will need to go to the ER. I cannot call in the medication at this time. b)I am uncomfortable managing this disorder. You must go to the ER now but I can call in the medication after you have been evaluated. c)I am concerned about your pain but can only call in 30 tabs. d)I am concerned about the pain and will call in the amount requested. e)I can understand your situation and will call in the medications now. f)I understand you are in pain but cannot call in medications until Monday. g)I don’t know

Center for Professional Health Test Your Knowledge Which of the following is a correct statement regarding addiction to narcotics? a)More people are addicted to prescription controlled substances than heroin, cocaine and other illicit drugs combined b)Controlled substance use accounts for more deaths by overdose than does heroin and cocaine combined c)Prescription controlled substances have a street value of about $1.00/mg d)Prescribed controlled substances are monitored from production to distribution to dispensing e)All of the above f)None of the above g)I don’t know

Center for Professional Health Board of Medical Examiners Complaint driven Judge practitioners based on behavior, not on patient outcome Distinguish between human error and intentional reckless behavior

Center for Professional Health Board Process Complaint is filed and reviewed that evidence exists of a possible violation: 1.An investigator is assigned to make an inquiry 2.A “notice of complaint” is sent to the doctor and an explanation may be requested 3.Investigator: Schedule a meeting or Just show up 4.An immediate suspension of the doctor’s license can be issued if the public is deemed at risk

Center for Professional Health Management of Prescribing The Board DOES have the expectation that the physician will create a record that shows: −Proper indication for the use of the drug −Monitoring of the patient −The response based on follow-up visits −Rationale for continuing or modifying therapy

Center for Professional Health Test Your Knowledge Which of the following are most correct with regards to the key issues around medical boards identifying misprescribing? a)Each state’s medical board has a defined definition of misprescribing regarding quantity and frequency of refills b)Medical boards look at prescribing patterns regardless of type of medication c)Medical boards do not use complaints as a means to recognize misprescibing d)Medical boards identify misprescribing for those physicians prescribing out of their scope of practice e)I don’t know

Center for Professional Health Test Your Knowledge From the list below, select the item(s) that the DEA sanctions. a)Self prescribing scheduled drugs b)Diversion of illicit drugs to others c)Maintenance of addictions d)Iatrogenic addictions e)All of the above f)None of the above g)I don’t know

Center for Professional Health Test Your Knowledge The DEA has the authority to deny, suspend, or revoke a DEA registration upon finding that the registrant has: a)Falsified a filed application b)Committed an act that would render DEA registration inconsistent with public interest c)Been excluded from Medicare or Medicaid program d)Been convicted of a felony relating to a controlled substance e)All of the above f)None of the above g)I don’t know

Center for Professional Health Proper Prescribing Practices

Center for Professional Health United States Department of Justice Drug Enforcement Administration Office of Diversion Control Practitioner’s Manual An Informational Outline of the Controlled Substances Act 2006 Edition DEA remains committed to the 2001 Balanced Policy of promoting pain relief & preventing abuse of pain medications.

Center for Professional Health Proper Prescribing Practices Safeguards for Prescribers: 1.Keep all prescription blanks in a safe place where they cannot be stolen. 2.Use electronic prescriptions when possible or use only one prescription pad at a time. 3.Use ONLY tamper-resistant prescription paper 4.Never sign blank prescriptions. 5.DO NOT use prescription blanks for writing notes 6.Assist the pharmacist when they telephone to verify information about a prescription order. 7.Contact the nearest DEA field office to obtain or to furnish information regarding suspicious prescription activities. DEA Practitioners Manual 2006; pg. 15

Center for Professional Health Proper Prescribing Practices Example: Name Strength Dosage form Quantity Indication Directions # of refills Pt’s full name & address Physician’s name, address & DEA # Manually signed Dr Suremakes Me Feel good Any Practice, USA cal-ford Patient: Wanna Feelgood Address: 1 Skid Row Way Today 2011 Hydrocodone/Acetamenophin 5/500 mg 1 tab po q4 hrs PRN pain Disp: #20 tabs (Twenty Tabs) – NO REFILLS Dispense as writtenSubstitution Suremakes M. Feelgood, M.D. DEA Practitioners Manual 2006; pg. 18

Center for Professional Health Proper Prescribing Practices Federal courts expect a “legitimate medical purpose in the usual course of professional practice.” Follow the general rules: 1.Avoid prescribing large quantities of controlled substances. 2.Avoid large numbers of prescriptions issued compared to other physicians.* 3.DO document history & physical examination. 4.DO screen for substance abuse. *Given your discipline DEA Practitioners Manual 2006 ed.

Center for Professional Health Proper Prescribing Practices 5.DO NOT warn patient to fill prescriptions at different pharmacies. 6.DO NOT issue prescriptions to patients known to divert drugs. 7.DO NOT issue prescriptions in exchange for sexual favors or for money. 8.AVOID prescribing controlled drugs at intervals inconsistent with legitimate medical treatment. 9.AVOID prescribing drugs when there is NO relationship between the drugs prescribed and condition being treated. DEA Practitioners Manual 2006 ed.

Center for Professional Health Prescribing Boundaries

Center for Professional Health Four Step Approach Step 1 – Workup with appropriate screening measures Step 2 – Implement full SBIRT – if a screen is positive Step 3 – Develop appropriate plan of care & reassessment criteria Step 4 – Document, Document, Document!

Center for Professional Health Test Your Knowledge Dr “V” is a young physician out of residency training for three years. She attended a US medical school with a heavy focus on academics and research, scored well on her family practice board exams and has had no academic difficulty. She is opening a solo practice in rural Louisiana. She has experimented with marijuana while in college but has not used any since then. She drinks 1-2 glasses of wine in a week with dinners. She had a father who was an alcoholic and her mother suffered with depression for many years.

Center for Professional Health Test your Knowledge There are some preventive measures to help with prescribing narcotics in your office. Based on the scenario in question above, what is the best option for this physician? a)Create an office policy of not prescribing schedule drugs to new patients. b)Recommend all refills be done over the phone. c)Advise patients that they must list all other physicians who prescribe narcotics for them. d)Provide the nurses with signed, extra prescriptions to refill only if the patient returns to the office. e)All of the above f)None of the above g)I don’t know

Center for Professional Health Test Your Knowledge The definition for misprescribing controlled substances includes prescribing drugs in quantities or frequencies inappropriate for the patient’s complaint or illness. Please select the scenario(s) below that constitute misprescribing? a)Prescribing only large quantities and at frequent intervals b)Prescribing to a patient with a history of ETOH addiction in recovery for 6 months without accurate documentation of addiction treatment plans c)Prescribing to family members without documentation of emergent situation d)Prescribing for minor injuries without having tried non- narcotic medications first e)Prescribing for health care professionals in your office setting f)All of the above g)None of the above h)I don’t know

Center for Professional Health Test Your Knowledge Ms “B” is a 65 year old female with fibromyalgia and depression. Her spouse died last week and she presents to your office because her pain is increased. The funeral is tomorrow and she needs only a few Vicodin® to get her through the day. If you prescribe the vicodin® for Ms “B”, you are crossing what prescribing boundary? a)Factitious disorders b)Medicalization of social problems c)Somatoform disorders d)Circumscribed medical illness e)I don’t know

Center for Professional Health Use, Dependence and Abuse “Addiction doesn’t come heralded by a brass band, it sneaks up on you, and sometimes with extraordinary speed” C. Everett Koop (former US Surgeon General), 2003

Center for Professional Health Use, Dependence and Abuse Appropriate use of controlled substances for pain control Temporary or long term DSM-IV: 2 opioid use disorders 1.Opioid Dependence 2.Opioid Abuse

Center for Professional Health Dependence Physical Dependence: A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (ASAM) Leading to clinically significant impairment or distress upon ceasing - withdrawal

Center for Professional Health Dependence Physical dependence necessitates the continued presence of a drug in order to prevent a withdrawal or abstinence syndrome. Substance dependence has several features in common with diabetes and hypertension −Chronic, relapsing −Genetic vulnerability −Physiologic brain changes −Responds to chronic disease management strategies, not short-term symptom relief

Center for Professional Health Treatment Prevents Relapse Relapse Rates

Center for Professional Health Tolerance Tolerance: Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction. Tolerance does not develop uniformly for all actions of these drugs, giving rise to a number of toxic effects. Tolerant users can consume doses far in excess of the dose they took.

Center for Professional Health Pseudoaddiction Pseudoaddiction: The iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug- seeking behaviors that are commonly seen with addiction. The relief seeking behaviors resolve upon institution of effective analgesic therapy.

Center for Professional Health Dependence vs. Abuse Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and are not the same as addiction. Use Tolerance Dependence Pseudoaddiction ≠ Abuse Addiction

Center for Professional Health Abuse Abuse: Manifested by three of the following within a 12-month period −Tolerance – increased amounts for same effect or diminished effect −Withdrawal syndrome −Larger amounts −Can’t cut down −Time spent in obtaining, using or recovering −Social, occupational or recreational activities are given up or reduced

Center for Professional Health Addiction Addiction: Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations It is characterized by behaviors that include the following: −Impaired c ontrol over drug use, craving, compulsive use, and continued use despite harm = 4c’s (ASAM) −Behavior is reinforcing; loss of control (NIDA)

Center for Professional Health Suspect Drug-Seeking Behavior in the Patient who…

Center for Professional Health Drug Seeking Patients 1.Transient-passing through 2.Feigns physical or psychological problems 3.Pressures the physician for a particular drug or multiple refills of a prescription 4.Red flags in presentation and PE findings 5.Assertive Personality, demanding, overacting

Center for Professional Health Drug Seeking Patients 6.Unwilling to provide references/medical records 7.No PCP 8.Cutaneous signs of drug use 9.Has no interest in diagnosis 10.Rejects all forms of treatment that do not involve narcotics

Center for Professional Health Test Your Knowledge Case 1: Pt complains of 10 out of 10 pain and calls frequently requesting increased dose of medications on post-op day #2 Case 2: Pt requests increased dose of medication 6 weeks after treatment for metastatic breast cancer with increased bone mets Pseudoaddiction Tolerance

Center for Professional Health Test Your Knowledge Case 3: Pt attempts to steal a prescription pad from your office Case 4: Pt traveled and ran out of medications on day 4 of their 10 day trip and is calling from out of town because they are having flushing, N/V/D, muscle pains and agitation Abuse Withdrawal

Center for Professional Health Cases

Center for Professional Health SBIRT S Screening – Screening patients at risk for substance abuse; inquiring about family history of addiction; using screening tools such as the NIAA 1-question screening tool for alcohol use, AUDIT, CAGE, CRAFT for adolescents, etc. BI Brief Intervention - Establish rapport with pt; ask permission; raise subject; explore pros/cons; explore discrepancies in goals; assess readiness to change; explore options for change; negotiate a plan for change-(motivational interviewing) RT Referral to Treatment – For patients responding positively to the screening tests, refer to AA, drug addiction clinic, pain clinic, counseling, etc.

Center for Professional Health Case 1: “I’m calling the Medical Board!”

Center for Professional Health Screening Ask 3 questions: 1.Are you a current, former or never tobacco user? 2.Do you sometimes drink beer, wine or other alcoholic beverage? 3.In the past have you used any of the following drugs (other than for medical reasons): _________?

Center for Professional Health Motivational Interviewing Developed late 1970’ – Bill Miller & Stephen Rollnick “Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”

Center for Professional Health Motivational Interviewing Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal. Focus is on “change talk”

Center for Professional Health Motivational Interviewing OARS: –(1) Open-ended questions –(2) Affirmations –(3) Reflective listening –(4) Summaries

Center for Professional Health Example - Summary "Let me stop and summarize what we've just talked about. Your not sure that you want to be here today and you really only came because your partner insisted on it. At the same time, you've had some nagging thoughts of your own about what's been happening, including how much you've been using recently, the change in your physical health and your missed work. Did I miss anything? I'm wondering what you make of all those things."

Center for Professional Health Referral to Treatment Addiction medicine specialist AA NA Other community-based programs Detox – inpt vs. outpt

Center for Professional Health Example

Center for Professional Health Case 2: Nurse Betty You are walking from your patient’s room heading toward conference. One of your favorite nurses runs up next to you as you walk and says, “Dr X I am so glad I saw you. I am having an awful migraine HA. Can you prescribe me some pain medication until I get home to take my migraine medicine? Maybe just 5-10 tabs of something strong like Percocet® or Lortab®? My sister had some for her M-HA and said they worked well for her.” You quickly write the prescription and after conference you are paged from the ER because nurse Betty just had a severe allergic reaction and your name was on the bottle. The sister, also a nurse, calls the medical board.

Center for Professional Health Case 2: Nurse Betty Wrote Rx and RN had bad reaction to it Proper prescribing issues Documentation Board investigations

Center for Professional Health Test Your Knowledge Most physicians who are sanctioned by the board for misprescribing controlled substances are most often sited for which of the following reasons? a)Poor documentation for indication and quantity of controlled substances b)Poor documentation of physical exam c)Poor documentation of complaint and review of systems d)Prescribing for a family member without documentation e)Self-prescribing with clear documentation f)Prescribing for a colleague with illegible writing g)I don’t know

Center for Professional Health Case 3: My Girlfriend’s Knee You are a third year resident dating a biochemistry graduate student. Over the weekend she fell playing tennis. Her knee is obviously swollen, red and tender to the touch. There are no open lesions and no signs of infection. You are on call in the hospital when she calls you. You suggest she goes to the ER but she insists she has to get back to the lab to run an important experiment before Monday. She is in a lot of pain and can hardly move it. She took two T-500 mg with only minimal improvement. She asks you to call in something so she can get back to the lab. You call in 10 tabs of hydrocodone/acetaminophen to last through the next two days and she leaves a message with her PCP’s office to come in on Monday.

Center for Professional Health Case 3: My Girlfriend’s Knee Is this a reportable issue? What is the best course of action?

Center for Professional Health Test your Knowledge A 55 year old woman stubbed her toe on the bedpost two weeks ago. She went to the ER after the event and her toe was buddy taped after the foot films showed ligamentous inflammation and soft tissue swelling without acute fracture. She received ten (10) hydrocodone/acetaminophen 5/500 tabs at that time. She drops into your clinic for refills and notes she is still anxious, depressed and upset that she cannot sleep well and she slept better on the hydrocodone. The toe hurts some but is improved overall and she is back at work. The swelling of the digit is resolved.

Center for Professional Health Test Your Knowledge What is the next best course of action? a) Refill the hydrocodone for a longer period of time b)Refill the hydrocodone for the same amount of time c)Refill the hydrocodone for less tabs d)Prescribe another narcotic instead of the hydrocodone e)Refill the hydrocodone but also address the anxiety issue f)Do not refill the hydrocodone g)I don’t know

Center for Professional Health Test Your Knowledge 1.List 5 characteristics of someone who maybe drug seeking. 2.What is SBIRT? 3.Describe motivational interviewing.

Center for Professional Health Test Your Knowledge Pt “X” presents to your office as a walk-in from Memphis, TN on Friday afternoon. He is new in town and is asking for a refill of his Xanax and hydrocodone. He says he is in between jobs and is just passing through. He will leave for New Jersey on Sunday morning for a Monday job interview. He takes both medications for renal stones that he has had for 5 years and they constantly irritate him. The pain is an 8-9 out of 10 on the pain scale when it is really bad and 5-6 daily. He does not have any medical records with him and cannot recall the doctor’s name in Georgia that gave him the last prescription. He ran out yesterday and does not have a prescription bottle with him. He cannot stay to see a consultant because he is leaving on Sunday.

Center for Professional Health Test Your Knowledge How many items in this history are red flags for potential drug abuse? a)None b)1 c)2 d)3 e)4 f)5 or more g)I don’t know

Center for Professional Health Test Your Knowledge Questions in the CAGE assessment include which of the following: a)Cut down on drinking b)Alcoholism in the family c)Guilty of a DUI d)Elevated mood with substance e)All of the above f)None of the above g)I don’t know

Center for Professional Health Questions & Answers

Center for Professional Health Summary Reflection and self-identification of possible risk factors Familiarize yourself with DEA and SMB rules and regulations Use proper prescribing practices Use SBIRT and identify at risk patients Treat pain appropriately

Center for Professional Health References Manchikanti L, Whitfield E, Pallone F. Evolution of the National All Schedules Prescription Electronic Reporting Act (NASPER): a public law for balancing treatment of pain and drug abuse and diversion. Pain Physician. Oct 2005; 8(4): Substance Abuse: The Nation’s Number One Health Problem; Key Indicators for Policy Update. The Robert Wood Johnson Foundation. February Bollinger LC. Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. The National Center on Addiction and Substance Abuse (CASA) Screening and Brief Intervention : Making a Public Health Difference (Join Together) Robert Wood Johnson, A Pocket Guide for Alcohol Screening and Brief Intervention. NIAAA 2005 Volkow, ND et al., Journal of Neuroscience 21, , McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000 Gelernter et al. Am J Hum Genet May;78(5): Drakenberg et al. Proc Natl Acad Sci U S A Mar 7;103(10):

Center for Professional Health Web Pages DEA webpage: Last accessed Rules of the TN State Board of Medical Examiners: Last accessed 8/27/10 TN State Board of Medical Examiners: Last accessed 8/27/10 TN State DEA Prescribing Monitoring Program: Federation of State medical Boards web page: Last accessed 8/27/0 FSBM: Last accessed 8/27/10 KASPER website: Manual: An Informational Outline of the Controlled Substances Act 2006 Edition National Institute on Drug Abuse (NIDA) National Survey on Drug Abuse and Health, SAMHSA MD Consult L.L.C. Bookmark URL: /das/book/view/ /959/I366.fig/top

Center for Professional Health Screening Tools For (+) screen: Tobacco: 5-A’s ETOH: Several options NIAAA’s 1 Q approach: −Do you drink beer, wine, or other alcoholic beverages? −Men: 5 or more drinks a day −Women: 4 or more drinks a day CAGE: Cut down, Annoyance, Guilty, Eye opener ASSIST: The Alcohol, Smoking, and Substance Involvement Screening Test – WHO; 8 Q

Center for Professional Health Screening Tools Other screening tools for ETOH: −AUDIT: 10 Q; reliable and valid tool; >8=risk/harmful ETOH consumption −MAST: Michigan Alcoholism Screening Test; 22 Q; ranks as no problem (<2); early or middle (3-5), and more problem drinker (6 or more) −CRAFT: 6 Q mnemonic for adolescents; 2 or more = problem drinking −DAST: Drug Abuse Screening Test; 28 Q; >5 problem −T-ACE: for pregnant women; adopted from CAGE See reference for “Join Together“ and NIAA pocket card