Charlene M. Dewey, M.D., M.Ed., FACP Co-Director, Vanderbilt Center for Professional Health William H. Swiggart, M.S., L.P.C./MHSP Co-Director, Vanderbilt Center for Professional Health Martha E. Brown, M.D. Assistant Medical Director, PRN UF Associate Professor of Psychiatry

 All speakers acknowledge that they developed, teach, and operate CME courses (fee) for physicians and other health care providers on proper prescribing of CPDs.

1: Discuss current information regarding controlled prescription drug abuse in the U.S., including how physicians continue to overprescribe to their patients 2: Become familiar with the components of screening, brief intervention and referral to treatment, (SBIRT) 3: Identify specific strategies to avoid risky prescribing to help physicians avoid trouble with their Boards or the DEA (including the use of the state prescription drug monitoring program and CME education)

 Introduction  Proper prescribing  Continuing Medical Education interventions  SBIRT  Small group activity

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

“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 MBE 1990, adapted by both the North Carolina and TN Boards of Medical Examiners

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 has almost doubled from 7.8 million to 15.1 million in the past decade (1992 to 2003)2  New drug users of pain relievers-2.4 million. [marijuana (2.1 million) or cocaine (1.0 million)] Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005.

 Up to 43% of physicians DO NOT ask about controlled prescription drug abuse when taking a patient's health history  Only 19% received any medical school training in identifying prescription drug diversion  Only 40% received training on identifying prescription drug abuse and addiction5  many are not trained to effectively handle drug-seeking patients  due to “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

SAMHSA 2006

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

Why Physicians Misprescribe Controlled Substances  Family of origin  Core personality  Patient types  Pharmacological knowledge  Professional practice system

ADDICTION TREATMENT WORKS

 Average Age = 51  Male = 88%  Female = 11%  N = 715 Medical School Graduation January 1996 – March % 5% 10% 27% 32% 21% 2%

January 1996 – March 2010 Total N = 715

January 1996 – March % 7% N = % 7% 9% 3% 15%

 Misprescribing can happen easily  Many physicians are not trained to identify substance abuse, diversion, or correct protocols for pain management  Medical Boards are becoming more punitive with physicians who misprescribe  DEA is scrutinizing prescribing practices and the flow of controlled substances  Education can be helpful and is imperative!

 Provide fact-based education  Treat pain effectively and safely  Reduce contribution to diversion/misuse  Use SBIRT to increase referrals and interventions/treatments  Recognize warning signs of abuse or misuse  Avoid future misprescribing  Assist with Medical Board requirements  Avoid legal or professional sanctions by SMB or DEA in future

 61 of 69 physicians who completed the Prescribing Controlled Drugs Course at CPH strongly agreed that the course should be taught to all practicing physicians (3/ /2012).  The overall average self score on ability to take a substance abuse history prior to the course on 69 physicians was 2.8 – compared to 4.6 after the course.

 Additional education of physicians after residency is needed  Continuing Medical Education Courses proven helpful  Prescribing Controlled Drugs  Program for Distressed Physicians  Maintaining Proper Boundaries (Vanderbilt)

 Small group  Identify why/how physicians misprescribe  Family Systems  Personal reflection  Role play of common patient presentations  Syllabus of key lectures and readings  Discuss practice organization  Understand SBIRT and other tools

 20 hour course to meet Board of Medicine requirements for pain management specialists in Florida scheduled for June 2012 (University of Florida)  Professional Development Series – On-line modules (Vanderbilt University Medical Center)

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.

 Screening, Brief Intervention and Referral to Treatment (SBIRT) is a well-studied screening and intervention procedure to improve patients’ short- term health outcomes and reduce health care costs.  The Joint Commission has proposed SBIRT as a performance measure for accreditation. SBIRT Proposed Accreditation Standards Could Compel U.S. Hospitals to Screen Patients for Addictions (Bob Curley, 9/11/09)

 Individual and family history  “Have you ever used or currently use….[fill in the blank]?”  tobacco, ETOH, marijuana, street drugs, prescription drugs or other recreational drugs  Identify & quantify use  Within your family, has anyone ever used or currently use…  Use standard form/tests:  5 A’s  CAGE, AUDIT, DAST, MAST, CRAFT, ASSIST, etc.  Combination: SMaRT

The University of Pittsburg SMaRT©: ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) Last accessed Jan 10,

35 year-old female with fibromyalgia and low back pain who is requesting opioids for pain management Things to watch for:  Red flags to indicate aberrancy/addiction  Techniques to elicit relevant history in a patient with pain  How to deal with an angry, demanding patient  Technique for screening, referral, and brief intervention (SBIRT) Adopted from: Jackson T, Dewey C, Swiggart W, Baron M and Moore D. Guidelines for Proper Opioid Prescription. Vanderbilt University School of Medicine 2009

 Break into small groups  Discuss question  Prioritize two ideas per group  Two minute report out  Large group discussion

 Statements: Legal issues and consequences for misprescribing are becoming more prevalent. The Joint Commission is considering requiring SBIRT as a quality indicator.  Question: How might you involve your state to require physician training in SBIRT, use of the PDMP for all patients, and training proper prescribing practices to avoid misprescribing and consequences of misprescribing?

More states are passing laws that regulate prescribing:  Regulations for pain clinics  Regulations for who can prescribe  CME hours required in order to prescribe long-term narcotics  Laws making diversion for own use a possible felony  State Prescription Drug Monitoring Programs

 Continue to push for additional education of our medical students and residents  Raise awareness of DEA rules and changes that occur  Implement laws on regular use of State Prescription Monitoring Program  Monitor state laws and regulations that may be draconian with education of legislators

Most physicians are not bad physicians but lack:  information  tools to deal with patients who have substance abuse or difficult pain issues  resources  Small group education can make a difference  Prevention is first priority

 Reviewed guidelines and regulations  Described CPD problem  Discussed SBIRT  Reviewed CME courses and benefits  Planned for improvements in each state  Reviewed consequences and future directions

 The Center for Professional Health, Vanderbilt University Medical Center, Nashville, TN.  Prescribing Controlled Drugs: Critical Issues & Common Pitfalls of Misprescribing, The University of Florida at Gainesville, FL.