1. USE OR ABUSE A QUESTION OF ACCESS

2. DRUG ABUSE Improper or Excessive Use or Misuse of a Drug or Illicit Drug

3. BRAIN CHANGES Drug or chemical use changes the brain Makes it harder to stop using drugs Encourages increased use to chase the high National Institute on Drug Abuse (NIH) Drug Facts: Understanding Drug Abuse and Addiction found at: https://www.drugabuse.gov/publications/drugfacts/understanding-drug- abuse-addiction

4. OVERDOSE MAPS The following slides - will show the United States from 2002 through 2014 - CDC statistical estimates - The colors range from dark green to off-white to red Dark GREEN 0-2 deaths per 100,000 Dark RED > 20 deaths per 100,000 - Courtesy of TIME ® via http://time.com/4260798/drug-epidemic- america/?xid=newsletter-briefhttp://time.com/4260798/drug-epidemic- america/?xid=newsletter-brief - Time data was obtained from County Health Rankings & Roadmaps project

5. 2002

6. 2004

7. 2006

8. 2008

9. 2010

10. 2012

11. 2014

12. WHAT DRUGS ---  Opioids – Oxycodone, Hydrocodone, Methadone, Fentanyl  Benzodiazepines – Alprazolam, triazolam, diazepam  Stimulants – Phentermine, Amphetamines ( Ritalin, Adderall, Concerta)  Ketamine  Illicit Drugs – Marijuana, Cocaine, LSD, Methamphetamine

13. ACCESS - HOW DO PEOPLE GET PRESCRIPTION DRUGS 1.Legitimately – Patient-Prescriber relationship 2.Diversion by prescription – Little documentation of need – “Pill Mill” 3.Illicit internet drug sites 4.Diversion – Healthcare professionals, pharmacy technicians, medication aides, etc. 5.Robberies -

14.  Deaths from opioid overdose by prescription narcotic painkillers Have tripled in the US since 2000 -WebMD 

15. HOW DO WE STOP ACCESS FOR ABUSE 1. Education 2. KTRACS 3. Stop Diversion

16. EDUCATION - - - - - Prescribers : - Black Box Warnings (new for immediate release) - CDC Guidelines for Prescribing Opioids – http://www.cdc.gov/drugoverdose/prescribing/resources.html - How to better monitor patients - Learn about abuse-deterrent formulations - Use tools like KTRACS - Monitor any drugs kept at the office - Be aware of office employees and any potential for diversion from the office or from patients

17. EDUCATION - - Pharmacists: - How to Counsel more appropriately – Appropriate dosing - Interactions with food and drinks - How to store prescriptions - What to do / Who to call in the event of accidental overdose - Being observant and listen to patient - Know the CDC Guidelines and Black Box Warnings - Use tools like KTRACS - Be aware of other employees with drug access

18. EDUCATION Nurses: - Be observant of the patient - Listen to verbal clues of misuse - Be aware of fellow employees Patients: - Talk with prescribers and dispensers - Learn where to go for help

19. KTRACS Designed to allow prescribers and dispensers to review patient history of controlled drug prescriptions filled by the patient 49 states have the prescription monitoring program InterConnect allows the KTRACS user to pull information from many other states 16 states have mandatory utilization requirements by prescribers and dispensers The program is NOT designed to prevent legitimate patients from obtaining drugs for their legitimate use. Allows collaboration between prescribers and pharmacies

20. DIVERSION - Drug diversion is the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber - - - CMS definition

21. WHEN HEALTHCARE PROFESSIONALS DIVERT Increased potential to divert following an injury or surgery Increased Accessibility to drugs or the ordering process Financial problems “Helping” a family member or friend Effects of Diversion Impaired Care Giver increases potential for error or errors of omission Patient denied pain medication and relief

22. DIVERSION - - ILLEGAL DISTRIBUTION Places where drugs are stored: BE observant of your fellow workers Even the most trusted can or may become a diverter LIMIT access Hospitals – Automated dispensing machines Pharmacies – Perpetual inventories - Lock up all controlled drugs - Question authenticity of peculiar prescriptions Long term care facilities – Keep drugs locked and utilize sign out sheets Prescriber’s offices – Keep script pads and drugs locked up Consumers – keep drugs up and out of sight – don’t advertise

23. .

24.  Deaths from opioid overdose by prescription narcotic painkillers Have tripled in the US since 2000 -WebMD 

25. PREVENTION OF OVERDOSES Abuse Deterrent Formulations – 5 different long-acting drugs oOxyContin – oxycodone – hard to crush making it unsuitable for dissolving or snorting oEmbeda – morphine sulfate and naltrexone hydrochloride in Extended- release Capsules – if crushed – naltrexone is an opioid antagonist oHysingla ER – hydrocodone – hard to crush and forms a viscous hydrogel which cannot be easily injected. oZohydro ER – hydrocodone – forms a viscous hydrogel in liquids or solvents oTarginiq ER – oxycodone and naloxone in an extended release formulation 1 immediate release (newly released) oOxaydo – oxycodone – an inactive ingredient adds the abuse deterrent feature causes burning in the sinuses and throat irritation if snorted

26. PREVENTION OF OVERDOSES Naloxone -  17 states plus DC have changed their laws to allow access and use of Naloxone. (Kansas is not one of these states)  Naloxone is a narcotic antagonist and can counteract an overdose of opioid drugs. Opioids cause depression of the central nervous and respiratory systems. Naloxone reverses those effects.  Naloxone used to treat overdoses comes in injectable and intranasal forms. Time to see an effect is 2 – 5 minutes and the effect lasts 30 minutes to an hour. (The person who has OD may need more than one shot as the Opioid have a longer half-life than naloxone. )  Kit – Evzio ® has 2 auto injectors  Nasal spray is designed to be administered while the person is lying down. A second dose may be required.

27. NALOXONE - CONTINUED Side Effects: - Chest Pains - Seizures - Allergic Reactions - Acute withdrawal leading to nausea/vomiting, sweating, shaking, burning sensation of the skin Drug interactions: - Tramadol - Topiramate (Qsymia/Topamax) - Clonidine - Yohimbine - All opioid drugs – as is expected

28. PREVENTION OF OVERDOSES As with all overdoses: Time is critical If naloxone is administered be prepared to give a second dose Get to medical treatment immediately Treatment – Addiction services: SAMHSA – website with all opioid treatment centers http://dpt2.samhsa.gov/treatment/directory.aspx

29. PROBLEMS FOR LEGITIMATE PATIENTS Laws and Regulations: 1.Limitations in quantities prescribed or dispensed 2.Denying medications to patients with known substance abuse 3.Black Box warnings 4.Manufacturer quotas on manufacturing lead to shortages 5.Quotas on how much a pharmacy can purchase for dispensing 6.Increasing costs to the patient for abuse-deterrent drugs 7.Pill Mills taking more of the available drugs for illicit use

30. HOW TO BETTER ENSURE ACCESS TO LEGIT PATIENTS Decrease diversion of all drugs Encourage use of KTRACS (prescription monitoring) One Prescriber with prescriber collaboration Allow prescribers to assess appropriate quantities One Pharmacy of the patient’s choice

31. REFERENCES: 1.National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. Retrieved April 4, 2016 from https://www.drugabuse.gov/publications/drugfacts/understanding- drug-abuse-addiction https://www.drugabuse.gov/publications/drugfacts/understanding- drug-abuse-addiction 2.Wilson, Chris. (2016, March 16) Watch How the Drug Overdose Epidemic Spread in America. TIME. Retrieved April 14, 2016, from http://time.com/4260798/drug- epidemic-america/?xid=newsletter-briefhttp://time.com/4260798/drug- epidemic-america/?xid=newsletter-brief 3.Centers for Medicaid and Medicare Services. 2012. Center for Program Integrity. 4.WebMD - http://www.webmd.com/mental-health/addiction/drug-overdose- naloxonehttp://www.webmd.com/mental-health/addiction/drug-overdose- naloxone 5.Centers for Disease Control and Prevention (CDC). CDC’s Guideline for Prescribing Opioids for Chronic Pain. 2016 March 15. Retrieved April 15, 2016 from http://www.cdc.gov/drugoverdose/prescribing/resources.html http://www.cdc.gov/drugoverdose/prescribing/resources.html 6.SAMSHA. Medication-Assisted Treatment for Substance Use Disorders. Opioid Treatment Program Directory. http://dpt2.samhsa.gov/treatment/directory.aspxhttp://dpt2.samhsa.gov/treatment/directory.aspx