1. Not What the Doctor Ordered: Prescription Drug Misuse & Abuse in Older Adults INSERT YOUR NAME HERE
This slide set provides 2 presentation aids:
Teaching Points - Key educational messages presented in the slide
Speaker Tips - Presentation tips on how to engage the audience and facilitate interactivity and areas for customization
Speaker Tips
YOU MAY WANT TO CUSTOMIZE THE FIRST SLIDE WITH THE DATE AND YOUR NAME
Let the audience know that you are interested in THEM.
The goal is to have the audience start getting comfortable with you, to start responding to your questions and PARTICIPATE! Adult learners learn more when they are actively engaged and not just sitting and listening.
SPEAK TO THE LITERACY LEVEL OF YOUR AUDIENCE!
Ask the audience: “How many of you have encountered this problem in older adults with whom you work?”

2. Older Adults Take More Medicine
Consume 1/3 of all prescription meds
One in four older adults has used psychoactive meds with abuse potential
Prescription drug misuse and abuse
is a growing problem
May be as high as 11% of
older adult population
Teaching Points:
Although illicit drug use is relatively rare among older adults compared to younger adults and adolescents, there is increasing evidence that prescription drug misuse and abuse is a growing problem in the older population (Simoni-Wastila and Yang, 2006).
Older adults are particularly vulnerable to misuse and abuse of prescription medications. Persons ages 65 and older make up less than 15 percent of the population but they consume about one-third of all prescription medications (CDC & Merck, 2004), and take more potentially addictive medications than any other age group (Blow, 2003). The prevalence of prescription drug abuse may be as high as 11% (Simoni-Wastila & Yang, 2006). One in four older adults has used psychoactive medications with abuse potential, and such use is likely to grow as the population ages (Simoni-Wastila & Yang, 2006).

3. Definitions Prescription Drug Misuse
The use of a medication other than as directed
May be accidental or willful
Prescription Drug Abuse
Intentionally taking medications that are not medically necessary
Teaching Points:
For our purposes, prescription drug misuse is the use of a medication other than as directed or indicated, including taking too little or too much of a drug, taking it too often, or taking it for too long, whether harm results or not (Katz, 2007). Prescription drug misuse can be either willful or accidental. Non-adherence with a medication regimen is a broad category of prescription drug misuse.
Prescription drug abuse refers to intentionally taking medications that are not medically necessary, or for the experience or feeling a drug causes.
Speaker Tip:
Ask the audience if they can give you some real life examples of “misuse” and “abuse.”

4. Misuse can Lead to Abuse
The pathway from appropriate use, through misuse to abuse can result from
Patient behavior
Prescriber behavior
Both
Teaching Points:
The pathway from appropriate medication use, through misuse to abuse can result from patient behavior, prescriber behavior, or both (Simoni-Wastila & Yang, 2006).
Speaker Tip:
Emphasize that it is BEHAVIOR driven and usually a combination of both patient and prescriber actions.

5. Prescription Drug Misuse Patient Behavior
Taking more of a drug than prescribed
Missing doses
Taking the wrong drug
Using a drug for other than the prescribed reason
Sharing or borrowing drugs
Using drugs that have expired
Combining drugs with alcohol or other substances
Teaching Points:
Increased medication use affords the opportunity for older adults to accidentally or intentionally misuse prescription medications. Prescription drug misuse by older adults can take many forms (Simoni-Wastila & Yang, 2006; CSAT Chapter 3, 1998). Patient behaviors include:
Taking more of a drug than prescribed
Missing doses
Taking the wrong drugs
Using a drug for other than the prescribed reason
Sharing or borrowing drugs
Not following instructions
Using drugs that have expired
Combining drugs with alcohol or other substances.
Speaker Tip:
Consider discussing like this: Remind the audience of the definition of “misuse”- taking a medication in a way OTHER than it was prescribed. Ask the audience if they have ever stopped taking an antibiotic that was prescribed for 10 days after 6 days because they “felt better” BUT saved the medicine because they might need it “later.” And some time later they started taking the leftover prescription medication. Is this drug misuse? YES, because in the first place, they didn’t take the medication for the 10 days for which it was originally prescribed AND they used it for another illness without the doctor’s ok, which is self-medicating. Is this a dangerous BEHAVIOR? YES! If someone displays this behavior with antibiotics (or other medications), might they ALSO display this behavior with more “abusable” drugs? Discuss other problematic behaviors with examples that you have observed in the community.

6. Prescription Drug Misuse Prescriber Behavior
Medications w/o indication
Multiple drugs from same class
Dose too high; duration too long
High risk drugs or inappropriate for elderly
Inadequate instructions for taking meds
Failure to question about use of alcohol or other drugs with abuse potential
Teaching Points:
Prescriber-related factors also place older adults at risk for prescription drug misuse, serious adverse effects, or abuse and dependence. Prescribing practices that are potentially dangerous include (CSAT Chapter 3, 1998; Simoni-Wastila & Yang, 2006):
Failure to consider the influence of aging on the effects of drugs in the body,
Ordering medications without adequate diagnoses or other indications for use,
Prescribing multiple drugs from the same therapeutic class,
Ordering drugs without knowing or reviewing whether they interact adversely with other medications the patient is taking,
Prescribing a drug at a higher dose and/or for a longer duration than recommended,
Prescribing for too long a duration without appropriate monitoring of drug reactions and patient adherence with the prescribed regimen,
Selecting drugs known to have a high risk for side effects or that are potentially inappropriate for use in older adults,
Failing to provide adequate instructions on how and when to take medications and what side effects to expect and report.
Failing to determine whether the patient uses alcohol or other substances with abuse potential
Speaker Tip:
Emphasize BEHAVIORS from the prescriber. Give some examples: patient complains of not sleeping and they get a prescription for a sleeping aid when the underlying cause might be unmanaged or poorly managed pain. Also emphasize that because older adults don’t fit the typical drug abuse “profile” and/or drug misuse/abuse is a “sensitive” topic, patients are not routinely, adequately screened.
Ask the audience what might be some consequences of Rx drug misuse before going to the next slide.

7. Prescription Drug Misuse is UNSAFE
Treatment failure
Increased health resource utilization
ER visits
Hospitalizations
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Teaching Points:
Prescription drug misuse can lead to treatment failure as well as increased health resource utilization, such as preventable emergency room visits and hospital admissions (Vik et al., 2006; Balkrishnan et al., 2003). Prescription drug abuse may proceed on a continuum from appropriate use for medical or psychiatric conditions through nonmedical use or misuse, to persistent abuse and dependence.
Speaker Tip:
Give some examples from your practice or what you have observed in the community.
Before the next slide ask the audience if they can identify some other behaviors associated with aging that might contribute to prescription drug misuse and abuse besides patient BEHAVIORS and prescriber BEHAVIORS .
It might lead to prescription drug ABUSE

8. Prescription Drug Misuse Risk Factors
Number of medications
Multiple prescribers
Inappropriate prescribing
Limited English language proficiency
Low health literacy
Memory problems
Hearing/Vision impairments
Treating symptoms and not the cause
Teaching Points:
Most prescription drug misuse by older adults is unintentional and there are many factors that contribute to or increase the risk of misuse (CSAT Chapter 3, 1998; Basca, 2008).
The use of numerous medications for chronic conditions, frequently with uncoordinated care between multiple prescribers
Failure to tell the doctor about over-the-counter medications, vitamins, and herbals
Inappropriate prescribing (e.g., prescribing the wrong medication or an inappropriate dose)
Instructions and package inserts written in small print or confusing language
Limited English language proficiency and low health literacy
Memory problems making it difficult to keep track of medication schedules
Hearing or vision problems that interfere with the ability to take medications correctly
Willingness of doctors to prescribe drugs for sleeplessness, anxiety and depression without investigating and treating the root cause of these problems.
Speaker Tip:
After the first bullet point, you may ask the audience if they ever do home visits. Medication management is a HUGE problem for many older adults. The photo in the next slide illustrates excessive medications in a patient’s home. Show the next slide, then click back to this slide to finish the discussion. You may also want to cite other examples of these risk factors that you have observed in your practice or while working with community-based older adults.
Transition to prescription drug ABUSE . . .

9. How Many is Too Many? Speaker Tip:
This photo illustrates excessive medications in a patient’s home. If you have a photo from your own practice, you should use it to illustrate the problems that are present in some community-based patient homes regarding medication management, which is a product of and contributes to prescription drug misuse and abuse.

10. Prescription Drug Abuse Older Adults
Drug misuse and abuse is present in 11% of older adults
Second only to alcohol abuse
ED visits doubled between 2004 & 2008
20% age 70 and older
1/3 required hospitalization
Projected to double over two decades, to 2.7 million by 2020
4.4 million will need substance abuse treatment
Teaching Points:
Prescription drug misuse and abuse—the intentional taking of prescription drugs that are not medically necessary—is present in 11% of elderly individuals.
Data from the National Survey on Drug Use and Health indicate that nonmedical use of prescription medications is second only to alcohol abuse among adults older than 55 (SAMHSA NDSUH, 2011).
Emergency department (ED) visits involving drug misuse and abuse by adults aged 50 or older more than doubled between 2004 and 2008 (SAMHSA, 2010).
One-fifth of ED visits were made by persons aged 70 or older.
More than one-third of ED visits made by older adults misusing or abusing pharmaceuticals resulted in a hospital admission; of these, nearly a quarter resulted in an admission to the intensive care unit.
Nonmedical use of psychotherapeutic drugs among adults aged 50 years and older is projected to double over two decades, to 2.7 million by the year 2020 (Colliver et al, 2006; Han et al, 2009), with 4.4 million in need of substance abuse treatment (Gfroerer et al, 2003).
Speaker Tip:
Now is a good time to talk about the baby boomers and how THEY are making such an impact on these statistics.
The “baby boom” generation (those born between 1946 and 1964) has experimented with alcohol and illicit drugs—such as marijuana, cocaine, heroin, methamphetamine—more than any previous generation and this group may have more lenient views on prescription medications and drug use compared to prior generations (Trevisan, 2008). Marijuana use is more common than nonmedical use of prescription drugs among adults aged 50-59, while nonmedical use of prescription drugs is more common in those aged 60 and older (SAMHSA, 2011).

11. Commonly Abused Medications
Opioid (narcotic) painkillers
Medicine for anxiety
Sleeping pills
Stimulants
Speaker Tips:
Pain medications were involved in 43% of those ED visits referenced on the prior slide! Ask the audience why they think these categories of medications are the most widely abused. Discuss why untreated pain leads to prescription drug abuse, including self-management with other prescription meds, borrowed medications and OTCs. Discuss the potential pathway where fear of addiction (by consumers and prescribers) leads to undertreated pain and may in turn lead to addiction- but through another indirect channel (prescription drug misuse and abuse).
Teaching Points:
Among ED visits by older adults, pain relievers were most commonly involved (43.5%), with narcotics the most popular type, followed by drugs used to treat anxiety or insomnia (31.%) and antidepressants (8.6%) (SAMHSA DAWN Report, 2010).
The most common prescription medications abused by people of any age are opioids (usually prescribed to treat pain), central nervous system (CNS) depressants (used to treat anxiety and sleep disorders) and stimulants (most often prescribed to treat attention deficit hyperactivity disorder). In the older adult, benzodiazepines prescribed to treat insomnia and anxiety, opioid analgesics to manage pain related to arthritis and hip fractures, as well as alcohol and over-the-counter medications are the primary drugs of abuse (SAMHSA DAWN Report, 2010).Many of these drugs can result in dependence in the older adult. Using lower doses may decrease the risk of abuse or dependence. However, fear of addiction, both by the patient and their doctor often results in inadequate treatment of anxiety, insomnia and pain and opens the door to self-management and prescription drug misuse or abuse (Simoni-Wastila L & Yang, 2006; CSAT Chapter 3, 1998).
Common Opioid Prescription Medications Commonly Prescribed Depressants
Generic Name
Brand Name
Morphine
MS Contin®, Kadian®, Avinza®
Codeine
Tylenol with Codeine®, Robitussin AC®
Hydrocodone
Vicodin®, Lortab®, Zydone®
Oxycodone
OxyContin®, Perdocan®, Percocet®, Tylox®, Roxicet®
fentanyl
Duragesic®
Benzodiazepines
diazepam (Valium®)
alprazolam (Xanax®)
clonazepam (Klonopin®)
Barbiturates
secobarbital (Seconal®)
mephobarbital (Mebaral®)
pentobarbital (Nembutal®)
Non-benzodiazepine sleep medications
zolpidem (Ambien®)
eszopiclone (Lunesta®)
zaleplon (Sonata®)

12. Prescription Drug Abuse is UNSAFE
Health gets worse
Higher risk of accidents
Higher risk of falls and injuries
Serious side effects
Physical dependence and addiction
Teaching Points:
Compared to younger adults, when older adults abuse medications, significantly more health problems arise due to increased sensitivity to medications, slower metabolism, a decrease in volume of distribution, and possible cognitive impairment, which makes self-monitoring of medication use and following directions from health care providers difficult.
The misuse and abuse of psychoactive drugs by older adults can result in drowsiness, sedation, confusion, memory loss and other impairment of cognitive function, which in turn may lead to falls and other accidents.
Organ systems can be damaged by prescription drug abuse and there may be a profound impact on the social and economic spheres of the older adult’s life, with negative impact on self-esteem, coping skills and relationships, adding to other cumulative life losses.
Once exposed to psychoactive drugs, older adults may be at greater risk for the development of dependence than their younger counterparts due to factors associated with aging (Simoni-Wastila & Yang, 2006). For instance, with age the liver becomes less efficient at filtering out medications from the body. Also, aging brains are more sensitive to the effects of drugs that act on the central nervous system.

13. Prescription Drug Abuse Risk Factors
Female gender
Social isolation or loss of social supports
History of mental health problems
History of substance abuse
Exposure or access to prescribed medications with abuse potential
Teaching Points:
Older women have been found to be at greater risk for prescription drug abuse than older men or younger women. Compared with older men, older women take more psychoactive drugs, especially benzodiazepines, and are more likely to be long-term users of these medications (CSAT Chapter 3, 1998).
Speaker Tip:
You may want to ask the audience why they think the items listed on the slide are risk factors- e.g. why does history of mental health problems contribute as a risk factor for prescription drug abuse?
Social isolation or loss of social supports, factors related to the provider and health care system, depression, and history of mental health problems or substance abuse may increase vulnerability for abusing prescribed medications (CSAT Chapter 3, 1998; Simoni-Wastila & Yang, 2006). Exposure or access to prescribed medications with abuse potential may be the single greatest risk factor for prescription drug abuse by older adults (Simoni-Wastila & Yang, 2006).
And with Medicare Part D, seniors have ACCESS . . .

14. Recognizing Prescription Drug Abuse Can Be Difficult
Older adult does not fit the typical drug abuser profile
No validated screening instruments to identify/diagnose drug abuse in geriatric population
Many diseases caused by substance abuse are common disorders in later life
Many symptoms of prescription drug abuse mirror common signs associated with aging
Teaching Points:
The older adult does not fit the typical drug abuser profile (Basca, 2008), and the signs of prescription drug abuse are less obvious in older adults than in younger people. Symptoms of drug abuse and dependence can be difficult to assess. Traditional signs of abuse (e.g. missed time from work, legal problems, etc.) are not as common in the older adult.
There are currently no validated screening instruments for identifying and diagnosing drug abuse in the geriatric population (Simoni-Wastila, 2006), and the guidelines and screening tests used are often designed for younger people and may not be easily applied to older adults (NIDA Research Report, 2011).
Many of the diseases caused by substance abuse—such as high blood pressure, stroke, dementia, or ulcers—are common disorders in later life, so health care providers and family members may not think of drug abuse as a cause (NIDA Research Report, 2011).
Many of the symptoms of prescription drug abuse mirror common signs associated with aging, such as shaky hands, mood swings, balance issues, confusion, and memory loss (Basca, 2006), thus making it even harder to subjectively detect in older adults. Some warning signs—such as sleep problems, falls, anxiety, depression, and memory problems—can also be signs of other health conditions. As a result, doctors and family members often do not realize that the person has a problem, and people may not get the help they need.
There are however, some very specific behaviors suggestive of drug abuse. 14

15. Warning Signs Prescription Drug Abuse
Sudden change in behavior
Withdrawal from family, friends, activities
Sleeping during day
Changes in personal grooming, hygiene
Worry about Are the drugs “really working” Having enough medication on hand
Giving excuses as to why they need pills
Sneaking or hiding pills
“Doctor shopping” for several prescriptions
Teaching Points:
Here are some warning signs to look for if you suspect an older adult has a drug problem (Sollitto, 2012; NIH Senior Health):
Behavior or mood change.
Withdrawal from family, friends, neighbors and lifelong social practices.
Sleeping during the day or signs of sleep disturbances.
Falls or other unexplained injuries, which might be a result of excessive sedation.
Changes in personal grooming and hygiene.
Excessive worry about whether mood-altering drugs are “really working”.
Self-medicating by increasing doses of prescribed drugs that “aren’t helping anymore” or supplementing prescribed drugs with over-the counter drugs.
Worrying about having “enough” medication on hand. Frequent requests for refills of certain medicines.
Giving excuses as to why they need the pills.
Sneaking or hiding pills.
Remorse or concern about taking pills.
Annoyance or discomfort when others talk about their use of medications.
"Doctor shopping" (moving from provider to provider in an effort to get several prescriptions for the same medication)
Receiving the same medication from more than one physician or pharmacy at approximately the same time.
Complaints about doctors who refuse to write prescriptions for medications they want.
Changing doctors or pharmacies.
Paying for medications out-of-pocket rather than using prescription drug insurance.

16. How to Help Someone with Prescription Drug Abuse?
Get them to talk to a doctor, counselor or other health professional
Encourage them to be honest about exactly how they are taking their medications
The sooner, the better
Teaching Points:
Seniors who abuse medications acquire them in the same way as younger drug abusers, including forging or altering prescriptions, impersonating physicians on the phone, seeking out prescribers with a reputation for writing prescriptions under dubious circumstances, doctor shopping to obtain prescriptions from multiple prescribers, filling prescriptions at different pharmacies to evade detection, ordering medications from illegitimate internet pharmacies, frequent visits to the emergency department for vague complaints with the hopes of obtaining pain or anti-anxiety medications, and sharing or borrowing prescription drugs from family and friends (Basca, 2008; SAMHSA NDSUH, 2011).
Families, caregivers and those working in the aging network may help prevent prescription drug abuse by being alert to the warning signs we just discussed.
Speaker Tip: Ask the audience if they have known anyone who had a problem with prescription medications. What happened? (You may not get any response here, as drug abuse can be a sensitive subject.) Ask the audience what they would do if they thought one of their friends or family member or client/patient in their program was having a problem with prescription medicine.
If you find someone you believe may have a problem, the most important step is to encourage the person to get help -- and the sooner the better -- in order to prevent some of the negative consequences that we talked about earlier (accidents, falls, etc.)

17. Case Study Place Holder
You may want to insert a case study here from your own practice or one that you are familiar with to illustrate the pathway from prescription drug misuse to abuse.

18. STAMP OUT Prescription Drug Misuse & Abuse Tool Kit
Program is brought to you by The American Society of Consultant Pharmacists (ASCP). STAMP OUT was developed by the ASCP Foundation and supported by an educational grant from Purdue Pharma L.P
Teaching Points:
A primary reason for continued escalation of prescription drug misuse and abuse is lack of education among all segments, including physicians, pharmacists, and the public (Manchikanti, 2007). Approaching a problem of this magnitude requires a collaborative effort between community leaders, law enforcement officials, health care practitioners, community-based programs, older adults and their family/caregivers. For the older adult population, addressing the factors related to willful and inadvertent misuse of prescription medication is a necessary part of prevention and early intervention (Basca, 2008).
With one-fifth of ED visits by older adults involving pharmaceutical misuse or abuse occurring among adults aged 70 or older, caregivers (e.g., adult children of aging parents) may be able to help prevent abuse by being alert to the symptoms and dangers. Education for caregivers about the abuse potential of certain medications and the early warning signs of abuse may be needed (SAMSHA DAWN Report, 2011).
This tool kit was developed to address some of these concerns and provide easy-to-use resources to deliver this important message to older adults and their families and caregivers, and others in the aging network.

19. STAMP Out Prescription Drug Misuse & Abuse Tool Kit Contents
Backgrounder
Getting Started
Flyer
PowerPoint Presentation w/Speaker Notes
Self-Assessment
Evaluation
Handouts
We’ll look at all the tool kit contents, but first I will go through the consumer PowerPoint presentation. The consumer presentation and materials are also available in Spanish.

20. Speaker Tips & Teaching Points
Notes Pages:
Speaker Tips & Teaching Points
The presentation includes speaker tips and the main teaching points for each slide, as well as whether the slide uses animation.

21. Attention Seniors: STAMP Out Prescription Drug Misuse & Abuse
Making the Best Use of Your Medicines
This is the Title slide for the consumer presentation. 21

22. Know Your Medicine
As long as I take the medication, it doesn’t matter at what time of day I take it.
True or False?
On days when I wake up feeling good, I don’t have to take my medication.
I had the same cold last year, so I can use the antibiotics I had left over for this cold.
The presentation starts with a quiz to involve the audience . . .
Speaker Tip: Generate some excitement here! Get people to raise their hands to answer the questions. You want to get the audience involved to create an active learning environment, so make this a game. Remember, at this point in the presentation, it’s not about the “right” answer, it’s about generating interest and active participation.
To encourage participation:
Consider giving candy or some “prize” to the first 1 or 3, etc. who answer the question.
Consider giving ALL who answer a token (paperclip, ticket, etc.) that can be entered in a drawing at the end of the presentation or give a prize to the person(s) who have the most tokens at the end of the presentation.
Be creative and make it fun!
Ask some of the people who answered “True” to tell you why. Ask some of the people who answered “False” to tell you why. Make sure that you don’t aggressively tell them that they are “wrong” if they answer incorrectly.
Use this opportunity to begin teaching about safe medicine use and preventing prescription misuse and abuse. Present your educational message in a POSITIVE manner (“It’s best if you…. because….; It’s safer if you….”) rather than a NEGATIVE manner (“That’s not right….” “You’re wrong…”).
Teaching Points:
The answer to all questions is FALSE. You must ALWAYS take medication as it is prescribed. If you want to take the medication differently that it is prescribed, check with the doctor BEFORE you make changes. If there are any questions about specific medicines, check with the doctor or pharmacist. You should NEVER save and use old medicine- it is not SAFE! 22

23. We Take More Medicine as We Get Older
Taking medicine prescribed by your doctor is usually safe and effective. But, as we age, our bodies change. We handle medicine differently than when we were younger.
. . . and introduces potential risks for medication-related problems.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Teaching Points:
Seniors are at risk for more medication-related problems because:
--Your body changes as it ages.
Your body processes slow down and medicines take longer to get out of your body when you are older than they do in someone younger.
--You are more likely to be taking multiple medications.
The more medicines, the more chance something bad might happen.
--You are more likely to see multiple prescribers (primary care doctor, specialists, dentists, etc.).
--You are more likely to have other medical problems and diseases that can be affected by medications (example: if you have a stomach ulcer and take medicine that can cause an upset stomach, it might be worse for you because you already have an ulcer).
--You are more likely to have physical difficulties (like arthritis in your hands) that could affect your ability to manage medications.
Arthritis could make it hard for you to open your medicine bottles and you might not take your medicines as they are prescribed because you can’t get the bottle(s) open.
…So, it is important to be careful with medicine. 23

24. Sometimes we don’t take medicine the way the doctor prescribes . . .
OOPS
Sometimes we don’t take medicine the way the doctor prescribes . . .
Speaker Tip: Ask the audience if they ALWAYS take their medications as prescribed. Do they finish all the antibiotic/cold medicines when they feel better? Do they ever take “old” medicine that they had left from another illness? You might ask them “why” they don’t take medicine as prescribed to get them talking. Let them be honest- we all are non-adherent! The important point is that they are recognizing that they ARE non-adherent and that this leads to unsafe use of medicine.
Teaching Points:
With increased medication use comes increased chance for people to take their medications incorrectly – either accidentally or on purpose.
There is a rise in the number of older adults who are taking their medications in the wrong way.
People don’t take medications correctly for a number of reasons. Some are:
They can’t read the directions; they don’t understand the directions;
They forget;
They don’t understand how the medication will help their illness (e.g. how you have to take blood pressure medication routinely even though you can’t “tell” if your BP is elevated- but when you take pain medicine, you know it works because the pain goes away);
They don’t believe medicine works;
They are afraid of side effects or are experiencing them;
They don’t have a good relationship/communication with their doctor (they may not even speak the same language);
They think they know their body better than the doctor does;
They listen to advice of friends and family which may be erroneous.
Speaker Tip: Before you go to the next slide, ask them HOW they might be taking medicine in the wrong way. Depending on the response, ask them if they have seen other people (of course not themselves!) do something that might not be safe with medicine. Then show the next slide. 24

25. What Are Some Ways We Take Medicine WRONG?
We take MORE
We take LESS
We take more OFTEN
We FORGET
We STOP before we are supposed to
We give OTHER people our medicine
We TAKE other people’s medicine
This slide introduces prescription drug MISUSE.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Speaker Tip: Acknowledge whatever “reasons” they have given for not taking medications as prescribed. As them if there were any “bad” consequences as a result.
Teaching Points:
Most prescription drug MISUSE is accidental or unintentional and there are many factors that contribute to or increase the risk of misuse (Simoni-Wastila & Yang, 2006; CSAT Chapter 3, 1998).
The use of many different medications prescribed by different doctors. Frequently the care is not coordinated between multiple prescribers.
Failure to tell the doctor about over-the-counter medications, vitamins and herbals.
Misinformation (wrong information) or missed information (they never got the information) about a medication. Instructions and package inserts written in small print or confusing language.
Memory problems making it difficult to keep track of medication schedules.
Hearing, vision or physical problems that interfere with the ability to take medications correctly.
Well meaning friends and relatives “share” their medications and offer advice that may not be in the older adult’s best interest.
MISUSE occurs when a person takes a medicine in a manner or at a dose that was not prescribed by the doctor.
Speaker Tip: Before you go to the next slide, ask the audience what might be some “bad” things that happen if they don’t take their medicines correctly. Then show the next slide.
This is PRESCRIPTION DRUG MISUSE 25

26. Prescription Drug Misuse is UNSAFE
What can happen if you misuse Prescription Drugs?
You might not get well
You might actually get sicker
You might have to go to the doctor or the hospital
It might lead to prescription drug ABUSE
This slide addresses the negative consequences of prescription drug misuse.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Speaker Tip: Did the audience come up with all these possible problems? Did they come with more negative outcomes?
Teaching Points:
MISUSE refers to non-adherence to prescription directions (over- or underutilizing medication). It leads to treatment failure, increased health resource utilization (additional MD visits, lab tests, preventable hospitalizations and emergency room visits).
MISUSE is UNSAFE!!! (as they can see from the possible negative outcomes listed on the slide)
Speaker Tip: Ask the audience if they know the difference between prescription MISUSE and ABUSE (based on the last bullet on this slide). What do they say? Encourage them to give their idea of what this means before you go to the next slide. 26

27. What if Someone Takes Prescription Drugs Wrong on PURPOSE?
MORE medicine than prescribed
More often than prescribed
For no MEDICAL reason
Or mixes medicine with alcohol or illegal drugs
This slide describes prescription drug ABUSE.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Teaching Points:
Prescription drug ABUSE:
Intentionally taking medications that are not medically necessary (example: taking a pain pill NOT for pain, but to “calm down”);
Taking medicine at a higher or more frequent dose to get a bigger or faster response (e.g. to get relief from pain);
Taking medicine not prescribed for them to feel good, feel better or calm down (taking someone else’s Valium® to feel better);
Taking medicine to “get high.”
Prescription drug misuse and abuse occurs in as many as 11% of seniors (1 out of about every 10 seniors).
Experts estimate that prescription drug ABUSE is under-recognized and under-treated in older adults.
Make sure the audience understands the difference between prescription drug MISUSE and ABUSE.
Misuse is using medication incorrectly (non-adherence) according to prescription directions for many reasons (not usually on purpose but due to misinformation [wrong information] or misunderstanding), while ABUSE is INTENTIONAL LY using medications incorrectly.
Prescription drug MISUSE can easily change into prescription drug ABUSE if the problems leading to the MISUSE are not detected and fixed.
Speaker Tip: Before you go to the next slide, ask the audience what they think the top 3 types of prescription drugs that are ABUSED most often. Then proceed to the next slide.
This is PRESCRIPTION DRUG ABUSE 27

28. Commonly Abused Medications
Opioid (narcotic) painkillers
Medicine for anxiety
Sleeping pills
Take these medicines only if YOUR
doctor prescribed them for YOU and
take them just as the doctor ordered!
This slide presents commonly abused medications.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Speaker Tip: Did the audience name pain, anxiety and sleep meds? What did they identify? Ask them if they can name any specific pain meds, any anxiety meds and any sleep meds. Have they known anyone that has had problems with these medications?
Teaching Points: There are many example of medications that can be abused. The following list identifies some that are commonly abused; this is NOT a complete list.
Examples of pain medicines that are commonly abused are:
- Morphine (MS Contin® and others) Codeine (Tylenol®with codeine and others)
- Hydrocodone (Vicodin®, Lorco® and others) Oxycodone (OxyContin® and others)
Examples of medicines for anxiety that are commonly abused are:
- Lorazepam (Ativan®) Alprazolam (Xanax®)
- Diazepam (Valium®) Clonazepam ( Klonopin®)
Examples of sleep medicines that are commonly abused are:
- Zolpidem (Ambien®) Zaleplon (Sonata®)
- Temazepam (Restoril®)
DO NOT DRINK ALCOHOL WITH THESE MEDICATIONS
Be on the lookout for duplicate medications prescribed by different doctors or dentists or during an emergency room or hospital visit (especially pain meds). It is ALWAYS important to make sure ALL prescribers know what meds you are taking. It is helpful to get all your prescriptions filled at the same pharmacy so they can watch out for duplicates.
Speaker Tip: Before you go to the next slide, ask the audience what might be some consequences (bad things) that might happen if someone ABUSES prescription medications. 28

29. Prescription Drug Abuse is UNSAFE
Health gets worse
Higher risk of accidents
Higher risk of falls and injuries
Serious side effects
Physical dependence and addiction
This slides describes the consequences of prescription drug abuse and discusses why older adults may be at greater risk for problems.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Speaker Tip: Did the audience come up with all of these negative consequences? You might reference any public figures that may have recently been in the news related to prescription drug mishaps to make it current and relevant.
Teaching Points:
People may think that taking ANY medication is safe because a doctor prescribed it. But taking too much of a medicine or taking it in ways other than how the doctor prescribed it is NOT safe.
Older adults may have serious problems with drug ABUSE due to several factors:
The older body cannot absorb and breakdown medicines as easily so the medicine remains in the body for a longer time.
Older brains may be at more risk for harmful effects of medications (memory and coordination).
Excessive use (ABUSE) of certain medications may have harmful effects on the heart and other organs of the body.
It is estimated that 1 out of 5 older adults is addicted to alcohol or prescription drugs!
Speaker Tip: Before you go to the next slide, ask the audience if they have any ideas about how to “spot” someone who might be abusing prescription drugs. 29

30. Recognizing Prescription Drug Abuse
Look for these signs . . .
Sudden change in behavior
Withdrawal from family, friends, activities
Rapid increase in the amount of medicine that is needed
Very frequent refills
“Doctor shopping” to get several prescriptions for the same medicine
This slide presents signs of prescription drug abuse.
Teaching Points:
There is no easy “test” to screen for drug ABUSE. It is up to the medical community to really talk with patients and family/caregivers to identify possible issues AND up to friends and family to keep an eye out for people who might be in trouble.
Many of the symptoms of prescription drug ABUSE are vague and commonly associated with aging or other diseases, making it even harder to detect in older adults. Some of these symptoms are shaky hands, mood swings, balance issues, disorientation and memory loss.
Other behaviors that are suggestive of prescription drug ABUSE:
Complaining about physicians who will not write prescriptions for preferred medications;
Sleeping during the day;
Paying for medications out-of-pocket rather than using prescription drug insurance;
Unexplained injuries which might be the result of excessive sedation;
Frequently “losing” medications or having them “stolen” in order to justify additional refills;
People who are medication abusers often go to many different doctors to get prescriptions for the same medication. One example reported was a patient in Georgia who got prescriptions for 3655 oxycodone tablets from 58 different doctors! 30

31. How to Help Someone with Prescription Drug Abuse?
Get them to talk to a doctor, counselor or other health professional
Encourage them to be honest about exactly how they are taking their medications
The sooner, the better
This slide describes how to help someone suspected of prescription drug abuse.
Speaker Tip: Ask the audience if they have known anyone who had a problem with prescription medications. What happened? (You may not get any response here, as drug abuse can be a sensitive subject.) Ask the audience what they would do if they thought one of their friends or family member was having a problem with prescription medicine.
Teaching Points:
The most important step is to encourage the person to get help -- and the sooner the better in order to prevent some of the negative consequences that we talked about earlier (accidents, falls, etc.) 31

32. STAMP Out Prescription Drug
Be Part of the Solution
STAMP Out Prescription Drug
Misuse and Abuse by
Safely
Taking
All
Medicine
Properly
Teaching Points:
The best way to STAMP out prescription drug MISUSE and ABUSE is prevention -- by taking medicine safely and EXACTLY as prescribed by the health care professionals (doctors, dentists, etc.).
Safely
Taking
All
Medicine
Properly
Speaker Tip: Before you go to the next 3 slides, ask the audience for some things they could do to make taking medicine safer. Encourage the audience to give you answers. If you have a white board or flip chart, consider writing down the answers that the audience gives you. Reward them for participation!
Note: They may not have any ideas around this question; they may not have thought about it before.

33. How to… STAMP Out Prescription Drug Misuse & Abuse
Keep an up-to-date list of all your medicines – prescription and over-the-counter
Take your medicine list to ALL your medical appointments: doctor, dentist, emergency room visits & hospital stays and share with your pharmacist
Take your medicine EXACTLY as prescribed
Only use the medicine for the reason it was prescribed
This slide presents KEY takeaway points.
Speaker Tip: This is the first of 3 KEY slides of takeaway points, so emphasize the information here. The material on these 3 slides is included in the Handout “Key Messages.”
Check off these items from the list of medicine safety ideas from the audience if the audience suggested some ideas and you wrote them on the white board or flip chart
Teaching Points:
Keep an up-to-date medicine list. Show the Handout “Personal Medication List”.
Take your medicine list to ALL your medical appointments: doctor, dentist, emergency room visits and hospital stays and share the list with your pharmacist. Frequently there is poor coordination of care between different health care professionals (i.e. they don’t talk to each other) and sometimes they prescribe the same (duplicate) medications. Example: your doctor prescribes a pain medicine for your arthritis and your dentist prescribes a pain medicine for your toothache. Are they the same medicine? Should you take both together? This issue might not occur if each prescriber had a copy of your medicine list AND you get all your prescriptions filled at the same pharmacy.
Take your medicine EXACTLY as prescribed. Make sure you understand how the medicine is going to help you and how you will know it is working. If you think you need to change your dose or stop your medicine, ask your doctor BEFORE you do it. Too little or too much medicine could cause a problem. You might be harmed, you may not get well, or you might get sicker.
Only use the medicine for the reason it was prescribed. Don’t second guess if an old medicine will work for what is wrong now. Y our condition may be different than before and your body may have changed so the old medicine may not be safe to use.

34. More STAMP Out Tip
If you are not sure how to take a medicine, ask your doctor or pharmacist
Ask your doctor or pharmacist about side effects to watch out for and interactions with other medications
Ask how the medicine will affect driving and other daily activities
Talk with your doctor BEFORE you change a dose or stop taking a medicine
This slide presents KEY takeaway points.
Speaker Tip: This is the second of 3 KEY slides of takeaway points, so emphasize the information here. The material on these 3 slides is included in the Handout “Key Messages.” Continue to check off these items from the list of medicine safety ideas that you wrote down on the flip chart.
Teaching Points:
Show the Handout “I Have a New Medicine”.
This information will help you get all your questions about your new medicine answered by your doctor and pharmacist BEFORE you start to take it. You are encouraged to take this with you to all your doctor visits and have the doctor go over all the information with you.
Make sure you know how to take all your medicines. Ask your doctor or pharmacist. ASK, ASK, ASK! There is no such thing as a silly question. If someone picks up your prescription from the pharmacy, you can call the pharmacist to ask your questions. Ask your doctor to write down instructions for you. Ask a friend or family member to go with you to the doctor’s office to help you write down all the information. Ask the pharmacist if there are devices or medication aids that will help you take medications correctly.

35. More STAMP Out Tips
Do not crush or break pills without checking with your doctor or pharmacist
Don’t use someone else’s medicine
Don’t share your medicine with anyone else
Don’t mix your medicines with alcohol
Don’t be afraid to ask for help in organizing your medicines
Schedule a yearly “medication check-up” with your doctor and pharmacist
This slide presents KEY takeaway points.
Speaker Tip: This is the last of 3 KEY slides of takeaway points, so emphasize the information here. The material on these 3 slides is included in the Handout “Key Messages.” Continue to check off these items from the list of medicine safety ideas on the flip chart. Consider rewarding those who participated.
Teaching Points:
Do not crush or break pills without checking with your doctor or pharmacist. Breaking or crushing sustained release tablets can be very dangerous because these medicines are formulated to release medicine over a period of hours. If you break the tablet, you get a blast of medicine at once and it can lead to an overdose.
Don’t use someone else’s medicine. Their body is not YOUR body and medications are prescribed based on a specific person’s body systems. That‘s like using a Volkswagen tire on a Ford truck; they are both tires, but the vehicles are very different and really need different tires to be safe.
Don’t mix your medicines with alcohol. Alcohol can make certain drug effects worse and can put you at risk for accidents and injury.
Don’t share your medicine with anyone else. You don’t want to be responsible for someone getting injured or sick because you gave them YOUR medicine! Remember, YOUR body is not THEIR body (refer to the tire example above).
Don’t be afraid to ask for help in organizing your medicines. Ask a family member, a caregiver, or your pharmacist!
Schedule a yearly “medication check-up” with your doctor and pharmacist. This is the time to get rid of all the medicines that your doctor has stopped. No reason to keep old medicine! Also, make sure your pharmacist is aware of any medications that your doctor has stopped so that the pharmacist can keep their record of your medicine up-to-date.

36. CLEAN OUT YOUR MEDICINE CABINET
And Finally. . .
If you want to help fight
Prescription Drug Misuse & Abuse
CLEAN OUT YOUR
MEDICINE
CABINET
Drugs in the medicine cabinet contribute to prescription drug misuse and abuse.
SLIDE IS ANIMATED: DRIVEN BY PAGE UP/PAGE DOWN OR MOUSE CLICKS. FAMILIARIZE YOURSELF WITH THE TRANSITIONS PRIOR TO LIVE PRESENTATION.
Teaching Points:
There is another, often overlooked, serious unintended consequence from prescription drug misuse. Older adults who keep large supplies of “leftover” medications in their medicine cabinets contribute to the risk for accidental poisoning of children who can access these drugs and provide a source of drugs for others to abuse. A majority of abused prescription drugs are obtained from family and friends, including from the home medicine cabinet.
Speaker Tip: Ask the audience: “When was the last time you cleaned out your medicine cabinet? Did you throw away many things? Did you keep old medicine? Why?” It will be interesting to see what they say.

37. The Medicine Cabinet can be DANGEROUS
Accidental poisonings, abuse and misuse often occur when people store old medications in their homes
A majority of abused prescription drugs are obtained from family and friends, including from the home medicine cabinet
You may become a target for burglary, theft or scams by those looking for drugs to abuse
This slide describes the dangers of keeping old or expired medications.
Teaching Points:
Go through your medicine cabinet once a year and get rid of all expired medicine. Expired medicine may not work OR some out-of-date medicines are actually harmful.
Go through your medicine cabinet once a year and get rid of all medications that are NOT currently prescribed for YOU. There is no reason to keep this old medicine.
By cleaning out your medicine cabinet, you won’t be stockpiling medicine and you won’t make yourself as much of a target for crime or a scam! Visitors and family members looking for medications to abuse or with which to experiment may look through your medicine cabinet when they visit your home and steal your medicines. This is especially true regarding those medications that we talked about being commonly abused: pain medicines, anxiety medicines and sleep aids. They may be using these medicines for themselves or they may sell them or give them to someone else. No matter what, you don’t want to accidentally be part of PRESCRIPTION DRUG ABUSE, do you? How would you feel if YOUR old medicine caused harm to someone?
Throw away ALL medicine that you are not currently using.
By keeping your medicine cabinet cleaned out, you also reduce the chance of accidental poisoning of younger children who might find a way to climb up and get into the medicine cabinet. Every year more than 71,000 children 18 years old and younger are seen in the emergency room for accidental overdoses of prescription medications and OTCs (over-the- counter products). Source:
Always keep your medications out of reach of children and pets.
Speaker Tip: Before going to the next slide, ask the audience: “How do you throw away medication?” “What do you do with it?” After you get some answers (Expect “throw it in the trash,” “flush it down the toilet,” “flush it down the sink.”), go to the next slide.

38. Prevent Poisonings, Misuse & Abuse and Protect the Environment
Properly dispose of unused/expired medicine
DO NOT FLUSH unused medications
DO NOT POUR them down a sink or drain
Take advantage of community drug take-back programs that allow the public to bring unused drugs to a central location for proper disposal
This slide describes how to properly dispose of medications.
Teaching Points:
Is anyone surprised by the information on this slide? Don’t flush medicine down the toilet and don’t flush it down the drain. Why do you think you shouldn’t do that?
Flushing and pouring medicine into our water system pollutes the earth and wildlife. Properly disposing of unused or expired medicine protects animals, pets and people.
More than 100 different medications have been found dissolved in lakes, rivers and streams throughout the world! And the main way they got there was from disposing of medication in the toilet and the sink. What is even scarier, is that traces of these medications can be found in drinking water in some parts of the world!
It’s our job to stop this source of pollution and help to keep the world’s water safe! Safety starts with YOU! Learn the safe way to dispose of medicines and take advantage of neighborhood take-back programs for unused medicines (explain what this is).
Speaker Tip: Show the Handout from the FDA on “How to Dispose of Unused Medicines.” You may want to provide this to your audience or answer questions about this. You may want to discuss the appropriate way to dispose of medications in the home. Explain what a community take-back program is.
Remind them that they should ALWAYS remove their name off of any prescription label that they dispose of for safety and privacy.

39. It’s Up to You to STAMP Out Prescription Drug Misuse & Abuse Why don’t you start today?
On this slide you can review the tactics to prevent medication misuse and abuse.
Speaker Tip: Ask the audience what they are going to start doing to make their medication use safer and to prevent prescription drug misuse and abuse.
Teaching Points:
Tactics to prevent medication misuse and abuse include:
Improving medication adherence.
Making sure that older adults understand how to take medications and what to avoid when taking a prescription medication.
Encouraging older adults to share concerns and ask questions about their medication.
Encouraging older adults to inform health care providers of all medications they take regularly.
Encouraging older adults to keep a current medication list, including prescription drugs, OTC products, supplements and herbals AND provide it to all their health care providers.
Providing aids, such as medication tracking charts and personal drug records.
Addressing communication barriers, including low health literacy, vision and hearing impairments and language barriers.
Community informational and interventional support programs.
Educating prescribers and other health care providers about the severity of the problem concerning prescription drug misuse and abuse.
Adequate treatment by health care providers of the underlying medical problems that yield symptoms (e.g. insomnia, pain and anxiety) rather that just symptom management.
Standardized screening protocols for physicians to assess for drug misuse or abuse.
Transitional care programs and home-based medication reviews.

40. For More Information
Prescription and Illicit Drug Abuse: Information on trend among older adults, tips on prevention, treatment
Substance Abuse and Mental Health Services Administration (SAMHSA) HELP (4357) SAMHSA
Find a Senior Care Pharmacist: Specializing in the medication needs of older adults
This slide provides resources for more information, including a web site to locate a Senior Care Pharmacist who specializes in the medication needs of older adults. You should familiarize yourself with these web sites before the presentation.
PLEASE MAKESURE THE LINKS ARE CURRENT
Link is current!!

41. Medication Disposal DisposeMyMeds.org Drug Take Back Network
An online resource to help find medication disposal programs at the local independent community pharmacy near you
Drug Take Back Network
Information on permanent and regularly recurring drug take-back events
SMARxT Disposal
This slide provides resources for information on disposing of medications. You should familiarize yourself with these web sites before the presentation.

42. The next slides show the additional tool kit contents.
The Tool Kit Outline describes the materials and how they are organized.

43. Attention Seniors: STAMP Out Prescription Drug Misuse & Abuse
Join us for a special program on making the best use of your medicines
Date: ___________________ Time:__________
Location: _______________________________ _______________________________________
This is the presentation flyer. The Flyer should be posted in areas with heavy traffic by seniors, families and caregivers at least two weeks prior to the presentation. 43

44. Self-Assessment Quiz
The Self-Assessment Quiz was created as a “fill in the missing word” game – so make it fun!

45. Evaluation
Program Evaluation.

46. Key Messages USE YOUR MEDICINE SAFELY
PREVENT MEDICATION MISUSE & ABUSE!
CLEAN OUT YOUR MEDICINE CABINET ONCE A YEAR
DISPOSE OF EXPIRED AND OLD MEDICINE PROPERLY
NEED MORE INFORMATION ON MEDICATION SAFETY?
Distribute and review the Key Messages discussed during the presentation to reinforce the information at the end of the presentation, after the Self-Assessment Quiz. Suggest that the Key Messages be posted in a prominent place in their home (e.g., refrigerator) and that it be used to check off certain tasks, such as completing an up-to-date medication list and cleaning out the medicine cabinet.

47. The purpose of this Handout is to assist in gathering information when new medications are prescribed to foster safe medication use practices.

48. This Handout provides a template to record a complete medication list, and includes instructions.

49. Consumer health information from the Food and Drug Administration.

50. Q&A with pharmacologist Michael Klein, PhD, director of the Food and Drug Administration Controlled Substance Staff.

51. This Handout provides consumer guidance for proper disposal of medications.

52. STAMP OUT Prescription Drug Misuse & Abuse Tool Kit
Program is brought to you by The American Society of Consultant Pharmacists (ASCP). STAMP OUT was developed by the ASCP Foundation and supported by an educational grant from Purdue Pharma L.P
The STAMP Out Prescription Drug Abuse and Misuse program was developed by the American Society of Consultant Pharmacists Foundation, and funded by an educational grant from Purdue Pharma. 52

53. STAMP Out Prescription Drug Misuse & Abuse
Tool Kit Available
ASCP.com/stampout

54. STAMP Out Prescription Drug Misuse & Abuse
QUESTIONS? 54