Could YOU Be a Pusher?

Prescription Drug Abuse and Implications for Medical and Mental Health Practitioners
Presented by Jan-Sheri Morris and Alissa Wulff

A Call For Action

Statistics
2010: 2.4 Million People Age 12+ Began Using Prescription Drug Medication for Non-Medical Reasons
1992 to 2002: The Number of Prescriptions for Controlled Drugs Increased 154.3%
1997 to 2007: Milligram per Person of Opioids Prescribed 74mg to 369mg Increase of 402%

2008: CDC Reported 15,000 Deaths From Overdoses of Pain Medication

Types and Costs of Drugs

In 2002: Abuse of Prescription Drugs cost U.S. nearly $181 Billion Commonly Abused Prescription Drugs
Opioids: Used to Treat Pain
Oxycodone (Percocet, Tylox, OxyContin) Hydrocodone (Vicodin, Lortab) Methadone (Dolophine)

Central Nervous System (CNS) Depressants: Used to Treat Anxiety and Sleep Disorders
Butalbital (Fiorinal/Fioricet) Diazepam (Valium) Alprazolam (Xanax)

Stimulants: Used to Treat ADHD, ADD

Methylphenidate (Ritalin, Concerta) Amphetamine/Dextroamphetamine (Adderall, Dexedrine)

Types and Costs of Drugs

Generic Name Acetaminophen w/Codeine (30mg) Diazepam (10mg) Fentanyl Patch Hydromorphone (4mg) Methylphenidate Oxycodone (80mg) Brand Name Tylenol #3 Valium Duragesic Patches Dilaudid Ritalin OxyContin Brand Cost Per Pill $5.64 $29.80 $24.35 $8.84 $8.82 $108.13 Street Value Per Pill $8.00 $100.00 $40.00 $5.00-100.00 $15.00 $800.00

Physical Warning Signs

It is important at a physician to be aware of the warning signs that your client may be abusing prescriptive drugs. There are many factors that can help you to determine if they indeed are misusing the drugs you prescribe. Here are a list of physical signs of abuse:
Stimulants (medications used to speed up brain activity causing increased alertness, attention, and energy that come with elevated blood pressure, increased heart rate and breathing)
Hyperactivity Shaking Sweating Dilated pupils Fast or irregular heart beat Elevated body temperature Seizures Paranoia/nervousness Repetitive behaviors Loss of appetite or sudden and unexplained weight loss

Sedatives/depressants (medications used to slow down or depress the functions of the brain and central nervous system)
Loss of coordination Respiratory depression Slowed reflexes Slurred speech Coma

Opioid analgesics (medications used to treat moderate-to-severe pain)

Sleep deprivation or "nodding Pinpoint/constricted pupils, watery or droopy eyes

Behavioral Warning Signs

Behavior changes may include: Sudden mood changes, including irritability, negative attitude, personality change Extreme changes in groups of friends or hangout locations Forgetfulness or clumsiness Lying or being deceitful, unaccounted time away from home/missed school days, Avoiding eye contact Losing interest in personal appearance, extracurricular activities or sports "Munchies" or sudden changes in appetite Unusually poor performance in school, on the field, in debate club or other activities Borrowing money or having extra cash Acting especially angry or abusive, or engaging in reckless behavior Visiting pro-drug websites

Approach
To identify potential abusers physicians can employ risk stratification
Patients at low risk need minimal structure, whereas those at greatest risk need more frequent visits, fewer pills per prescription, specialist-level care, and urine drug tests Consider saliva drug testing (FDA-approved; CLIA-waived office-based rapid screening kits are available) Consider hair drug testing for measuring long-term use (use a reliable lab) Screen patients for substance abuse and other forms of psychological dependence prior to prescribing controlled substances.

Treating Addictions
Addiction in pain patients is rare and occurs in approximately 4 in 10,000 patients treated with opioids. Addiction is often difficult to detect in this population. While true opioid addiction is rare in patients with chronic pain, it does occur and needs to be treated with firm compassion. Addiction and abuse affects people of all ages and all races. It is important to treat addiction as you would any other medical condition by avoiding defensiveness, avoidance, anger and display a professional, empathetic and non-judgmental.

Creating New Behavior

As a physician it is important to teach your client coping skills in order to kick the prescription abuse. If you as the primary provider are unable to provide help to your client it is always best to refer them to an addition specialist or to a facility that specializes in helping people withdraw from drugs. Below are some cue questions to ask your client about their abuse: How long have you had this problem? What, if anything, prompted it? How severe are your symptoms? Do you have a past history of drug abuse or addiction? Has anyone in your family had a history of drug abuse or addiction?

Being Productive
Many physicians have difficulty discussing critical issues with patients. A CASA report finds that over 40% of physicians have difficulty discussing substance abuse, including abuse of prescription drugs, with their patients compared with less than 20% having difficulty discussing depression. Some conversations will be needed just to convince patients to take their medication; other conversations will focus on taking medication properly, and still others on the touchy subject of abuse. Always be proactive with teaching your clients the proper way to use their prescriptive drugs so that they are using them properly. If you do suspect that abuse is present be firm and offer alternatives. Tips such as practicing verbal responses to handle difficult situation such and saying it is not your choice to prescribe at this time. Another option could be to refer them to the clinics policy when prescribing prescriptive drugs to a client who may be experiencing dependence problems. Another option is to direct them to the licensing board and federal government rules and regulations.

Medical Training with SA

Less than 40% of National Physicians Receive Training in Medical School to Identify Prescription Drug Abuse or Recognize the Warning Signs
More than 90% Fail to Detect Symptoms of Substance Abuse

National Center on Addiction and Substance Abuse at Columbia University Survey: 648 Primary Care Physicians with 510 Adults Receiving Care for 10 Substance Abuse Programs
More that 50% Patients Reported Primary Care Physician Didnt Address Their Substance Abuse More than 40% Patients Reported Primary Care Physician Missed Diagnosis of Substance Abuse Disorder Only 25% Patients Were Involved In Their Decision To Seek Treatment Less than 20% Primary Care Physicians Considered Themselves Very Prepared to Identify Alcohol or Drug Dependence

Monitoring
Prescription Drug Monitoring Programs
State By State No National Database; Most States Allow Neighboring States to Access Database
43 States Have Databases to Track Pain Prescriptions; Only 35 Have Operational PDMPs 9 States Require Doctors to Access PDMP Under Certain Circumstances

Study by University of Toledos College of Medicine Found Doctors or Pharmacists Who Reviewed State Drug Data Changed How They Managed Their Cases 41% Of The Time
61% Prescribed Non-Opioid Drug or Less Dosage Than Originally Planned 39% Prescribed More Than Originally Planned After Determining Patient Did Not Have History of Opioid Use

Future Implications Call For Compliance on Federal, State, and Local Levels to Maximize Efficient Data Collection and Analysis

What Do YOU Think?

Should Doctors Be Mandated to Check Electronic Databases for Prior Drug Abuse or Doctor Shopping? Does This Breach Patient Confidentiality?

New York State: I-Stop Bill

Goal: Keeping Powerful Opioid and Anti-Anxiety Drugs Out of Hands of Addicts and Dealers
Requiring New Electronic Prescription Database; Electronic Scripting Physicians and Pharmacists Writing or Filling Schedule II, III, IV, and V drugs MUST Enter Prescriptions Into Database Immediately Currently They Have 45 Days to Enter Prescriptions
Complaint of Current Slow Functioning System

Bill Will Place Fines on Doctors Failing to Immediately Report

$500 for First Time Offenders; Up to Thousands for Repeated Offenses

Thoughts?

We Must Work Towards Efficient Practices and Communication

Questions? Comments?

References
American College of Preventive Medicine. (2011). Use, Abuse, Misuse, and Disposal of Prescription Pain Medication Time Tool. Retrieved from http://www.acpm.org/?UseAbuseRxClinRef#. Farley, J. (June 15, 2012). Regulation of Prescription Drugs Could Spell Trouble for Patients. Retrieved from http://www.thirteen.org/metrofocus/2012/06/ regulation-of-prescription-drugs-could-spell-trouble-for-patients/. Office of National Drug Control Policy. (2011). A Response to the Epidemic of Prescription Drug Abuse. Retrieved from http://www.whitehouse.gov/ ondcp/prescription-drug-abuse. Office of National Drug Control Policy. (2011). Epidemic: Responding To Americas Prescription Drug Abuse Crisis. Retrieved from http:// www.whitehouse.gov/sites/default/files/ondcp/issues-content/ prescription-drugs/rx_abuse_plan_0.pdf. Polydorou, S., Gunderson, E.W., & Levin, F.R. (2008). Training Physicians To Treat Substance Use Disorders. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC2741399/. Wisniewski, M. (May 20, 2012). Doctor Shopping: States Cracking Down On Prescription Drug Abuse. Huffington Post. Retrieved from www.huffingtonpost.com/2012/05/031/doctor-shopping- prescriptiondrugs-abuse-states_n_1557728.html.