8/4/2013
Easy ways to save patients’ lives: How to
prevent, recognize and deter prescription
drug abuse.
Chris Stock, PharmD, BCPP
Professor (Adjunct), U of U
Clinical Pharmacy Specialist, VAMC
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8/4/2013
Attending the presentation will enhance pharmacists' knowledge
of available information regarding pain medication abuse and
possible opportunities for intervention and patient and prescriber
education.
• Attendees will be able to:
1) State the statistics of pain medication abuse occurring in the
United States, among various demographic groups.
2) Specify the impact of the under treatment of pain and
inadequate pain relief.
3) Identify a number of ways to deter pain medication abuse in
the homes of families in the United States.
4) Identify the dangers associated with non medical use of
prescription pain medications.
5) Identify means to reduce the risk of prescription opioid
abuse
At the end of the presentation you will be able to correctly answer these questions:
1) According to Utah regulations, pharmacists can authorize a pharmacy technician to
access the Utah Controlled Substance Database.
True or False
2) According to Utah regulations, prescribers can authorize a non-medical clinic
employee to access the Utah Controlled Substance Database.
True or False
3) According to the National Survey on Drug Use and Health 2011 results, which
group is most likely to engage in the non-medical use of opioid prescription
medications?
• 1. 12-15 years old
• 2. 18-25 years old
• 3. 26-45 years old
• 4. Over 65 years old
4) The National Associations of Boards of Pharmacy has promoted which of the
following methods to deter inappropriate prescribing as well as abuse of controlled
substances.
• 1. National database of “doctor shoppers”
• 2. National database of “pill mill” doctors
• 3. Searchable national database of controlled substance prescriptions
• 4. National hot line for reporting pharmacy robberies
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INCB* 2012 Annual Report
North America IS:
• THE BIGGEST illicit drug market in the world.
• HIGHEST drug-related mortality rate.
– 1 in every 20 deaths in North America (1564age)
• Overdose deaths
• HIV/AIDS
• Trauma-related deaths including MVAs
International Narcotics Control Board of UN
Economic Costs of Drug Abuse
Department of Justice 2011
$193 Billions
$11,416,232
Crime
Productivity
Health
$68,403,082
$113,277,616
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8/4/2013
Past Year Illicit Drug Use among Persons Aged 12 or Older: 2011
Marijuana
29,739,000
Rx drugs
14,657,000
Opioids
11,143,000
Hallucinogens
4,069,000
Cocaine
3,857,000
Inhalants
1,861,000
Heroin
620,000
-
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2012.
Costs of Abuse of Prescription Drugs 2006
$53 Billions
$2.20
$0.94
$8.20
Productivity
Criminal Justice
Treatment
Medical
$42.00
Hansen, et al. Economic CostsClin J Pain 2011;27:194–202
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Drug's Costs
$53 Billions
Hydromorph
2%
Fentanyl
0%
Meperidine
4%
Other
4%
OxyContin
14%
Morphine
5%
Oxycod
11%
Codeine
8%
Methadone
12%
Hydrocod
24%
Darvon
16%
Hansen, et al. Economic CostsClin J Pain 2011;27:194–202
Who is abusing, misusing, dying?
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Age Groups: Non-medical Pain Reliever Use: 2011
1,500,000
12 to 17
18 to 25
6,600,000
3,600,000
26+
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2012.
Nonmedical Use of Pain Relievers 2010-11 among Persons Aged 12 or Older
SAMHSA 2012 NSDUH Survey Report
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8/4/2013
• What are the consequences?
Addiction
Bridging (may be related to addiction
or unmanaged pain)
Overdose
Addiction
• Chronic disease of the portions of the brain
that control
– Reward
– Motivation
– Memory
• Root causes can be traced back to
–
–
–
–
Genetics
Environment
Resiliency
Culture
ASAM: Public Policy Statement: Definition of Addiction (Long Version) 2011
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Spectrum of use: Age 12 and over
Abuser/Addict
2,000,000
Users
Abstainers
11,000,000
241,000,000
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2012.
Past Year Dependence Criteria among Persons Aged 12 or Older
1
2
3
4
5
Millions
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2012.
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Past Year Received Treatment for Drug Dependence: 12 or Older: 2011
5,000,000
4,500,000
4,000,000
Have Abuse
Dependence
3,500,000
Treatment
gap
3,000,000
2,500,000
2,000,000
1,500,000
Received
Treatment
1,000,000
500,000
Substance Abuse-and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and
Total
Dependent
Total 12-4713.
Treated Rockville, MD: Substance
Health: Summary of National Findings,
NSDUH
Series H-44, HHS Publication No. (SMA)
Abuse and Mental Health Services Administration, 2012.
“BRIDGING”
• Using what ever is available on the street to
temporarily substitute for or replace the drugs you have
become addicted to.
– Oxycodone
– Hydrocodone
– Suboxone
– Methadone
– Tramadol
– Above plus Seroquel, gabapentin, benzodiazepine,
etc.
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Why do we care
Sources: National Vital Statistics System. Mortality data. Available at http://www.cdc.gov/nchs/deaths.htm.
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Rate/100K population of unintentional drug overdose deaths 1970–2007.
1996
OxyContin
1986
<1%
addiction
risk debate
2001
TJC – pain tx a standard
2004
FSMB Mandates pain tx
1996
Pain Soc: 5th Vital Sign
1998
FSMB Loosens Opioid
rx’ing
2007
Purdue guilty re:
Oxy fraud
One death every 19 minutes. Increase has been driven by increased use of opioid analgesics.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm
Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013
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Gender: 38, 329 Overdose Deaths 2010
15,323
Male
Female
23,006
Mack, Jones, Paulozzi (CDC). MMWR, July 2, 2013
Compton, Volkow, Throckmorton (NIDA/FDA) Ann Intern Med. 2013;158:65-66
Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013
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Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013
WHY?
Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013
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Sources of drugs:
4.4% 0.4%
4.8%
6.7%
Friend/relative - Free
MD
11.4%
Friend/relative - $
Other
55.0%
Friend/relative - Stole
Dealer
Internet
17.3%
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2012.
Utah DOH 2013 http://www.health.utah.gov/vipp/pdf/FactSheets/RxOpioidDeaths.pdf
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Tramadol
• It IS an OPIOID!
• It is a CS in UTAH!
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Who Is At Risk?
“Adverse Selection”
• Those individuals who are most likely to
receive chronic opioid therapy are also those
who are most likely to develop opioid
abuse/dependence.
– Histories of sexual, physical abuse
– History/risk of other substance abuse
– Current/history of other psychiatric illness
– “This patient is hard to manage!”
»Mark Sullivan, MD, PhD, U Wash
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Percentage of patients and prescription drug overdoses, by risk group
CDC January 13, 2012 / 61(01);10-13
10
%
10
%
40
%
80
%
40
%
20
%
RISK GROUP:
10% high doses (≥100 mg morphine per day) by a single doc
40% of overdoses
10% high doses (≥100 mg per day) by MULTIPLE docs
40% of overdoses.
80% low doses (<100 mg per day) by a single doc
20% of overdoses.
Drug overdose rate for women 2009-2010
Mack, Jones, Paulozzi (CDC MMWR July 2, 2013
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8/4/2013
Veterans Are At Risk
Higher rates among VA patients
Other risks
•
•
•
•
•
Opioid dose > 100mg morphine equiv. per day
Known alcohol and cocaine abuse
Combo with benzos
Chronic (> 90 days) opioids
Sleep apnea
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Where are overdoses occurring
CDC 2008 data
Who Is At Risk?
•
•
•
•
Veterans
Women
Prescribed high dose opioids
From:
– Utah, Nevada, Colorado, Idaho, Oregon,
Washington, Arizona, New Mexico, Alaska,
Oklahoma, Lousiana, Florida, etc.
• History/vulnerability for substance abuse
• Current or history of psychiatric illness
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What about pain?
Pain Sensations and Relievers
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How are we doing treating pain?
• Perception of how well pain is managed is strongly
tied to patients’ overall satisfaction with hospital
experience
From: http://www.medicare.gov/HospitalCompare/
What are we doing about abuse and overdoses?
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8/4/2013
FDA Actions to date:
• Encouraged pharma to develop data on the
comparability of various formulations of
naloxone
• REMS for opioids focused on prescriber and
patient education
• Reschedule hydrocodone (Lortab/Vicodin)
Schedule II
• Approval of “Abuse Deterrent” Formulations
Possible Abuse Deterrents
Mechanism
Purpose
Physical modification of tablet Prevent crushing, chewing
Chemical
Prevent extracting
Add antagonist
Add aversive agent
Block the effect or get sick if
misused
Get sick if misused
Depot formulation
Assure medication is in body
Pro-drug
Becomes active only in
bloodstream
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Unintended Consequence of Changing OxyContin Formulation
Cicero, et al. NEJM July 12, 2012
OxyContin Reformulated
• Medical provider responsibilities
– Prescribe wisely
» Use Prescription Drug Monitoring Programs
– Follow prescribing guidelines
» State’s
» Federation of State Medical Boards new
guidelines
– Laboratory toxicology analysis
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Help MDs interpret tests by understanding Opioid Metabolism
Buprenorphine ----> Norbuprenorphine
Robert Swotinsky MD, 11/2006
MRO Question board
Education
•
•
•
June 28, 2013
Emphasizes Balance Between Appropriate Pain Management and
Prevention of Prescription Drug Abuse & Diversion
CHICAGO – The American Medical Association (AMA) is now
offering an updated pain management education program to
provide physicians with up-to-date information on the assessment
and management of pain. Funding for this update was made
possible by support from the Prescribers' Clinical Support System
for Opioid Therapies, a group of health care organizations led by
the American Academy of Addiction Psychiatry that received grant
funding from the Substance Abuse and Mental Health Services
Administration.
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UT: State Board of Pharmacy, PDMP database
“Controlled Substance Database-CSD”
http://www.dopl.utah.gov/programs/csdb/
•Database providing data on the
dispensing of Schedule II-V drugs by
all retail, institutional, and outpatient
hospital pharmacies, and instate/out-of-state mail order
pharmacies records
•Does not contain information from
prescriptions filled at federal
facilities, pharmacies licensed by
other states, or controlled
substances administered in an inpatient setting
•Monthly CSD training available for
two hours of continuing education
towards license renewal
requirements
•To register for the database visit
https://login2.utah.gov/user/create
Who uses/accesses CSD?
• MD’s > 80%
• Pharmacists < 30 %
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Actions to take when CSD accessed?
•
•
•
•
Refuse to prescribe?
Contact pharmacy?
Refuse to fill?
Contact prescriber?
• Reporting?????
Can you identify “legitimate” medical use
from CSD?
• You can see:
– Multiple rx’s
– Multiple prescribers
– Multiple pharmacies
– Overlapping dates
– “Traveling” to get prescriptions filled
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You cannot see:
• This weeks prescriptions (yet)
• VA, HILL AFB or other federal data!
• 50,000 veterans, 10000’s of prescriptions
• Rx’s from other states (yet)
• Marijuana, cocaine, non-prescribed benzos
• INTENT (i.e. is there a ‘legitimate’ medical
purpose?)
• Results of any urine drug testing
• Are they taking it or diverting it?
Can you fill a prescription?
• What constitutes “knowing the prescription is
being not being used for ‘legitimate’ medical
purpose?”
– Is it going to be diverted
– Is it going to be intentionally abused, i.e.
injected, snorted, smoked, chewed to get
high
VS
– Misused to treat unmanaged pain
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UTAH – Legislative Actions
•
1995 – Utah Controlled Substance Database
•
2007 –H.B. 137 to created Prescription Pain Medication Program
•
2009 – Utah Clinical Guidelines on Prescribing Opioids is released.
•
2010 – H.B. 28 Utah Controlled Substance Database registration
mandatory
•
2011 –S.B. 61 Four hours prescribing classes required each licensing
period
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Screening, Brief Intervention, and Referral to Treatment (SBIRT)
• Comprehensive, integrated, public health
approach in primary care centers,
hospital emergency rooms, trauma
centers, and other community settings to
prevent problems earlier.
http://www.samhsa.gov/prevention/SBIRT/index.aspx
SBIRT in a nutshell
• ASK – about tobacco, alcohol and drug use
• ASSESS – by brief screen if positive:
• ADVISE – of need to change, non-judgemental,
personal message (meaningful to them)
• ASSIST – by motivational interviewing to facilitate
change if resistant or referral for specialty care if
accept or need
• ARRANGE FOLLOW-UP – to support, measure
and reinforce change
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Opioid Risk Tool (ORT)
• Predicts aberrant behavior
• Based on
• Gender, Age, Personal and Family substance abuse
history, Sexual abuse history, Psychiatric conditions
present
• Total Score Risk Category
• Low Risk 0 – 3
• Moderate Risk 4 – 7
• High Risk > 8
Reference: Webster LR. Predicting aberrant behaviors in opioidtreated patients
http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf
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Screener and Opioid Assessment (SOAPP)
• Never, sometimes, often, always scale
• 24 questions
• Only 14 are scored and predict aberrant
behavior
• 2, 7, 10, 11, 12, 13, 15, 17, 18, 19, 20, 22, 23, 24
• A score of 7 or higher is considered positive risk
http://www.epicmentoring.com/files/SOAPP_v1.pdf
CAGE, CAGE AID
• 4 Questions about alcohol and/or drug use
• Felt need to Cut down use?
• Feel Angry/annoyed when your use is mentioned?
• Feel Guilty or forgo responsibilities when you use?
• Need an Eye-opener or need to use to get your day or
activities started or steady nerves?
• 1 positive = 79% sensitive 77% specific
• 2 positive = 70% sensitive 85% specific
• If positive, further assessment or referral should be made.
http://www.cqaimh.org/pdf/tool_cageaid.pdf
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Drug Abuse Screening Tool (DAST)
•
•
•
•
28 Questions
Self-administered
Score 6-11 = further evaluation
Score 12 or higher = refer for treatment
http://www.drtepp.com/pdf/substance_abuse.pdf
Substance Abuse Subtle Screening Inventory (SASSI)
• 67 item self-administered questionnaire
• PROPRIETARY
• must pay to use
http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/66
_SASSI.pdf
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Adult Substance Use Survey (ASUS)
The ASUS-R is part of the SAM Computer Software Application
http://aodassess.com/assessment_tools/asus/
UT: “Use only as directed” •Program designed
http://www.useonlyasdirected.org/
for medical
professionals as well
as the general public
•Focuses on abuse,
safe use, safe
storage, and safe
disposal of
prescription
medications
•Offers a support
forum to medical
professionals
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National: AWARERxE; The Medicine Abuse Project
http://medicineabuseproject.org/
•National website focused
on providing information on
prescription medication
abuse to parents and
grandparents, health care
providers, communities and
law enforcement, and
educators
•Shares personal stories of
individuals affected by
prescription drug abuse
•Provides recent news
stories related to
prescription drug abuse
Educate to Prevent Overdoses
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Signs of Opioid Overdose
• Check: Appears sleepy, hard to arouse
• Listen: Shallow breathing, snoring, raspy or
gurgling sounds
• Look: Bluish or grayish lips, fingernails, skin
• Touch: Clammy/sweaty skin
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Where is naloxone distribution occurring?
At the end of the presentation you will be able to correctly answer these questions:
1) According to Utah regulations, pharmacists can authorize a pharmacy technician to
access the Utah Controlled Substance Database.
True or False
2) According to Utah regulations, prescribers can authorize a non-medical clinic
employee to access the Utah Controlled Substance Database.
True or False
3) According to the National Survey on Drug Use and Health 2011 results, which
group is most likely to engage in the non-medical use of opioid prescription
medications?
• 1. 12-15 years old
• 2. 18-25 years old
• 3. 26-45 years old
• 4. Over 65 years old
4) The National Associations of Boards of Pharmacy has promoted which of the
following methods to deter inappropriate prescribing as well as abuse of controlled
substances.
• 1. National database of “doctor shoppers”
• 2. National database of “pill mill” doctors
• 3. Searchable national database of controlled substance prescriptions
• 4. National hot line for reporting pharmacy robberies
37
8/4/2013
38