Searching for answers: proper prescribing of controlled prescription drugs.NIDA NIDA National Institute on Drug Abuse
NIDA National Institute of Dramatic Arts (Australia)
NIDA Northern Ireland Development Agency (UK)
NIDA Northern Ireland Dairy Association 2011). This represents around 20% of those aged 12 or older in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . The DEA (DEA 2011) reports that in 2009 there were seven million Americans aged 12 years and older who abused controlled prescription drugs for nonmedical purposes within the past month. This is a 13% increase since 2008.
Three classes of controlled prescription drugs are most commonly abused: opiates, such as oxycodone oxycodone /oxy·co·done/ (-ko´don) an opioid analgesic derived from morphine; used in the form of the hydrochloride and terephthalate salts.
n. (OxyContin Ox·y·con·tin
A trademark for the drug oxycodone.
ETH-Oxydose, OxyContin, OxyFast, Oxy-IR, Oxynorm (UK), Roxicodone, Supeudol (CA)
Pharmacologic class: Opioid agonist [R], Percocet[R]), hydromorphone
(Dilaudid[R]) or hydrocodone (Vicodin[R]); sedative-hypnotics including benzodiazepines Benzodiazepines Definition
Benzodiazepines are medicines that help relieve nervousness, tension, and other symptoms by slowing the central nervous system.
Benzodiazepines are a type of antianxiety drugs. (such as Xanax[R], Ativan[R], Klonopin[R], Valium[R]), and stimulants (such as Adderall[R], Dexedrine[R], Ritalin[R], amphetamine amphetamine (ămfĕt`əmēn), any one of a group of drugs that are powerful central nervous system stimulants. Amphetamines have stimulating effects opposite to the effects of depressants such as alcohol, narcotics, and barbiturates. , Concerta[R]). Currently, of these three classes of medications, the most commonly diverted and abused medications are the opiate opiate /opi·ate/ (o´pe-it)
1. any drug derived from opium.
2. hypnotic (2).
1. drugs. The rapidly increasing distribution of prescription opioids (whether from legitimate prescriptions or Internet pharmacies) has helped increase the abuse of these medications, as well as the threats posed by diversion of the medications (ONDCP ONDCP Office of National Drug Control Policy 2011).
The statistics on prescription drug prescription drug Prescription medication Pharmacology An FDA-approved drug which must, by federal law or regulation, be dispensed only pursuant to a prescription–eg, finished dose form and active ingredients subject to the provisos of the Federal Food, Drug, abuse are startling: in 2009, an average of 6,027 individuals per day abused prescription pain relievers for the first time, and 2,500 teens daily use prescription drugs to get high for the first time (DEA 2011). One in seven teenagers has admitted to abusing prescription drugs in the past year to get high. Many of the teenagers have the misconception that prescription drugs are easier to get than illicit drugs, that they are safer than illegal drugs, and that they are not addictive (DEA 2011). Substance abuse, including controlled prescription medication, has become one of the nation's primary health problems, now affecting millions of individuals. The rate of controlled prescription drug abuse almost doubled from 7.8 million to 15.1 million in the years 1992 to 2003 (Manchikanti 2007). The CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation reports that opioid prescription painkillers caused more drug overdose Drug Overdose Definition
A drug overdose is the accidental or intentional use of a drug or medicine in an amount that is higher than is normally used. deaths than cocaine and heroin combined, while the number of individuals abusing prescription drugs is larger than the number of individuals abusing cocaine, hallucinogens, heroin, and inhalants combined (CDC 2011).
BATTLING DIVERSION WITH NASPER
"Pill mills" have received the most attention in the ongoing battle to prevent misuse, abuse, and diversion of controlled prescription drugs. The lure of financial gain at the expense of individuals who have addiction problems is being fought by state and federal law enforcement. Dishonest professionals who are prescribing excessively without legitimate reasons are being investigated and arrested. One of the tools that have aided law enforcement has been the prescription monitoring programs (PMP See point-to-multipoint and portable media player.
PMP - Portable Media Player ) developed in many states. The SAMHSA SAMHSA Substance Abuse and Mental Health Services Administration National All Schedules Prescription Electronic Reporting (NASPER) Act of 2005 provided for the establishment of a controlled substance monitoring program in each state (Manchikanti, Whitfield & Pallone 2005). This law requires that dispensers of drugs report to their state within one week of dispensing a controlled substance. It also required that a searchable database Refers to databases on the Web that are searchable by typing in a query. The term is quite redundant because all databases are searchable. In fact, that is one of their major features. be developed in each state containing the reported information that would be accessible by other states. The Alliance of States with Prescription Monitoring Programs currently lists 48 states having legislation authorizing the creation and operation of a prescription monitoring program (Alliance of States with Prescription Monitoring Programs 2012). Only 40 states, however, have a PMP that is operational and currently collecting data from prescribers and dispensers, while reporting information from the database to authorized users.
TYPES OF MISPRESCRIBING PROFESSIONALS
Unfortunately, addressing the illegal procurement and diversion of controlled prescription drugs is only part of the problem. Professionals more often misprescribe for other reasons than financial gain. Misprescribing can be broadly defined as prescribing scheduled drugs in quantities and frequencies inappropriate for the patient's complaint or illness. This may include prescribing controlled substances in large quantities or at frequent intervals and progression to multiple medications in the same medication class. Other misprescribing issues include prescribing controlled substances for family members or for friends and colleagues without a true physician/patient relationship. Often in the above situations, inadequate records are kept by the prescribing professional. Many medical boards have adopted the philosophy that "it is not what you prescribe, but how well you manage the patient's care, and document that care in legible form, that is important" (Minnesota Board of Medical Practice 1990). The types of medical professionals who have prescribing privileges allowing them to write prescriptions for controlled substances are varied. Physicians, dentists, nurse practitioners, and physician assistants can all prescribe prescription medications for patients. The professionals who misprescribe can fall into several different categories. The four D's--dated, disabled, duped, and dishonest--were first outlined by Wesson and Smith (1990) and then adopted by the American Medical Association (AMA). Within the CME CME
See: Chicago Mercantile Exchange
See Chicago Mercantile Exchange (CME). program at the Center for Professional Health, Spickard and colleagues (1999, 1998) built onto this model by adding dismayed and dysfunctional in order to enhance the understanding of the role of physician wellness and levels of training in prescribing.
The dated professional often fails to keep current for many different reasons. Multiple new medications and treatments are discovered yearly, making the task of keeping up with the pace of medical knowledge daunting, particularly if the professional is practicing in a primary care field where a wider variety of disorders are treated (rather than in a narrowly defined specialty). At times, there is a lack of knowledge about other effective treatment options simply because the professional does not attend ongoing continuing medical educational courses, feeling they know the "best way to treat a particular problem."
The disabled professionals may have their own impairment issues, which may impact their judgment. Professionals are no different than the general population, in that they suffer the same type of impairment problems at a similar and possibly, at times, a higher prevalence. One of the most common issues is alcohol and other drug problems. If a professional has a problem with alcohol and/or drugs, it makes the professional more likely to be in denial in denial Psychiatry To be in a state of denying the existence or effects of an ego defense mechanism. See Denial. about the issues occurring with the patient or to be "more generous" in their prescribing of controlled medications. Of equal concern is that the professional's judgment is impaired to the point that they see their ability to prescribe as an easy way to get drugs for themselves in order to continue their own addiction problems. However, it is not just alcohol and other drugs that may cause impairment issues in professionals. Misprescribing can occur when the prescriber has problems with psychiatric disorders such as depression, bipolar disorder bipolar disorder, formerly manic-depressive disorder or manic-depression, severe mental disorder involving manic episodes that are usually accompanied by episodes of depression. , and anxiety as well as medical problems that can cause decreased concentration or cognition problems. There is also the issue of dementia in some aging professionals, which affects their ability to practice and may lead to misprescribing and medical errors.
The lack of substance abuse education both in the training professionals receive and in the continuing medical education continuing medical education See CME. required throughout their careers leads to the professional who is duped, as the professional fails to detect deception by their patient. In one study, only 19% of physicians had received any medical school training in identifying prescription drug diversion and only 40% received training on identifying prescription drug abuse and addiction (CASA 2005). At the same time up to 43% of physicians do not even ask about controlled prescription drug abuse when taking a patient's health history (CASA 2005). Currently, there appears to be a lack of substance abuse training in many medical schools. Few medical schools require a mandated clerkship in substance abuse such as the one offered in the Department of Psychiatry at the University of Florida University of Florida is the third-largest university in the United States, with 50,912 students (as of Fall 2006) and has the eighth-largest budget (nearly $1.9 billion per year). UF is home to 16 colleges and more than 150 research centers and institutes. (Gold & Teitelbaum 2010). Professionals through their own denial or lack of understanding of impairment problems often do not recognize the possible warning signs of addiction in their patients or themselves. The professional may believe their patients are always telling the truth about their symptoms, how they "lost" their prescription medication, or why they need early refills. This is particularly true when the patient does not fit the preconception pre·con·cep·tion
An opinion or conception formed in advance of adequate knowledge or experience, especially a prejudice or bias.
Noun 1. the professional has of how someone with substance abuse problems presents.
At times a professional gives a prescription as a quick fix due to time constraints. The professional may be dismayed secondary to time constraints, too many patients scheduled, emergencies in the practice, or any number of other practice issues. The professional may feel the only way to get everything done is by taking the "easy way out." This may mean prescribing what the patient asks for or wants, rather than risking a possible confrontation. A commonly recited example is when a busy physician prescribes a controlled substance for a new patient requesting the drug but fails to complete a full screening and background check due to time and patient flow. The physician may simply give a prescription rather than taking time to explore the alternative treatment options available for that patient and thus avoids any conflict. It is much easier for the medical professional to give the prescription than to complete a thorough investigation and expend the time to provide other treatment options. They are avoiding the critical discussions and interactions with the patient in order to keep their office on schedule and prevent a patient complaint to the board while feeling as if they have provided "appropriate" care of their patient.
At times a professional is dysfunctional, finding it hard to say no to any request from a patient, family member, friend, or colleague. Many professionals when asked a favor by someone they closely know have a difficult time setting an appropriate professional boundary professional boundary Professional ethics An ill-defined psychosocial 'frontier' maintained between a professional and a Pt or client. See Dual relationship, Sexual misconduct, Slippery slope. . The issue of treating oneself or a close family member/friend often was not addressed in the professional's education. The American Medical Association (AMA 1993) in their Principles of Medical Ethics medical ethics The moral construct focused on the medical issues of individual Pts and medical practitioners. See Baby Doe, Brouphy, Conran, Jefferson, Kevorkian, Quinlan, Roe v Wade, Webster decision. (Policy E-8.19) states that physicians should not generally treat themselves or their family members for multiple reasons. The reasons include that their objectivity may be compromised; their personal feeling may unduly influence their medical judgment; they may fail to probe sensitive areas when taking a medical history; or they may be inclined to treat problems beyond their expertise or training. It is also felt that it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members (AMA 1993). Although the guidelines were developed in June 1993, professionals have often continued to prescribe controlled prescription drugs to family, friends, and themselves.
UNDERSTANDING SUBSTANCE ABUSE
Since prescription drug abuse is this nation's fastest growing drug problem (ONDCP 2011), it is important to understand the larger picture of substance abuse. The Drug Abuse Warning Network The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors Drug-related visits to hospital emergency departments and Drug-related deaths investigated by medical examiners and coroners [https://dawninfo.samhsa.gov/default.asp]. stated that in 2005 there were 816,696 emergency department visits involving an illicit drug illicit drug Street drug, see there (Manchikanti, Whitfield & Pallone 2005). This represents 2,200 opportunities every day in emergency departments alone for physicians and other healthcare workers to screen and refer patients to appropriate substance abuse treatment (Manchikanti, Whitfield & Pallone 2005). Whether it involves legal substances such as tobacco, alcohol and prescription drugs or illicit drugs, substance abuse is a major patient safety issue. As noted above, a CASA (2005) study reported that only 40% of physicians surveyed received training on identifying prescription drug abuse and addiction. Additionally, physicians often fail to offer treatment to addicted patients and only 55% routinely recommended addiction treatment (Friedman, McCullough & Saitz 2001).
One of the ways a professional can avoid inappropriately prescribing for a patient is to understand the risk factors for substance abuse or dependency. Substance abuse is defined by the American Psychiatric Association (2000) in the DSM-IV-TR as "a maladaptive Maladaptive
Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.
Mentioned in: Cognitive-Behavioral Therapy pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances." Problems may manifest themselves as failure to fulfill major role obligations in their lives, recurrent use of substances in physically hazardous situations, recurrent legal problems related to their substance use, or recurrent problems in social or interpersonal settings secondary to substance use. If a patient is substance dependent their disease may be manifested by tolerance, withdrawal, taking larger amounts of the substance, unsuccessful efforts to cut back on their use, a large amount of time spent trying to get the substance, important personal activities given up because of substance use, or continued use despite recurrent problems related to or caused by the substance (APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated.
APA - Application Portability Architecture 2000).
Professionals should screen for risk factors, as well as warning signs of drug addiction drug addiction
or chemical dependency
Physical and/or psychological dependency on a psychoactive (mind-altering) substance (e.g., alcohol, narcotics, nicotine), defined as continued use despite knowing that the substance causes harm. in their patients. There are a number of screening questionnaires for alcohol and/or drug use that can be used in the medical setting, many of which the patient can fill out themselves before seeing the medical professional. Screening and brief interventions can make a difference in identifying more patients with substance abuse problems, as well as decreasing risky behaviors (Anderson et al. 2008).
Professionals should be aware that many risk factors exist for developing a substance abuse problem, including a positive family history of addiction, a past history of sexual or other type of abuse, history of risk-taking behaviors, chronic pain syndromes, etc. Additionally, professionals should suspect drug-seeking behavior in their patients who demonstrate any of the behaviors listed in Table 1 (DEA 1999).
EDUCATING HEALTHCARE PROFESSIONALS
Vanderbilt University's Center for Professional Health (CPH) has been training and educating physicians about proper prescribing practices for over a decade (Spickard 1999, 1998). In collaboration with CPH, Martha E. Brown, M.D. at the University of Florida and her colleagues have offered a misprescribing course for almost seven years. Based on experiences in both courses, it appears most course participants were never trained in substance abuse identificaiton or proper prescribing practices around substance abuse (Swiggart, Ghulyan & Dewey In press). These experiences verify what has been reported in the literature, that routine screening for substance use or abuse (particularly in primary care and emergency department settings) is not commonplace (Hettema et al. 2009). Barriers to screening and brief interventions include physicians' doubts regarding treatment efficacy, lack of self efficacy, lack of knowledge (Holland, Pringle & Barbetti 2009), as well as, low confidence and lack of training in medical school and residency (McEwen 2009). Screening, brief intervention A Brief intervention is a technique, similar to an intervention, to help reduce alcohol misuse. It work in two ways:
- by getting people to think differently about their alcohol use so that they begin to think about or make changes in their alcohol consumption.
Continuing medical education (CME) can be an effective tool to remedy this lack of training and education. Educational strategies involving training and practice have a much better chance of changing practitioner behavior when focusing on the process of learning (Davis et al. 2011). The three-day CME course currently offered by the Center for Professional Health at Vanderbilt (http://www.mc.vanderbilt.edu/cph) and at the University of Florida Addiction Medicine addiction medicine Substance abuse The health field that addresses the needs of individuals addicted to substances of abuse including alcohol and illicit drugs–eg, cocaine, marijuana, heroin, and others; AM focuses on prevention and treatment and mental health Division (www.drmarthabrown.com) titled "Prescribing Controlled Drugs: Critical Issues and Common Pitfalls" was developed to teach new skills and substance abuse identification, teach appropriate prescribing practices, and facilitate the physician's and other professional's understanding of his/her personal motivations in the patient encounter (Swiggart, Spickard & Dodd 2002; Spickard et al. 1999, 1998). The majority of the physician participants are mandated or sanctioned to attend by their individual state medical board or physician's health program. A major reason for such sanctions is inadequate records around pain management or other scheduled drug use. The following is a checklist of chart entries that should be noted. While states may vary in their approach to an investigation, an adequate chart is the physician's most valuable defense. The chart should minimally contain the following:
1. Diagnosis/problem list
2. Number of office visits
3. Controlled prescriptions
5. Medical monitoring history/PMP
6. Urine drug screens
7. Step prescriptions (try non-narcotics first)
10. Comprehensive medical therapy
11. Diagnosis evidence
Dewey (2011) suggests a four-step approach for every patient. Step one is history taking and screening for substance abuse using SBIRT, including individual and family substance abuse history, and asking "have you ever used or do you currently use" tobacco, alcohol, marijuana, street drugs, prescription drugs, or other recreational drugs. Substance use should be identified and quantified with the rest of the patient's presenting and past history. If the screen is negative no further substance use intervention is needed. If that screen is positive, then the physician would proceed to step two and provide the remaining components of SBIRT: the brief intervention using motivational interviewing techniques and the referral to treatment if warranted based on the patient's issues. Step three is to determine an appropriate plan of care by developing a treatment plan that includes nonaddictive pharmaceutical and other treatment modalities and referrals, determining criteria for success and failure of treatment, providing informed consent relative to risk/benefits of any scheduled drug prescribed and scheduling regular monitoring of patient condition, laboratory results, side effects Side effects
Effects of a proposed project on other parts of the firm. , etc. Step four involves documenting the patient's history, physical and supporting evidence (labs, radiographs, etc.), informed consent given, any plans developed, medications prescribed, compliance, and follow up (Dewey et al. Under review). Practice procedures that the medical professional can use to avoid being cited for misprescribing are delineated in Table 2.
Educational programs for physicians should include teaching about the biological underpinnings of substance abuse including the interaction of reward pathways in the brain, the efficacy of treatment, and the necessary competency to treat or make informed referrals. Barriers and risk factors are important to address. Data from the Vanderbilt CME course demographics and assessments inform us that physicians referred to the CME courses usually have one or more of the following five risk factors: (1) family of origin patterns that interfere with the physician's ability to ask appropriate questions or deal with certain behaviors because of familial taboos of discomfort; (2) core personality issues such as conflict avoidance or passivity and acquiescing to patient demands; (3) patient type problems such as having a large numbers of drug seeking patients or other challenging patient types in their practice; (4) pharmacological knowledge issues where the physician is out of date regarding newer drugs or particular interactions; and (5) professional practice system problems such as poor charting, as well as, sloppy administrative practices allowing drug diversion within the office system. (Spickard et al. 1998).
Physicians most at risk for complaints appear to be family practice and general internist internist /in·tern·ist/ (in-ter´nist) a specialist in internal medicine.
A physician specializing in internal medicine. physicians practicing in solo practices in small communities (Spickard et al. 1998). Often access to pain clinics and substance abuse referral resources are limited in these circumstances, placing extreme pressure on the individual physician to solve a multitude of patient problems. Preventative education needs to occur at all levels of training and be reinforced for the practicing physician.
Controlling prescription drug abuse has rapidly become one of the nation's most pressing problems in healthcare. The lack of substance abuse education and training of healthcare professionals has added to the problem. The proper prescribing of prescription drugs needs to be emphasized not only in medical training, but by the licensing boards, requiring continuing medical education on the issues prior to being licensed or renewing one's license.
Healthcare providers need to recognize that even brief interventions by providers have proven effective in reducing substance abuse in patients. Medical professionals need to understand and incorporate appropriate prescribing guidelines into their practices in order to: (1) not be afraid to treat pain and other conditions with controlled prescription drugs when necessary and (2) screen, identify, and intervene with patients who have or are at risk of developing substance abuse or dependency problems.
Additionally, they need to talk with their patients about the benefits versus risks of using the medications, helping them to make informed decisions about their medical care, while minimizing the risk of abuse and addiction. Prescription monitoring programs need to be fully functional in every state so they can help healthcare professionals begin to recognize those patients who may already have addiction problems. It would be wise to take a lesson from Franz Kafka who wrote in A Country Doctor, "To write a prescription is easy but to come to an understanding with people is hard" (Manson 2005). By educating themselves and their patients, physicians can help them make informed decisions about prescription drugs, while curbing their own desire to try and relieve all of their pain and suffering with a prescription.
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Center on Addiction and Substance Abuse The Center on Addiction and Substance Abuse (CASA) was established in 1992 by Joseph A. Califano, Jr. The stated, official goals of the organization, now called the National Center on Substance Abuse at Columbia University, are
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : The National Center on Addiction and Substance Abuse (CASA).
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Martha E. Brown, M.D. (a); William H. Swiggart, M.S., LPC/MHSP (b); Charlene M. Dewey, M.D., M.Ed., FACP FACP Fellow of the American College of Physicians.
1. Fellow of the American College of Physicians
2. Fellow of the American College of Prosthodontists (c) & Marine V. Ghulyan, M.A. (d)
(a) Associate Professor of Psychiatry, UF College of Medicine, Department of Psychiatry, Addiction Medicine Division, Gainesville, FL.
(b) Assistant in Medicine, Co-director, Center for Professional Health, Vanderbilt University Medical Center The Vanderbilt University Medical Center (VUMC) is a collection of several hospitals and clinics associated with Vanderbilt University in Nashville, Tennessee. It comprises the following units:
- Vanderbilt University Hospital
- Monroe Carell, Jr.
(c) Associate Professor of Medicine, Co-director, Center for Professional Health, Associate Professor of Medical Education and Administration, Vanderbilt University Medical Center, Nashville, TN.
(d) Research Analyst II, Center for Professional Health, Vanderbilt University Medical Center, Nashville, TN.
Please address correspondence to Martha E. Brown, M.D., Associate Professor of Psychiatry, University of Florida College of Medicine, Department of Psychiatry, Addiction Medicine Division, 8491 NW 39th Avenue, Gainesville, FL 32606; phone: (352) 265-5300; email: email@example.com or www.drmarthabrown.com
TABLE 1 Suspected Drug Seeking Behaviors in Patients Possible drug seeking behavior in a patient may include: * Manipulative behavior * Assertive personality, often demanding immediate action * Pressures the professional for a particular medication * Has no interest in diagnostic tests * Refuses to see a consultant for a second opinion * Resists attempts to verify history or get old records * Fails to keep their appointments * Feigns physical or psychological problems * Self diagnoses * Will not accept alternative medications * Rapid increases in amount of medication used * Frequent, early refill requests * Utilizes a child or an elderly person when seeking controlled substances, particularly stimulants TABLE 2 Practice Procedures For Prescribing Professionals Helpful strategies for the treating professional include: * Require all patients to sign a patient informed consent agreement * Require all pain patients to sign a pain contract * Do frequent urine drug screens on all patients receiving controlled substances on an ongoing basis (no patient should be excluded including the 80-year-old grandmother) * Require the patient to use only one pharmacy * Keep meticulous records, documenting reason for prescribing, presenting complaint, impression, and treatment plan * Make sure your workup is sufficient to support your diagnosis * Strongly consider noncontrolled medication options or alternative procedures * Protect prescription pads * Explain the risk versus benefit with the patient and document this * Do not prescribe controlled substances to your family, friends, or yourself * Have clear office procedures on drug refills, pain contracts, lost medication, and phone prescriptions * Listen to your pharmacist * Learn to say no * Review the ongoing need of the patient for controlled substances at each visit
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|Author:||Brown, Martha E.; Swiggart, William H.; Dewey, Charlene M.; Ghulyan, Marine V.|
|Publication:||Journal of Psychoactive Drugs|
|Date:||Mar 1, 2012|
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