The Dark Art. Of Supervising & Managing Controlled Substances

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1 The Dark Art Of Supervising & Managing Controlled Substances David A. Frenz, M.D. Vice President & Executive Medical Director North Memorial Health Care Robbinsdale, Minn. 27 October

2 Disclosures I m employed by North Memorial Health Care I don t have any financial relationships with the pharmaceutical or medical device industries I will be discussing off label uses of medications Disclosure will occur verbally and in the footnotes of relevant slides

3 Key Reference Parran TV. Using Pearls to Avoid Pitfalls. In: ASAM Review Course in Addiction Medicine. Chevy Chase, MD: American Society of Addiction Medicine, 2008, p

4 AARP

5 Time (8 15 Sep 2014)

6 Some Preliminaries

7 Adv Psychiatr Treat 2000;6:57 1 Countertransference

8 2 Mission Creep Stay within your scope of practice How did I wind up with responsibility for this medication?!

9 3 First Do No Harm Then cure sometimes and comfort always Can J Psychiatry 2008;53:189

10 Assessment

11 1 Clear Diagnosis Treat syndromes, not symptoms Can J Psychiatry 2008;53:189

12 Can J Psychiatry 2008;53:189

13 2 Adequate Work-Up Take your time Obtain outside medical records Fill in gaps by ordering new studies and obtaining additional consultations Neurology Neuropsychology Neurosurgery Orthopedic surgery Pain medicine Physical medicine & rehabilitation

14 3 Baseline Data Validated symptoms scales and functional measures I m a big fan of the PROMIS family of instruments Pain Interference Applied Cognition Et cetera

15

16

17 4 Prior Therapeutic Trials Document the outcomes of prior therapeutic trials Medications that aren t controlled substances Psychotherapy Physical therapy Conducting your own trials is ideal

18 5 Assess Risk Opioid Risk Tool (ORT) D.I.R.E. Score Et cetera

19 FP Essentials 432 Pain Med 2005;6:432

20 6 Contraindications Addiction Diversion

21 Addict Behav 2014;39:1176

22 Fam Pract Manage 2001;8:37

23 Medicare Learning Network

24 Prescribing

25 1 Medication Agreement Is considered prudent Little evidence of effectiveness Content Goals Responsibilities Clinic policies Ann Intern Med 2010;152:712

26 North Memorial Health Care

27 2 Informed Consent Capacity Disclosure Risks Benefits Alternatives Voluntariness Carlat Addict Treat Rep 2014;2(3):1

28 3 Initiating Therapy Start low Go slow

29 4 Medication Selection Use medications within a class with the lowest abuse potential Medications that are highly reinforcing should be avoided Quick onset Short duration of action

30 Textbook of Substance Abuse Treatment, 4th ed, 2008, p. 216

31 5 Medication Schedules Fixed-dose schedules are preferable to demand dosing Demand dosing = reinforcing

32 6 Avoid Polypharmacy Concurrent use of agents from the same medication class Medications from different classes that potentiate each other > 2 Benzodiazepines + opioids

33 6 Limit Quantity Frequent visits Multiple prescriptions with do not dispense dates

34 Prescription for clonazepam was issued on with a do not dispense date of Patient information has been permanently redacted

35 Monitoring

36 1 Documentation Patient forms EHR templates SmartPhrases (Epic) 7 As

37 David Frenz, M.D.

38 FP Essentials 432

39 1 Documentation Analgesia Affect (psychological) Activities of daily living (functional status) Add up pills (pill count) Adjunctive therapies Adverse reactions (medication side effects) Aberrant drug-related behavior (and medication adherence) FP Essentials 432

40 2 Assess for Change Scales and measures Strongly consider setting an a priori goal Example: 25% improvement Medications that fail to offer benefit should be discontinued

41 3 Dispensing Records Minnesota Prescription Monitoring Program PDMP

42 Patient information has been permanently redacted

43 4 Toxicology Illegal drugs Non-medical use of prescription medications Medications you are prescribing

44 4 Toxicology Quick and dirty Clinic-based immunoassays False positives/negatives Gold standard GC/MS ( confirmation )

45 Patient prescribed clonazepam. Immunoassay was negative for benzodiazepines. Patient information has been permanently redacted

46 Same patient as prior slide. GC/MS was appropriately positive for clonazepam. Patient information has been permanently redacted

47 4 Toxicology Is it their pee? Observed collection Assay for other prescribed medications on their medication list (e.g., antidepressants) Community paramedic No problem! We ll come to you.

48 5 Pill counts In your clinic At a local pharmacy Community paramedic

49 CONFIDENTIAL MEDICAL REPORT Mental Health & Addiction Care North Memorial Health Care 3366 Oakdale Avenue North #200 Robbinsdale, MN T F Doe, Jane DOB: MRN: Physician s Orders 1. Pill count on demand Patient will bring current medication bottle to the pharmacy Pharmacist please count tablets remaining in the bottle Pharmacist please complete the table below Pharmacist please fax this document to my attention Date pill count was performed Pharmacist name License number Telephone number Medication Date medication was dispensed Number of pills remaining Suboxone 2. Diagnoses F11.90 (opioid use disorder) Z (high-risk medication monitoring) David A. Frenz, M.D. NPI: Example pill count form to be completed by a community pharmacist

50 Problems

51 1 Lost & Stolen Medications Ask for a copy of the police report Do not replace the missing medications Offer comfort cares

52 2 Withdrawal Management Opioid withdrawal syndrome Clonidine 0.1 mg tablets; take 1 tablet PO four times per day as needed for symptoms of withdrawal; hold and call my office if you get dizzy or lightheaded; #28 tablets with no additional refills Hydroxyzine pamoate 25 mg capsules; take 1 to 2 capsules PO four times per day as needed for anxiety, restlessness or insomnia; #56 capsules with no additional refills Ondansetron 8 mg tablets; take 0.5 to 1 tablet PO three times per day as needed for nausea or vomiting; #21 tablets with no additional refills Clonidine, hydroxyzine and ondansetron are not FDA approved for opioid withdrawal syndrome

53 2 Withdrawal Management Opioid withdrawal syndrome (cont) Over-the-counter ibuprofen and loperamide per labeled instructions Seek emergency medical attention, by 911 if needed, if you have severe symptoms of withdrawal despite these measures Ibuprofen and loperamide are not FDA approved for opioid withdrawal syndrome

54 2 Withdrawal Management Benzodiazepine withdrawal syndrome Clonidine 0.1 mg tablets; take 1 tablet PO four times per day as needed for symptoms of withdrawal; hold and call my office if you get dizzy or lightheaded; #28 tablets with no additional refills Hydroxyzine pamoate 25 mg capsules; take 1 to 2 capsules PO four times per day as needed for anxiety, restlessness or insomnia; #56 capsules with no additional refills Ondansetron 8 mg tablets; take 0.5 to 1 tablet PO three times per day as needed for nausea or vomiting; #21 tablets with no additional refills Clonidine, hydroxyzine and ondansetron are not FDA approved for benzodiazepine withdrawal syndrome

55 2 Withdrawal Management Benzodiazepine withdrawal syndrome (cont) Levetiracetam 250 mg tablets; take 2 tablets PO two times per day for 4 days; then take 1 tablet PO two times per day for 4 days; then take 1 tablet PO daily for 4 days; then stop taking levetiracetam; #28 tablets with no additional refills Over-the-counter ibuprofen and loperamide per labeled instructions Seek emergency medical attention, by 911 if needed, if you have severe symptoms of withdrawal despite these measures Levetiracetam, ibuprofen and loperamide are not FDA approved for benzodiazepine withdrawal syndrome

56 3 Discontinuing Controlled Substances Taper if feasible and safe Offer comfort cares if immediate discontinuation is needed Refer for a higher level of care Emergency department Addiction treatment

57 4 Terminating Care Try to avoid Just kicks the can down the proverbial road Good reasons to terminate care Forging or altering a prescription Medication diversion Dangerous or threatening behavior

58 FP Audio 433

59 Contact Information David A. Frenz, M.D. Mental Health & Addiction Care North Memorial Health Care 3366 Oakdale Avenue North #200 Robbinsdale, MN

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