Practice News.. The Patient Portal. On Call. And Ted Herwig MD. The Opioid Crisis..the good, the bad and the ugly.

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1 Practice News.. April 2016 Second Quarter Bickford Health Associates, PC/Ted Herwig MD 714 Main Street Yarmouthport, MA Telephone (508) Fax (508) ******************************* The Patient Portal, are YOU connected? ****************************** And Ted Herwig MD Patient Education Focus: (See: bickfordhealth.com) Drug Addiction By Mayo Clinic The Opioid Crisis..the good, the bad and the ugly. It is difficult to pick up the local newspaper without seeing evidence of the toll the misuse of opioids has caused in our community. Governor Baker enacted new measures in March to deal with the state s opioid epidemic. Opioid prescriptions are being scrutinized by the pharmacy, the state and insurance companies. How have we responded to this epidemic? The good news is, we have made changes over the years to be more judicious in our prescribing practices. We do have patients who are in need of opioids, and they are prescribed, along with a contract to sign, random urine checks and other measures to keep everyone as safe as possible. We meet together to look for alternative methods for pain management and dose reductions. The bad news is, sometimes prescriptive narcotics fall in to the hands of unscrupulous people. And the really ugly news is, people die. We do not want to be part of the problem, rather, we want to be part of the solution to end these casualties on Cape Cod. SV Duenas NP Cris Reid NP Drug Addiction is a complex illness according to the National Institute on Drug Abuse. Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory and inhibitory control over behavior. That is why addiction is a brain disease. Some individuals are more vulnerable than others to becoming addicted, depending on the interplay between genetic make-up, age of exposure to drugs and other influences. Nora D. Volkow MD December 2012 Kay O Keeffe NP The Patient Portal If you aren t familiar with encrypted portal is the patient portal, read on. integrated with your It is an online application electronic health record. that allows you to Through this portal, you communicate and interact have the ability to send a with us via the internet. This message, request a is a service that is available medication refill, or request to patients in the practice an appointment. You may 24 hours a day. This also view and update On Call personal information, and review lab results and other documents. If you aren t WEB ENABLED, the first step is to call or come by and register for this service at the front desk. After signing a consent form, you will be assigned a User Name and Password. Once you log in for the first time, you will be asked to change your password. We hope you join us! Susan V Duenas NP Are you aware that Bickford Health Associates, which includes Jeffrey Martens MD, Kay O Keeffe NP, Cris Reid NP and Susan Vecchione Duenas NP, along with our office suite partner, Ted Herwig MD, have a rotation call schedule? This means that you can call our main number, , after hours and get some expert advice, when you need it, day or night.

2 Prescription drug abuse By Mayo Clinic Staff Prescription drug abuse is the use of a prescription medication in a way not intended by the prescribing doctor. Prescription drug abuse or problematic use includes everything from taking a friend's prescription painkiller for your backache to snorting or injecting ground-up pills to get high. Drug abuse may become ongoing and compulsive, despite the negative consequences. An increasing problem, prescription drug abuse can affect all age groups, but it's more common in young people. The prescription drugs most often abused include opioid painkillers, sedatives, anti-anxiety medications and stimulants. Early identification of prescription drug abuse and early intervention may prevent the problem from turning into an addiction. Signs and symptoms of prescription drug abuse depend on the specific drug. Because of their mindaltering properties, the most commonly abused prescription drugs are: Opioids, such as oxycodone (Oxycontin, Roxicodone) and those containing hydrocodone (Vicodin, Lortab, Norco), used to treat pain Anti-anxiety medications and sedatives, such as alprazolam (Xanax) and diazepam (Valium), and hypnotics, such as zolpidem (Ambien), used to treat anxiety and sleep disorders Stimulants, such as methylphenidate (Ritalin, Concerta, others), dextroamphetamine and amphetamine (Adderall XR) and dextroamphetamine (Dexedrine), used to treat attentiondeficit/hyperactivity disorder (ADHD) and certain sleep disorder

3 Signs and symptoms of prescription drug abuse Opioid painkillers Sedatives and anti-anxiety medications Constipation Drowsiness Nausea Confusion Feeling high (euphoria) Unsteady walking Slowed breathing rate Slurred speech Drowsiness Poor concentration Confusion Dizziness Poor coordination Problems with memory Increased pain with higher doses Slowed breathing Other signs include: Stealing, forging or selling prescriptions Taking higher doses than prescribed Excessive mood swings or hostility Increase or decrease in sleep Poor decision-making

4 Appearing to be high, unusually energetic or revved up, or sedated Continually "losing" prescriptions, so more prescriptions must be written Seeking prescriptions from more than one doctor When to see a doctor Talk with your doctor if you think you may have a problem with prescription drug use. You may feel embarrassed to talk about it but remember that medical professionals are trained to help you, not judge you. It's easier to tackle the problem early before it becomes an addiction and leads to moreserious problems. Teens and adults abuse prescription drugs for many reasons, such as: To feel good or get high To relax or relieve tension To reduce appetite or increase alertness To experiment with the mental effects of the substance To maintain an addiction and prevent withdrawal To be accepted by peers or to be social To try to improve concentration and academic or work performance Many people fear that they may become addicted to medications prescribed for medical conditions, such as painkillers prescribed after surgery. However, people who take potentially addictive drugs as prescribed don't often abuse them or become addicted. Risk factors for prescription drug abuse include: Past or present addictions to other substances, including alcohol and tobacco Family history of substance abuse problems Younger age, especially the teens or early 20s Certain pre-existing psychiatric conditions Exposure to peer pressure or a social environment where there's drug use Easier access to prescription drugs, such as having prescription medications in the home medicine cabinet Lack of knowledge about prescription drugs and their potential harm Older adults and prescription drug abuse

5 Prescription drug abuse in older adults is a growing problem, especially when they combine drugs with alcohol. Having multiple health problems and taking multiple drugs can put seniors at risk of misusing drugs or becoming addicted. Abusing prescription drugs can cause a number of problems. Prescription drugs can be especially dangerous and even lead to death when taken in high doses, when combined with other prescription drugs or certain over-the-counter medications, or when taken with alcohol or illegal drugs. Medical consequences Here are examples of serious consequences of prescription drug abuse: Opioids can cause low blood pressure, a slowed breathing rate and potential for breathing to stop, or a coma. Overdose has a significant risk of death. Sedatives and anti-anxiety medications can cause memory problems, low blood pressure and slowed breathing. Overdose can cause coma or death. Abruptly stopping the medication may cause withdrawal symptoms that can include nervous system hyperactivity and seizures. Stimulants can cause dangerously high body temperature, heart problems, high blood pressure, seizures or tremors, hallucinations, aggressiveness, and paranoia. Physical dependence and addiction Because commonly abused prescription drugs activate the brain's reward center, it's possible to develop physical dependence and addiction. Physical dependence. Physical dependence (also called tolerance) is the body's response to longterm use. People who are physically dependent on a drug may need higher doses to get the same effects and may experience withdrawal symptoms when cutting back or abruptly stopping the drug. Physical dependence may also become evident if a drug the body becomes adjusted to over time, even without dosage change, is stopped abruptly. Addiction. People who are addicted to a drug can have physical dependence, but they also compulsively seek a drug and continue to use it even when that drug makes their lives worse. Other consequences Other potential consequences include: Engaging in risky behaviors because of poor judgment Using illegal drugs Being involved in crime Motor vehicle accidents

6 Decreased academic or work performance Troubled relationships Your primary care doctor may be able to help you overcome a prescription drug abuse problem. However, if you have an addiction, your doctor may refer you to an addiction specialist or to a facility that specializes in helping people withdraw from drugs. What you can do To prepare for your appointment, make a list of: All the medications you're taking, including over-the-counter drugs, herbs and supplements, as well as the dose and frequency Any symptoms you're experiencing Key personal information, including any major stresses or recent life changes Questions to ask your doctor Questions to ask your doctor may include: What are my treatment options? How long does it take for treatment to work? Should I see a specialist? How can we manage my other health conditions during treatment? Do you have any brochures or other printed material I can have? What websites do you recommend? What to expect from your doctor Your doctor may ask these questions: What prescription medications do you take? How much and how often do you take them? 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? Do you use recreational drugs? Do you smoke? Has anyone in your family had a history of drug abuse or addiction?

7 Doctors generally base a diagnosis of prescription drug abuse on medical history and answers to other questions. In some cases, certain signs and symptoms also provide clues. Blood or urine tests can detect many types of drugs. These tests can also help track the progress of a person who's getting treatment. Treatment options for prescription drug abuse vary, depending on the type of drug used and your needs. But counseling, or sometimes psychotherapy, is typically a key part of treatment. Treatment may also require withdrawal (detoxification), addiction medication and recovery support. Counseling A licensed alcohol and drug counselor or other addiction specialist can provide individual, group or family counseling. This can help you: Determine what factors may have led to the prescription drug abuse, such as an underlying mental health problem or relationship problems Learn the skills needed to resist cravings, avoid abuse of drugs and help prevent recurrence of prescription drug problems Learn strategies for developing positive relationships Identify ways to become involved in healthy activities that aren't related to drugs Learn the steps to take if a relapse happens Withdrawal Depending on the prescription drug and usage, detoxification may be needed as part of treatment. Withdrawal can be dangerous and should be done under a doctor's care. Opioid withdrawal. Opioid tapering involves gradually decreasing the dose of medication until it's no longer used. Other medications such as clonidine (Catapres), a drug mainly used for high blood pressure can be used to help manage opioid withdrawal symptoms during this process. Buprenorphine, buprenorphine with naloxone (Suboxone) or methadone may be used by doctors under specific, legally regulated and monitored conditions to ease symptoms of withdrawal from opioid painkillers. Vivitrol, a version of the drug naltrexone, given by injection once a month by a health care provider may help people stay off opioids early in their recovery. Withdrawal from sedatives or anti-anxiety medications. If you've used prescription sedatives or anti-anxiety drugs for a long time, it may take weeks to slowly taper off them. Because of withdrawal symptoms, it can take that long for your body to adjust to low doses of the medication and then get

8 used to taking none at all. You may need other types of medication to stabilize your mood, manage the final phases of tapering or help with anxiety, and you'll need to work closely with your doctor. Stimulant withdrawal. There are no approved drugs used for treating stimulant withdrawal. Treatment typically focuses on tapering off the medication and relieving withdrawal symptoms such as sleep, appetite and mood disturbances. Overcoming prescription drug abuse can be challenging and stressful, often requiring the support of family, friends or organizations. Here's where to look for help: Trusted family members or friends Your doctor, who may be able to recommend resources Self-help groups, such as a 12-step program Your church or faith group School counselor or nurse Support groups, either in person or from a trustworthy website Your employee assistance program, which may offer counseling services for substance abuse problems You may be embarrassed to ask for help or afraid that your family members will be angry or judgmental. You may worry that your friends will distance themselves from you. But in the long run, the people who truly care about you will respect your honesty and your decision to ask for help. Helping a loved one It can be difficult to approach your loved one about prescription drug abuse. Denial and anger are common reactions, and you may be concerned about creating conflict or damaging your relationship with that person. Be understanding and patient. Let the person know that you care about his or her well-being. Encourage your loved one to be honest about drug use and to accept help if needed. A person is more likely to respond to feedback from someone he or she trusts. If the problem continues, further intervention may be necessary. Intervention It's challenging to help a loved one struggling with drug problems or other destructive behavior. People who struggle with addictive behaviors are often in denial or unwilling to seek treatment. And they may not recognize the negative effects their behavior has on themselves and others. An intervention can motivate someone to seek help for addictive behaviors.

9 An intervention is a carefully planned process involving family and friends and others who care about a person struggling with addiction. Consulting an intervention professional (interventionist), an addiction specialist, psychologist or mental health counselor can help you organize an effective intervention. This is an opportunity to confront the person about the consequences of addiction and ask him or her to accept treatment. Think of an intervention as giving your loved one a clear opportunity to make changes before things get really bad. Prescription drug abuse may occur in people who need painkillers, sedatives or stimulants to treat a medical condition. If you're taking a commonly abused drug, here are ways to decrease your risk: Make sure you're getting the right medication. Make sure your doctor clearly understands your condition and the signs and symptoms. Tell your doctor about all your prescriptions, as well as overthe-counter medications, herbs and supplements, and alcohol and drug use. Ask your doctor whether there's an alternative medication with ingredients that have less potential for addiction. Check in with your doctor. Talk with your doctor on a regular basis to make sure that the medication you're taking is working and you're taking the right dose. Follow directions carefully. Use your medication the way it was prescribed. Don't stop or change the dose of a drug on your own if it doesn't seem to be working without talking to your doctor. For example, if you're taking a pain medication that isn't adequately controlling your pain, don't take more. Know what your medication does. Ask your doctor or pharmacist about the effects of your medication, so you know what to expect. Also check if other drugs, over-the-counter products or alcohol should be avoided when taking this medication. Never use another person's prescription. Everyone is different. Even if you have a similar medical condition, it may not be the right medication or dose for you. Don't order prescriptions online unless they're from a trustworthy pharmacy. Some websites sell counterfeit prescription and nonprescription drugs that could be dangerous. Preventing prescription drug abuse in teens Young people are at especially high risk of prescription drug abuse. Follow these steps to help prevent your teen from abusing prescription medications. Discuss the dangers. Emphasize to your teen that just because drugs are prescribed by a doctor doesn't make them safe especially if they were prescribed to someone else or if your child is already taking other prescription medications. Set rules. Let your teen know that it's not OK to share medications with others or to take drugs prescribed for others. Emphasize the importance of taking the prescribed dose and talking with the doctor before making changes.

10 Discuss the dangers of alcohol use. Using alcohol with medications can increase the risk of accidental overdose. Keep your prescription drugs safe. Keep track of quantities and keep them in a locked medicine cabinet. Make sure your child isn't ordering drugs online. Some websites sell counterfeit and dangerous drugs that may not require a prescription. Properly dispose of medications. Don't leave unused or expired drugs around. Check the label or patient information guide for disposal instructions, or ask your pharmacist for advice on disposal. References 1. DrugFacts: Prescription and over-the-counter medications. National Institute on Drug Abuse. Accessed Aug. 11, Prescription drugs. National Council on Alcoholism and Drug Dependence Inc. Accessed Aug. 11, Prescription drug abuse. National Institute on Drug Abuse. Accessed Aug. 11, Becker W, et al. Prescription drug misuse: Epidemiology, prevention, identification, and management. Accessed Aug. 11, Commonly abused drugs charts. National Institute on Drug Abuse. Accessed Aug. 11, Intervention Tips and guidelines. National Council on Alcoholism and Drug Dependence Inc. Accessed Aug. 11, Specific populations and prescription drug misuse and abuse. Substance Abuse and Mental Health Services Administration. Accessed Aug. 11, How to dispose of unused medicines. U.S. Food and Drug Administration. Accessed Aug. 11, Fact sheet: A response to the epidemic of prescription drug abuse. Office of National Drug Control Policy. Accessed Aug. 11, Drug facts: Prescription drugs. NIDA for Teens. Accessed Aug. 11, What to do if you have a problem with drugs: For teens and young adults. National Institute on Drug Abuse. Accessed Aug. 20, 2015.

11 12. Selected prescription drugs with potential for abuse. National Council on Alcoholism and Drug Dependence Inc. Accessed Aug. 11, Felicilda-Reynaldo RFD. Recognizing signs of prescription drug abuse and addiction, Part 1. Nursing Pharmacology. 2014;23: Rohren CH (expert opinion). Mayo Clinic, Rochester, Minn. Aug. 24, Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. Aug. 26, Vivitrol (prescribing information). Waltham, Mass.: Alkermes Inc.; Accessed Aug. 25, Sept. 19, 2015 Original article: Mayo Foundation for Medical Education and Research. All rights reserved