ASPMN Conference Baltimore, Maryland

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1 ASPMN Conference Baltimore, Maryland Prescribing Controlled Substances Managing Risk and Optimizing Outcomes September 13, 2012 Tracey Fremd, NP Tracey Fremd Consulting, Inc. Most Common Uses for Controlled Substance Prescribing Acute pain Chronic pain Cancer pain Psychiatric disorders 1

2 Chronic pain is the most common use for controlled substance prescribing and carries the highest potential for abuse Chronic Pain Annual Prevalence in the United States 1. Lethbridge Cejku M, Rose D, Vickerie J. Summary health statistics for U.S. adults: National Health Interview Survey, National Center for Health Statistics. Vital Health Stat 10(228) Seget S. Pain Management: World Prescription Drug Markets. New York, NY: PJB Medical Publications; Theta Report Lipton RB et al. Neurology. 2007;68(5): Coeytaux RR, Linville JC. Headache. 2007;47(1): Weir PT et al. J Clin Rheumatol. 2006;12(3): Oxman MN et al. N Engl J Med. 2005;352(22): Under Treatment of Acute Pain, Chronic Pain, & Cancer Pain Perceptions regarding chronic pain and opioids Limited knowledge and skills Fear of regulatory scrutiny Fear of substance abuse / addiction Increased abuse and misuse of prescription drugs over the last decade 2

3 Illicit Drug Use Age 12 or Older 7. Office of Applied Studies, Substance Abuse and Mental Health Services Administration(SAMHSA). Results from the 2009 National Survey on Drug Use and Health: National Findings Current Nonmedical Use of Prescription Type Drugs, By Type, Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2009 National Survey on Drug Use and Health: National Findings Emergency Room Visits Nonmedical Use of Narcotic Pain Relievers Estimated number of ER visits involving nonmedical use of narcotic pain relievers increased 111% from 2004 to Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2009 National Survey on Drug Use and Health: National Findings

4 Sources of Non medically Used Analgesics 1 >60% of opioids used by non patients are obtained from friends or family members 7. Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2009 National Survey on Drug Use and Health: National Findings Protecting Your License Know Your State Requirements Each state has its own language that permits the prescribing of controlled substances 4

5 For Nurse Practitioners 4 states require a collaborative agreement with their supervising physician to prescribed controlled substances 17 states have no restrictions on writing controlled substances 22 states have additional requirements that must be met in order to prescribe controlled substances 8 states do not permit Scheduled ll prescribing 4states do not permit controlled substance prescribing for weight loss 2 states have pending language for controlled substances (Hawaii, and Missouri) These are just a few examples of state and federal requirements please be familiar with your State's requirements Maintain DEA CS II IV License (Q 3 years) Notify DEA immediately if your practice location changes Be familiar with that DEA investigative process Register to access your State s Prescription Drug Monitoring Program (PDMP) Each State has its own unique requirements for obtaining DEA certification 5

6 Nurses What Do We Bring to the Table? Registered Nurses are critical team members Advocate for quality patient care RNs observe for and identify aberrant behaviors Notify providers of unusual behaviors or suspicious activity RNs Help Educate Other RNs, Professional and Support Staff Provide staff education about the warning signs of misuse, abuse or addictive behaviors Importance of careful documentation of patient compliance (or non compliance) by RNs and support staff Understand regulatory processes of prescribing controlled substances Use Their Patient Assessment Skills Patient s functional response to medication (improved work, ADLs, family time) Over sedation Poor medication response (changes in VAS scale) 6

7 Protecting Your Patients Opioid Agreements Urine Drug Testing Prescription Drug Monitoring Programs Patient centered UDT Not the Gotcha test Great clinical value in managing medications Introduce in a positive way, similar to any other laboratory test One of the tests we do for all patients being treated with pain medications is a UDT. This helps us with safe medication prescribing and see how the medications are working. Assist in the interpretation of urine drug test (UDT) Engage in open dialogue with patients Discuss with patients how UDTs can help direct safe patient care, ensure medication compliance and identify potential harmful behaviors 7

8 Document Your Findings!!! Both positive and negative findings are critical to assessing patients response to medication, documenting medication compliance and recording functional changes Consider Reviewing These Additional Resources As well as your National, State and Local professional organizations Prescription Drug Monitoring Programs 8

9 Prescription Drug Monitoring Programs (PDMP) State by State registration variance Electronic data base of patient specific prescription controlled substance use Information usually includes prescriber ID, medication, dose, amount filled and fill date. Part of a comprehensive risk management strategy. Opiate Agreements Components of an Opiate Agreement Patient and prescriber/practice enter into an agreement regarding opiate prescribing One prescriber/practice for agreed medications Keep medications in a safe place Comply with drug testing requests Medications are refilled during business hours only with an appointment 9

10 Opiate agreement continued Agrees to use only one pharmacy for controlled substances Agrees to additional support services when necessary Violation of opiate agreement will result in discharge from the practice (or discontinuation of prescribing medications) Patient and staff sign an updated agreement once per year or with verbal warning. Risk Management Plans: Putting the Pieces Together Universal Precautions A standardized approach to the assessment and ongoing management of chronic pain patients 9. Gourlay DL et al. Pain Med. 2005;6(2): Random and Routine Drug Toxicology Screening TRUST BUT VERIFY 10

11 Monitoring Adherence: Urine Drug Monitoring Important tool for risk mitigation in the management of chronic pain with opioids Only one component of overall risk management plan Opioid Treatment of Chronic Pain: Major Concerns Misuse Abuse Addiction Use of a medication for a purpose other than as indicated Use of illicit drug for a nonmedical purpose A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors Safe Prescribing Principles Refer to a Specialist Risk Adherence Monitoring Manage & Mitigate Risk Risk Assessment 9. Gourlay DL et al. Pain Med. 2005;6(2):

12 Risk Triage Guide 1 Risk Level Low Medium High Patient Characteristics No history of substance abuse; minimal risk factors History of substance abuse (not prescription opioids); significant risk factors Active substance abuse or addiction (prescription opioids); significant risk factors Suggested Clinical Management Pain can typically be managed by PCP Co-manage with addiction and/or pain specialists If aberrant behaviors are observed, consider increasing to next risk category Opioids MAY NOT be appropriate in the PCP setting Refer to specialist to manage comorbid pain and addictive disorder Continue to manage medical care and monitor specialized care PCP, primary care provider. 9. Gourlay DL et al. Pain Med. 2005;6(2): Encouraging & Monitoring Adherence with Clinical Support Tools Effective Patient Provider Communication Informed Consent for High-risk medication Treatment Agreement Adherence monitoring (e.g., UDT) 9. Gourlay DL et al. Pain Med. 2005;6(2): Understanding Risk and Adverse Events Leading to a Regulatory Review or Compliance Audit Overdose of a patient/patient death Arrest of the patient in possession of a prescription medication Arrest of a patient or employee involved in the sale or unlawful distribution of prescription medications Whistleblowers (up to 25% of recovered fines) 12

13 Be Informed!!! What you need to know if the DEA knocks on your door Determine if you are a witness or a target of investigation This will change the context of the visit from the DEA Remain calm Know your rights/ contact legal counsel Close all chart cabinets and remove any patient information from within view of the reception window Dismiss all patients practice for the day and post an office closed notice on the front door Dismiss all noncritical staff (receptionist, MAs, billing staff ) As an RN/NP you may be dismissed, too 13

14 Once admitted they have full access to all medical records, computer programs and documents regarding patient care Compile a list of all patients whose charts were reviewed/removed Homework Really..homework??? Questions? 14

15 Thank you Tracey Fremd, NP