Easy ways to save patients lives: How to prevent, recognize and deter prescription drug abuse.

Transcription

1 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 1

2 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? years old years old 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 2

3 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 (15-64age) 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 3

4 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) Rockville, MD: Substance Abuse and Mental Health Services Administration, 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 Costs Clin J Pain 2011;27:

5 Hydromorph 2% Fentanyl 0% Drug's Costs $53 Billions Meperidine 4% Morphine 5% Other 4% OxyContin 14% Codeine 8% Oxycod 11% Methadone 12% Hydrocod 24% Darvon 16% Hansen, et al. Economic Costs Clin J Pain 2011;27: Who is abusing, misusing, dying? 5

6 Age Groups: Non-medical Pain Reliever Use: ,500,000 6,600,000 3,600, to to 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) Rockville, MD: Substance Abuse and Mental Health Services Administration, Nonmedical Use of Pain Relievers among Persons Aged 12 or Older SAMHSA 2012 NSDUH Survey Report 6

7 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)

8 Spectrum of use: Age 12 and over 2,000,000 Abuser/Addict Users 11,000,000 Abstainers 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) Rockville, MD: Substance Abuse and Mental Health Services Administration, Past Year Dependence Criteria among Persons Aged 12 or Older 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) Rockville, MD: Substance Abuse and Mental Health Services Administration,

9 Past Year Received Treatment for Drug Dependence: 12 or Older: ,000,000 4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 Have Abuse Dependence Treatment gap 2,000,000 1,500,000 Received Treatment 1,000, ,000 Substance Abuse -and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, Total NSDUH Dependent Series H-44, HHS Publication No. (SMA) Total Treated Rockville, MD: Substance Abuse and Mental Health Services Administration, 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. 9

10 Why do we care Sources: National Vital Statistics System. Mortality data. Available at 10

11 Rate/100K population of unintentional drug overdose deaths OxyContin 2001 TJC pain tx a standard 2004 FSMB Mandates pain tx 1986 <1% addiction risk debate 1996 Pain Soc: 5 th 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. Jones, Mack, Paulozzi (CDC). JAMA, February 20,

12 Gender: 38, 329 Overdose Deaths ,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,

13 Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013 WHY? Jones, Mack, Paulozzi (CDC). JAMA, February 20,

14 Sources of drugs: 4.8% 6.7% 4.4% 0.4% 11.4% 55.0% Friend/relative - Free MD Friend/relative - $ Other 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) Rockville, MD: Substance Abuse and Mental Health Services Administration, Utah DOH

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16 Tramadol It IS an OPIOID! It is a CS in UTAH! 16

17 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 17

18 Percentage of patients and prescription drug overdoses, by risk group CDC January 13, 2012 / 61(01); % 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 Mack, Jones, Paulozzi (CDC MMWR July 2,

19 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 19

20 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 20

21 What about pain? Pain Sensations and Relievers 21

22 How are we doing treating pain? Perception of how well pain is managed is strongly tied to patients overall satisfaction with hospital experience From: What are we doing about abuse and overdoses? 22

23 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 Add antagonist Add aversive agent Depot formulation Pro-drug Prevent extracting Blockthe effect or get sick if misused Get sick if misused Assure medication is in body Becomes active only in bloodstream 23

24 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 24

25 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. 25

26 UT: State Board of Pharmacy, PDMP database Controlled Substance Database-CSD 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 Who uses/accesses CSD? MD s > 80% Pharmacists < 30 % 26

27 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 27

28 You cannot see: This weeks prescriptions (yet) VA, HILL AFB or other federal data! 50,000 veterans, 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 28

29 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 H.B. 28 Utah Controlled Substance Database registration mandatory 2011 S.B. 61 Four hours prescribing classes required each licensing period 29

30 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. 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 30

31 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 31

32 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 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. 32

33 Drug Abuse Screening Tool (DAST) 28 Questions Self-administered Score 6-11 = further evaluation Score 12 or higher = refer for treatment Substance Abuse Subtle Screening Inventory (SASSI) 67 item self-administered questionnaire PROPRIETARY must pay to use _SASSI.pdf 33

34 Adult Substance Use Survey (ASUS) The ASUS-R is part of the SAM Computer Software Application UT: Use only as directed Program designed 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 34

35 National: AWARERxE; The Medicine Abuse Project 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 35

36 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 36

37 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? years old years old 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

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