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 2016 www.doctorfrenz.com
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
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. 130 138.
AARP
Time (8 15 Sep 2014)
Some Preliminaries
Adv Psychiatr Treat 2000;6:57 1 Countertransference
2 Mission Creep Stay within your scope of practice How did I wind up with responsibility for this medication?!
3 First Do No Harm Then cure sometimes and comfort always Can J Psychiatry 2008;53:189
Assessment
1 Clear Diagnosis Treat syndromes, not symptoms Can J Psychiatry 2008;53:189
Can J Psychiatry 2008;53:189
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
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 www.nihpromis.org
www.assessmentcenter.net
www.assessmentcenter.net
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
5 Assess Risk Opioid Risk Tool (ORT) D.I.R.E. Score Et cetera
FP Essentials 432 Pain Med 2005;6:432
6 Contraindications Addiction Diversion
Addict Behav 2014;39:1176
Fam Pract Manage 2001;8:37
Medicare Learning Network
Prescribing
1 Medication Agreement Is considered prudent Little evidence of effectiveness Content Goals Responsibilities Clinic policies Ann Intern Med 2010;152:712
North Memorial Health Care
2 Informed Consent Capacity Disclosure Risks Benefits Alternatives Voluntariness Carlat Addict Treat Rep 2014;2(3):1
3 Initiating Therapy Start low Go slow
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
Textbook of Substance Abuse Treatment, 4th ed, 2008, p. 216
5 Medication Schedules Fixed-dose schedules are preferable to demand dosing Demand dosing = reinforcing
6 Avoid Polypharmacy Concurrent use of agents from the same medication class Medications from different classes that potentiate each other 1 + 1 > 2 Benzodiazepines + opioids
6 Limit Quantity Frequent visits Multiple prescriptions with do not dispense dates
Prescription for clonazepam was issued on 03-17-2016 with a do not dispense date of 04-24-2016. Patient information has been permanently redacted
Monitoring
1 Documentation Patient forms EHR templates SmartPhrases (Epic) 7 As
David Frenz, M.D.
FP Essentials 432
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
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
3 Dispensing Records Minnesota Prescription Monitoring Program PDMP
Patient information has been permanently redacted
4 Toxicology Illegal drugs Non-medical use of prescription medications Medications you are prescribing
4 Toxicology Quick and dirty Clinic-based immunoassays False positives/negatives Gold standard GC/MS ( confirmation )
Patient prescribed clonazepam. Immunoassay was negative for benzodiazepines. Patient information has been permanently redacted
Same patient as prior slide. GC/MS was appropriately positive for clonazepam. Patient information has been permanently redacted
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.
5 Pill counts In your clinic At a local pharmacy Community paramedic
CONFIDENTIAL MEDICAL REPORT Mental Health & Addiction Care North Memorial Health Care 3366 Oakdale Avenue North #200 Robbinsdale, MN 55422 T 763-581-5372 F 763-581-5361 Doe, Jane DOB: 00-00-0000 MRN: 0000000 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) Z79.899 (high-risk medication monitoring) David A. Frenz, M.D. NPI: 1598727240 Example pill count form to be completed by a community pharmacist
Problems
1 Lost & Stolen Medications Ask for a copy of the police report Do not replace the missing medications Offer comfort cares
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
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
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
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
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
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
FP Audio 433
Contact Information David A. Frenz, M.D. Mental Health & Addiction Care North Memorial Health Care 3366 Oakdale Avenue North #200 Robbinsdale, MN 55422 763-581-5372 david.frenz@northmemorial.com