Div iversion & Pain Management February ry 5, , 2020 th - - PowerPoint PPT Presentation

Div iversion & Pain Management February ry 5, , 2020 MDONS 30th

th Annual Conference

Linda Vanni, MSN, RN-BC, ACNS-BC, NP, AP-PMN Nurse Practitioner, Pain Management Professional Pain Education & Consulting, LLC

Conflict of In Interest

• Linda Vanni - None

Objectives

• Define the components of controlled substance

diversion

• Identify the legal issues related to diversion
• Describe how diversion can affect the care of the
• ncology patient

Diversion

• Drug diversion is a medical and legal concept involving the transfer of

any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use. ... The term comes from the "diverting" of the drugs from their original licit medical purpose.

• Drug diversion - Wikipedia
• https://en.wikipedia.org › wiki › Drug diversion
• So far in 2018, doctors were involved in 42.46% of diversion incidents,

making them the most common diverters, compared to 26.32% in

• 2017. Nurses were involved in 28.49% of incidents, positioning them

as second most likely, as compared to 41% in 2017.Sep 10, 2018

MAPS

DEA M Methods of f Div iversion Patient In Involvement Scott Bri rinks D DEA Coordinator

Patients:

• Who demand immediate attention
• Who make appt. at the end of the appt. day or show up after

regular business hours

• Not interested in exams or diagnostic tests
• Unwilling to give permission for obtaining previous health

records (my doc went out of business)

• Requesting pain meds for pets (fentanyl patch for Fido)
• Calling in pain medications (Providence out pt. pharmacy)
• Lost medication, or it was stolen, or failure to pack (top of car)
• Offering to buy other patient’s medications (that blue pill)
• Takes half the prescription and sells the rest (Karmanos pt.)
• Alters prescriptions (the changing methadone script)

SAMSHA, 2017

https://w //www.practic icalp lpain inmanagement.com/author

• r/1880

1/cheattle le 2019 2019

Our Oncology Patients

• It is unethical not to treat oncologic pain
• Don’t forget to assess for possible diversion by family (implanted

device)

• What measures can we take to prevent diversion?
• Pill counts (a little help from the clerk)
• Drug screens (granddaughter), new frontier screening
• Small amount of controlled substances at a time
• Screening tools
• Of course, the MAPS
• Requesting early refills; wrong pain treatment plan, new treatment

related pain, pseudo-addiction ?

Tolerance, Physical Dependence & Addiction

Tolerance

• Effects diminish over time. Tolerance is not an inevitable consequence of

chronic opioid therapy

Physical dependence

• A predictable physiological response that occurs with continuous use
• Manifest by symptoms of withdrawal if use is abruptly discontinued or an

antagonist is given

• Taper the dose to prevent withdrawal

Addiction

 A primary, chronic, neurobiologic disease: impaired control over drug

use, compulsive use, craving and continued use despite harm

 Addiction is a complex condition, a brain disease that is manifested by

compulsive substance use despite harmful consequence

American Psychiatric Association, 2017

Pseudo Addiction

• “Addiction-like” behavior may signal inadequate pain control or

intensification, progression of pain

gabapentin abuse

Michigan Board of Pharmacy now reporting gabapentin on MAPS Gabapentin now classified as Schedule V controlled substance in Michigan Ohio Substance Abuse Monitoring Network issued alert, February 2017 Fifth most prescribed drug in nation (GoodRx) Can enhance euphoria caused by opioids and stave off drug withdrawals Bypasses the blocking effects of medications used for addiction treatment, enabling patients to get “high” while in recovery (STAT, 2017) 1/5 of those abusing opioids misuse gabapentin (Addiction, 2016) 300 mg pill sells for as little as 0.75 cents on the street

Mic ichigan OPEN

(M (Mic ichigan Opioid ioid Pres escribing Engagement Network)

• Aims to ensure appropriate acute pain care, while protecting

patients and communities.

• Reduce excess acute care opioid prescribing.
• Eliminate new persistent opioid use among post op patients.
• Reduce unintended opioid distribution into local communities.
• Improve opioid disposal practices.
• Collaborated with MSQC to develop a new evidence –based
• guide to assist providers in prescribing opioids after surgery
• Research done by The OPEN team; numbers are based on maximum opioid use

reported by 75% of patients who had that type of surgery—surgeons wrote prescriptions for four times larger than patients actually utilized Michigan-open.org

Mic ichigan Opioid Laws Regarding Potential for Div iversion

Act No. 246 Public Acts of 2017

• Beginning June 1, 2018, before an opioid is prescribed to a

patient, a prescriber shall provide the following information: How to properly dispose of an expired, unused, or unwanted controlled substance. That the delivery of a controlled substance is a felony under Michigan Law.

• After providing the information described above, the

prescriber shall obtain the signature of the patient or the patient's representative on a start talking consent form as described by section (4) of PA 246 of 2017. The signed form shall be kept in the patient's medical record. o The requirement does not apply if the controlled substance is prescribed for inpatient use.

Required Opioid Education

 PA 246 of 2017 requires prescribers to provide Opioid

Education using the state's or similar Start Talking Form when prescribing an Opioid drug. It does not have to be used when prescribing any other controlled substance that does not contain an Opioid.

Patient Education Sheet for Controlled Substances

Patient Education

 Set pre-operative realistic expectations regarding pain by using scripting:

 “Your pain control is very important to us. However, we also need to keep you safe.”  “It is normal to have pain after surgery.”  “It is our responsibility to keep your pain under control to allow you to do the things you

need to do to get better and go home.”

 “It is your responsibility to keep us informed about your pain, any side effects you

experience, and if you are able to do the things you need to do to get better.”

• Communicate with patients about a realistic pain management goal for elective

procedures

• Pain control is important, set goals, inform patients about risk benefit ratio and side

effects when dosing medications

 Be a patient advocate, the safety of the patient is the first priority  Education of patients is an important part of pain control

Public Act 248

• Beginning June 1, 2018, before prescribing or dispensing to

a patient a controlled substance in a quantity that exceeds a 3-day supply, a licensed prescriber shall obtain and review a MAPS report concerning that patient.

• If the dispensing occurs in a hospital or a freestanding

surgical outpatient facility and the controlled substance is administered to the patient in the hospital or facility.

• Beginning June 1, 2018, before prescribing or dispensing a

controlled substance to a patient, a licensed prescriber shall register with MAPS.

State Legislation

• Bill 274 Prohibits more than 7-day supply of
• pioids within a 7 day period for an acute

condition

• Bill 270 Must have a bona fide prescriber-patient

relationship to prescribe (delayed implementation)

• Bill 47 Requires methadone clinics & physician
• ffices that dispense buprenorphine on premises

report to MAPS

• If a provider issues multiple prescriptions of the same drug
• n the same date but with instructions that the

prescriptions be filled at a later date, such as a “do not fill until date” is the provider mandated to check MAPS on the date the prescriptions are issued or on the dates they are filled?

• a. The MAPS mandate is tied to the date the prescription is

issued, not the date it is filled or subsequent refill dates. Before issuing a new prescription for a schedule 2-5 controlled substance, the prescriber must obtain and view a MAPS report.

Use of Prescription Drug Monitoring Programs (PDMP)

• All 50 states up and running
• Reporting of all controlled substances, many in real

time

• Practice patterns for usage varies by state
• Maybe integrated into EMR
• Many PDMPs auto calculate daily MME
• Non-scheduled medications maybe added by

individual state if drug abuse detected, i.e. Ohio and gabapentin (December, 2016)

Mic ichigan Automated Prescription System (M (MAPS)

NARxCHECK in Summary MPage

• NarxCare drug information is automatically updated once it is opened from MPage.
• Provider must select View Drug Report in order to access and view detailed report.

Obtains and aggregates information about:

• Number of providers
• Number of dispensing pharmacies
• Amount of drug equivalent units/days supply
• Amount of drug overlap in history
• Current number of active prescriptions

Calculates these factors for multiple time periods, scales the factors based upon reference tables built from actual PMP data

Score ranges from 0-999

• Higher score = greater potential for abuse
• last digit = # of active Rxs

NarxCare Scoring

Scores and Indicators

• Narx Scores, Overdose Risk Score,

and Red Flag indicators are all presented below the header

• A brief explanation of each score

and indicator is available at any of the “explain” links.

• Clinical Guidance and suggestions

are also included with the explanation.

Report Overview

Graphs

Graphs are provided to reveal important details of prescription use. Providers are listed on the left, and color-coded prescriptions are graphed in reverse time order.

Report Overview

Full Prescription Detail

The bottom of the report contains additional detail for each prescription dispensed to the patient.

Report Overview

Sample Drug Report

Using the MAPS as a teaching and information tool!

• Be careful with interpretation i.e. Pet scripts
• See if scripts written prior to surgical event
• Limit amount of drug prescribed, less drug in home
• Practitioners on call (covering), different names
• Look for different classes of controlled substances order by
• ther providers, i.e. neurology—Lyrica, PCP--benzos
• Calculate out how much drug should be left
• Share the MAPS report with the patient

Fentanyl: where did id it it all ll go wrong?

Fentanyl27 FEBRUARY 2018 ANALYSIS

• Developed in early 1960’s
• When created, most powerful opioid in world
• 100 x stronger than morphine
• FDA approval 1968
• Available for use on own in 1972
• From 1979 onward illicit forms developed in illegal labs
• 1980’s transdermal patch developed
• 1998 Actiq approved, cancer pain only
• 2005-2006 off label use rampant
• 2013 street use of Fentanyl climbs
• 2015 Onsolis
• 2016 3rd wave of US Opioid Crisis
• Fentanyl deaths up 540% since 2016, China Issues

Fentanyl

• Fentanyl and Other Synthetic Opioids:
• primarily sourced from China and Mexico
• the most lethal category of opioids used in the United States
• Traffickers— wittingly or unwittingly— are increasingly selling

fentanyl to users without mixing it with any other controlled substances and are also increasingly selling fentanyl in the form of counterfeit prescription pills

• Fentanyl suppliers will continue to experiment with new fentanyl-

related substances and adjust supplies in attempts to circumvent new regulations imposed by the United States, China, and Mexico.

Fentanyl (Lazanda)

• Nasal fentanyl
• 5 Minute Peak onset
• Sticks to nasal passages through the use of

pectin

• REMS

Risk Evaluation & Mitigation Strategies REMS

Hospice Environment REMS Kit it

• On behalf of the Virginia Association for Hospice and

Palliative Care, we are pleased to offer this toolkit, "Risk Evaluation & Mitigation (REM): Strategies to Promote the Safe Use of Opioids". This toolkit represents one year of work by VAHPC members across the state, all of whom are committed to excellence in hospice care and responsible use of medications for our hospice patients.

• For further clarification, please contact: The Virginia

Association for Hospices and Palliative Care Post Office Box 70025 • Richmond, VA 23255-0025 • Phone (804) 740-1344 • Fax (775) 599-2677 Email info@virginiahospices.org 1

SE SEPTEMBER 10, , 2018

18.7M pil ills ls lo lost t due to healt lthcare emplo loyee misu isuse & th theft ft

• 18.7 million pills and $164 million were lost due to drug diversion

during the first half of 2018.

• This compares to Protenus’ previous report, which found 20.9

million pills and $301.1 million were lost because of diversion incidents throughout all of 2017.

• Protenus’ report is based on 179 incidents of medication

tampering, theft or fraud reported in the news between January 1 and June 30, 2018.

• The Baltimore-based organization defined drug diversion as “the

transfer of drugs by healthcare workers from a legal use to an illicit one.”

• 166% more legally prescribed opioids were stolen in 2018 than

the year prior. 34% of incidents of diverted opioids happened in hospitals, followed by private practices, long-term care facilities and pharmacies. 67% by doctors and nurses.

2019 DRU RUG DIVE IVERSION DIG IGEST 47.2 million doses lost due to healthcare employee misuse and theft in 2018 Protenus, Inc.

Diversion & Substance Abuse in Health Care Providers

• Estimate of occurrence – 10-11% of health care providers

Samsha, ANA, 2019

• Only a fraction of offenders ever caught
• Offenders include chiefs to frontline staff, all disciplines
• Access is large factor i.e. anesthesia
• Five classes most abused, per DEA:
• Opioids
• Depressants
• Hallucinogens
• Stimulants
• Anabolic steroids

Patterns and Trends that can indicate diversion, TJC JC cont.

• Controlled substances are removed:
• With no doctor’s orders.
• For patients not assigned to the nurse.
• For recently discharged or transferred patients.
• Product containers are compromised.
• Substitute drug is removed and administered

while controlled substance is diverted.

• Verbal order for controlled substances is created

but not verified by prescriber.

Patterns and Trends that can indicate diversion, TJC JC cont.

• Prescription pads are diverted and forged to obtain controlled

substances

• Self-prescribed controlled substances by prescriber
• Volume removed from premixed infusion (VA epidural)
• Multidose vial overfill diverted
• Prepared syringe contents replaced with saline solution (fanny

packs)

• Medication is documented as given but not administered to the

patient

• Excessive pulls for PRN medications for one provider compared

to peers

• Drug dispensing machines show discrepancies or overrides
• Waste is not adequately witnessed (Waste “buddies”)

Patterns and Trends that can indicate diversion, TJC JC cont.

• Controlled substance waste is removed from unsecure waste

container (Needle boxes)

• Controlled substance waste in syringe is replaced with saline
• Expired controlled substances are diverted from holding area
• Patients continue to complain about excessive pain, despite

documented administration of pain medication (APS a.m. rounds)

• Potential falsification of medical records indicated by:
• Late documentation of certain medications only
• Co-workers assisting others in completing documentation
• “Batching” assessments and treatments for pain
• Frequent efforts to help other nurses administer pain medication
• Unauthorized individual orders for controlled substances on

stolen DEA Form 222.1

Health Care Div iverter Traits

• Offering to pass medications
• Frequent disappearances
• Trips to their car
• Extra shifts
• Being in the med room at the beginning and end of shift
• Changes in personality, appearance, work performance,

judgment

• Using an “enabler”
• The enabler can go down also
• Duty to report
• You maybe saving someone’s life

Joe Aron-Security, Ascension, 2018

The effect healthcare provider diversion has on patient safety

• Inadequate patient pain relief
• Potentially unsafe care due to impaired

practitioner

• Potential for organizational suits and legal

issues

• Exposure to infectious diseases
• Contaminated needles, drugs vials

Patterns and Trends that can indicate div iversion, , TJC JC cont. Recommendations

• Prevention always comes first. Health care facilities are

required to have systems in place to guard against theft and diversion of controlled substances.

• Even with such prevention safeguards, health care facilities

must have systems to facilitate early detection.

• Appropriate response for staff can be summarized as "see

something, say something."

Quic ick Safety by The Joint Commission Is Issue 48 | April 2019 Dru rug div iversion and im impaired health care workers

Regulatory requirements for reporting drug diversion in health care

• rganizations include the following:
• Drug Enforcement Administration (DEA) — report immediately, per

federal regulation (21 CFR 1301.76; 2014)5

• State regulatory board and/or professional assistance
• Law enforcement
• Pharmacy board
• Food and Drug Administration (FDA) Office of Criminal

Investigations (OCI) for tampering cases

• Office of Inspector General (OIG)

Legal Is Issues

CDC Recommendations Regarding Morphine Milligram Equivalents (MMEs)

CDC Mobile App, MME calculator

Opioid Guideline App is designed to help providers apply the recommendations of CDC’s Guideline for Prescribing Opioids for Chronic Pain into clinical practice by putting the entire guideline, tools, and resources in the palm of their hand. Managing chronic pain is complex, but accessing prescribing guidance has never been easier. The application includes a Morphine Milligram Equivalent (MME) calculator*, summaries of key recommendations and a link to the full Guideline, and an interactive motivational interviewing feature to help providers practice effective communications skills and prescribe with confidence. Free Download The new CDC Opioid Guideline App is now available for free download on Google Play (Android devices) and in the Apple Store (iOS devices).

Thank you very much for everything that you do!

Questions???