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

Div iversion & Pain Management February ry 5, , 2020 th Annual Conference MDONS 30 th 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 oncology 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 or/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 opioids 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 offices that dispense buprenorphine on premises report to MAPS

• If a provider issues multiple prescriptions of the same drug on 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.

NarxCare Scoring 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