Easy ways to save patients lives: How to prevent, recognize and - - PDF document

8/4/2013 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

8/4/2013 2 Attending the presentation will enhance pharmacists' knowledge

• f 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

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 non9medical 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 non9medical use of opioid prescription medications?

• 1.

12915 years old

• 2.

18925 years old

• 3.

26945 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 At the end of the presentation you will be able to correctly answer these questions:

8/4/2013 3

• THE BIGGEST illicit drug market in the world.
• HIGHEST drug9related mortality rate.

– 1 in every 20 deaths in North America (159 64age)

• Overdose deaths
• HIV/AIDS
• Trauma9related deaths including MVAs

INCB* 2012 Annual Report

International Narcotics Control Board of UN

North America IS:

Economic Costs of Drug Abuse Department of Justice 2011

$113,277,616 $68,403,082 $11,416,232 Crime Productivity Health

$193 Billions

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• Substance Abuse and Mental Health Services Administration,

, NSDUH Series H944, HHS Publication No. (SMA) 1294713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

620,000 1,861,000 3,857,000 4,069,000 11,143,000 14,657,000 29,739,000

• 5,000,000

10,000,000 15,000,000 20,000,000 25,000,000 30,000,000 35,000,000

Heroin Inhalants Cocaine Hallucinogens Opioids Rx drugs Marijuana

$42.00 $8.20 $2.20 $0.94

Costs of Abuse of Prescription Drugs 2006

$53 Billions

Productivity Criminal Justice Treatment Medical

Hansen, et al. Economic CostsClin J Pain 2011;27:194–202

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OxyContin 14% Oxycod 11% Hydrocod 24% Darvon 16% Methadone 12% Codeine 8% Morphine 5% Meperidine 4% Hydromorph 2% Fentanyl 0% Other 4%

Drug's Costs $53 Billions

Hansen, et al. Economic CostsClin J Pain 2011;27:194–202

Who is abusing, misusing, dying?

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Substance Abuse and Mental Health Services Administration, , NSDUH Series H944, HHS Publication No. (SMA) 1294713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

1,500,000 3,600,000 6,600,000 12 to 17 18 to 25 26+

Nonmedical Use of Pain Relievers 2010$11 among Persons Aged 12 or Older

SAMHSA 2012 NSDUH Survey Report

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• What are the consequences?

Addiction Bridging (may be related to addiction

• r 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: !"#$$%&'(

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Spectrum of use: Age 12 and over

Abstainers Users

!)

2,000,000 11,000,000 241,000,000

Substance Abuse and Mental Health Services Administration, , NSDUH Series H944, HHS Publication No. (SMA) 1294713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

*

1 2 3 4 5 Millions

Substance Abuse and Mental Health Services Administration, , NSDUH Series H944, HHS Publication No. (SMA) 1294713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

8/4/2013 9

• 500,000

1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000

Total Dependent Total Treated

+$

Substance Abuse and Mental Health Services Administration, , NSDUH Series H944, HHS Publication No. (SMA) 1294713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Have Abuse Dependence Received Treatment

Treatment gap

“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.

8/4/2013 10

Why do we care

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8/4/2013 11

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One death every 19 minutes. Increase has been driven by increased use of opioid analgesics.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

)?$ .0;=;, Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013

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Mack, Jones, Paulozzi (CDC). MMWR, July 2, 2013 23,006 15,323 Male Female

Gender: 38, 329 Overdose Deaths 2010

Jones, Mack, Paulozzi (CDC). JAMA, February 20, 2013 Compton, Volkow, Throckmorton (NIDA/FDA) Ann Intern Med. 2013;158:65-66

8/4/2013 13

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

@AB

8/4/2013 14

Sources of drugs:

55.0% 17.3% 11.4% 6.7% 4.8% 4.4% 0.4% Friend/relative - Free MD Friend/relative - $ Other Friend/relative - Stole Dealer Internet

Substance Abuse and Mental Health Services Administration, , NSDUH Series H944, HHS Publication No. (SMA) 1294713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Utah DOH 2013 http://www.health.utah.gov/vipp/pdf/FactSheets/RxOpioidDeaths.pdf

8/4/2013 15

8/4/2013 16

Tramadol

• It IS an OPIOID!
• It is a CS in UTAH!

8/4/2013 17

Who Is At Risk?

• 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

“Adverse Selection”

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CDC January 13, 2012 / 61(01);10913

RISK GROUP: 9..(≥100 mg morphine per day) by a single doc 40% of overdoses 9.. (≥100 mg per day) by MULTIPLE docs 40% of overdoses. 39/ (<100 mg per day) by a single doc 20% of overdoses.

80 % 10 % 40 % 40 % 20 % 10 %

Drug overdose rate for women 200992010

Mack, Jones, Paulozzi (CDC MMWR July 2, 2013

8/4/2013 19

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

8/4/2013 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

8/4/2013 21

What about pain?

Pain Sensations and Relievers

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How are we doing treating pain?

• Perception of how well pain is managed is strongly

tied to patients’ overall satisfaction with hospital experience

From: http://www.medicare.gov/HospitalCompare/

What are we doing about abuse and overdoses?

8/4/2013 23

• 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

FDA Actions to date:

Possible Abuse Deterrents

Mechanism Purpose Physical modification of tablet Prevent crushing, chewing Chemical Prevent extracting Add antagonist Block the effect or get sick if misused Add aversive agent Get sick if misused Depot formulation Assure medication is in body Pro-drug Becomes active only in bloodstream

8/4/2013 24

Unintended Consequence of Changing OxyContin Formulation Cicero, et al. NEJM July 12, 2012 OxyContin Reformulated

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8/4/2013 25

• Robert Swotinsky MD, 11/2006

MRO Question board

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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
• ffering an updated pain management education program to

provide physicians with up9to9date 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.

8/4/2013 26

UT: State Board of Pharmacy, PDMP database “Controlled Substance Database9CSD”

http://www.dopl.utah.gov/programs/csdb/

• Database providing data on the

dispensing of Schedule II9V drugs by all retail, institutional, and outpatient hospital pharmacies, and in9 state/out9of9state mail order pharmacies records

• Does not contain information from

prescriptions filled at federal facilities, pharmacies licensed by

• ther states, or controlled

substances administered in an in9 patient setting

• Monthly CSD training available for

two hours of continuing education towards license renewal requirements

• To register for the database visit

https://login2.utah.gov/user/create

Who uses/accesses CSD?

• MD’s > 80%
• Pharmacists < 30 %

8/4/2013 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

8/4/2013 28

You cannot see:

• This weeks prescriptions (yet)
• VA, HILL AFB or other federal data!
• 50,000 veterans, 10000’s of prescriptions
• Rx’s from other states (yet)
• Marijuana, cocaine, non9prescribed 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

8/4/2013 29

• 002= Utah Controlled Substance Database
• ; –H.B. 137 to created Prescription Pain Medication Program
• 0 – Utah Clinical Guidelines on Prescribing Opioids is released.
• – H.B. 28 Utah Controlled Substance Database registration

mandatory

• –S.B. 61 Four hours prescribing classes required each licensing

period

UTAH – Legislative Actions

8/4/2013 30

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• Comprehensive, integrated, public health

approach in primary care centers, hospital emergency rooms, trauma centers, and other community settings to prevent problems earlier.

http://www.samhsa.gov/prevention/SBIRT/index.aspx

SBIRT in a nutshell

• ASK – about tobacco, alcohol and drug use
• ASSESS – by brief screen if positive:
• ADVISE – of need to change, non9judgemental,

personal message (meaningful to them)

• ASSIST – by motivational interviewing to facilitate

change if resistant or referral for specialty care if accept or need

• ARRANGE FOLLOW9UP – to support, measure

and reinforce change

8/4/2013 31

Opioid Risk Tool (ORT)

http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf

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• Low Risk 0 – 3
• Moderate Risk 4 – 7
• High Risk > 8

Reference: Webster LR. Predicting aberrant behaviors in opioid9 treated patients

8/4/2013 32

Screener and Opioid Assessment (SOAPP)

http://www.epicmentoring.com/files/SOAPP_v1.pdf

• 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

http://www.cqaimh.org/pdf/tool_cageaid.pdf

• 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 Eye9opener 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.

8/4/2013 33

Drug Abuse Screening Tool (DAST)

http://www.drtepp.com/pdf/substance_abuse.pdf

• 28 Questions
• Self9administered
• Score 6911 = further evaluation
• Score 12 or higher = refer for treatment

Substance Abuse Subtle Screening Inventory (SASSI)

http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/66 _SASSI.pdf

• 67 item self9administered questionnaire
• PROPRIETARY
• must pay to use

8/4/2013 34

Adult Substance Use Survey (ASUS)

The ASUS9R is part of the SAM Computer Software Application http://aodassess.com/assessment_tools/asus/

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

http://www.useonlyasdirected.org/

8/4/2013 35 National: AWARERxE; The Medicine Abuse Project

• National website focused
• n 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

http://medicineabuseproject.org/

Educate to Prevent Overdoses

8/4/2013 36

• !

8/4/2013 37

Where is naloxone distribution occurring?

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 non9medical 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 non9medical use of opioid prescription medications?

• 1.

12915 years old

• 2.

18925 years old

• 3.

26945 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 At the end of the presentation you will be able to correctly answer these questions:

8/4/2013 38