Transcript Prescription Drug Abuse - UCSF Department Of Medicine

Prescription Drug Abuse
UCSF SBIRT Collaborative Education
Project
Elinore McCance-Katz MD, PhD
Learning Objectives
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Describe the high prevalence of prescription drug
misuse and associated etiologic and social factors.
Illustrate the wide distribution of opioid receptors in
the brain and link the use of opioids to increased
vulnerability to addiction for some individuals.
Explain the clinician’s obligation to treat chronic pain,
while identifying and treating addiction should it occur.
Apply best practices in the treatment of chronic pain
with opioids.
List warning signs of opioid misuse and discuss how a
clinician might respond.
Identify and apply therapeutic options should a
substance use disorder be identified.
What Prescriptions Drugs
Get Abused?
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Principally opioids (main focus of this module)
 Most common: hydrocodone (Vicodin),
oxycodone (Oxycontin): relief of pain
Anxiolytics: benzodiazepines (Xanax, Valium),
barbiturates (butalbital, Fiorecet): reduce
anxiety, insomnia
Stimulants: amphetamine (Adderall),
methylphenidate (Ritalin): attention deficit
disorder, narcolepsy
Epidemiology of Prescription
Drug Misuse and Abuse
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In 2006, approximately 7.0 million persons
were current users of psychotherapeutic drugs
taken nonmedically (2.8 percent of the U.S.
population). This class of drugs is broadly
described as those targeting the central
nervous system, including drugs used to treat
psychiatric disorders (NSDUH, 2007).
Pain relievers - 5.2 million
Tranquilizers - 1.8 million
Stimulants - 1.2 million
Sedatives - 0.4 million.
Epidemiology of Prescription
Drug Misuse and Abuse
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It is generally believed that the broad availability of
prescription drugs (e.g., via the medicine cabinet, the Internet,
and physicians) and misperceptions about their safety make
prescription medications particularly prone to abuse.
Among those who abuse prescription drugs, high rates of other
risky behaviors, including abuse of other drugs and alcohol,
have also been reported (another good reason to be doing
urine tox screens in your clinic (see Mod 9).
Most commonly abused classes of prescription drugs
Opioids, such as OxyContin and Vicodin, which are most often
prescribed to treat pain;
Central nervous system (CNS) depressants, such as Valium
and Xanax, which are used to treat anxiety and sleep
disorders; and
Stimulants, which are prescribed to treat certain sleep
disorders and attention deficit hyperactivity disorder (ADHD),
and include drugs such as Ritalin and Adderall.
If You Decide that Opioid Therapy
for Chronic Nonmalignant Pain is
Indicated for Your Patient
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Consider use of the California Prescription
Monitoring Program to check history of
patient’s prescriptions for controlled
substances (http://ag.ca.gov/bne/cures.php)
In order to obtain access to the PDMP system Prescribers and
Pharmacists must first register with CURES by submitting an
application form electronically at https://pmp.doj.ca.gov/pmpreg/. In
addition, your registration must be followed up with a signed copy of
your application and notarized copies of your validating documentation
which includes: Drug Enforcement Administration Registration, State
Medical License or State Pharmacy License, and a government issued
identification. You can mail your application and notarized documents
to:
Bureau of Narcotic Enforcement (BNE) Attn: PDMP Registration P.O.
Box 160447 Sacramento, CA 95816
To obtain a CURES report complete form available at:
http://ag.ca.gov/bne/pdfs/BNE1176.pdf
If You Decide that Opioid Therapy
for Chronic Nonmalignant Pain is
Indicated for Your Patient
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Have a Treatment Plan/Informed Consent
(documentation of risk/benefit) on the chart (DGIM has a
Treatment Agreement that can be used)
Treatment Agreement (use for those at high risk for
abuse/addiction)
 One physician/one pharmacy
 UDS when requested
 Agreement to return for pill count when asked to do
so
 Medication Levels
 Number/frequency of all refills
 Reason for discontinuation (violation of agreement,
misuse of medication, abuse of other substances)
Informed Consent
SPECIFIC RISKS OF THE TREATMENT (long-term
opioid use):
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Side effects (short and long term)
Physical dependence, tolerance
Risk of drug interactions or combinations (respiratory
depression)
Risk of unintentional or intentional misuse (abuse,
addiction, death)
Legal responsibilities (disposing, sharing, selling)
Paterick et al., 2008
If You Decide that Opioid Therapy
for Chronic Nonmalignant Pain is
Indicated for Your Patient
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Check urine drug screen initially and
periodically to show:
 Illicit
drug use highly correlated with opioid
abuse/addiction
 Confirm use of the drug you’re prescribing
 POS tests may be less sensitive, but quick
answer
 If patient disputes result/becomes
angry/defensive: send to lab for UDS with
GC/MS confirmation (more expensive and
will take longer, but most accurate (‘gold
standard’)
If You Decide that Opioid Therapy
for Chronic Nonmalignant Pain is
Indicated for Your Patient
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Pill counts should be part of
management
Should be done by licensed personnel
only
May be most useful early in treatment
and can be combined with urine
toxicology at a nursing or pharmacist
visit (no MD visit needed)
If You Decide that Opioid Therapy
for Chronic Nonmalignant Pain is
Indicated for Your Patient
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Periodic review:
Evidence of analgesia
 Treat side effects
 Enhanced social/employment functioning
 Overall improved quality of life
 Family assessment
 Unsatisfactory: review other options
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You can always get a consultation:
Pain specialists
 Psychiatrist (co-occurring mental illness is
common)
 Addiction specialist
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Risks/Concerns of Chronic
Opioid Therapy
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“Causing Addiction” in persons without
abuse or dependence history with opioids
“Feeding” an existing addiction
Causing a relapse in a patient in stable
remission
Diversion of medication by a patient with or
without pain
None of these risks are adequately quantified
for any patient population, but they are not
negligible
Identification of Prescription
Opioid Abusers
Deterioration in
home/work
 Resistance to
changes in therapy
 Use of drug by
injection or nasal
route
 Early refills
 Lost/stolen
prescriptions
 Doctor shopping
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Prescription forgery
 Abuse of other
substances
 Frequent ED visits
 Unauthorized dose
increases
 Nonmedical use
 Refuses
UDS/referral to
specialist
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Approaching Patient with
Aberrant Medication-Taking
Behavior
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Take non-judgmental stance
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Use open-ended questions
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State your concerns about the behavior
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Examine the patient for signs of flexibility
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Is the patient more focused on specific opioid or pain
relief?
Approach as if they have a relative contraindication to
controlled drugs (if not absolute contraindication)
Take pressure off yourself by referring to clinic policies
Passik & Kirsh, 2005
What to do if Your Patient
Develops a Substance Use
Disorder with
Prescribed Opioids
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Therapeutic Options:
Combination of medication treatment plus
psychosocial/psychotherapeutic interventions:
Inpatient (usually detoxification; short term
pharmacotherapy) followed by:
 Residential
 Intensive outpatient
 Individual/Group Drug Counseling
 +/- Maintenance pharmacotherapy
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Know the options in your community
Treatment for Opioid
Dependence
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Pharmacotherapy Options (following medical
withdrawal)
Antagonist Treatment (naltrexone)
Opioid Assisted Therapy
Methadone
 Buprenorphine
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Psychotherapies (motivational interviewing,
Relapse Prevention, educational groups,
substance abuse group therapy; individual drug
counseling, 12-Step)
Medical Withdrawal: Should
not be Used Alone
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Use of medications to gradually reduce
physical dependence
Taper off of opioids
High relapse rate without ongoing
treatment (>90% within 1 year)
Maintenance Medications
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Antagonist treatment: Naltrexone 50 mg/d
(oral)
Blocks opiate agonist effects
 Infrequently used:
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Physician lack of knowledge of treatment
 Poor acceptance by patients
Has been shown to be effective in motivated
groups (health care professionals, those in
criminal justice system)
Formulations: tablet, once a month injectable
(alcohol indication currently)
Could be difficult to implement if patient has a
pain syndrome, but could be considered if other
analgesic interventions were provided
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Maintenance Medications
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Methadone
 Most
widely utilized pharmacotherapy for
opioid dependence
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Schedule II drug
Specialized treatment programs must be used if
patient has opioid addiction
Restricted numbers of take-home doses
Induces tolerance to acute dose of opioid
Does not induce full tolerance to all opioid effects (e.g.
sedation at peak plasma concentration)
Reduced crime, increased employment, improved
health, decreased risk related to diseases common to
drug users (HIV, Hep C)
Maintenance Medications
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Buprenorphine
 Opioid
partial agonist
 Lower abuse liability
 Schedule III
 Available by prescription
 Waiver needed for physician to be able to
prescribe
 Only CSAT/DEA waivered physicians can
prescribe (no PAs, NPs)
 Allows for office-based treatment of
opioid dependence
Clinical Expectations for
Chronic Opioids
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Pts on chronic opioids with suspected/ high risk
of misuse should be on DGIM pain agreement
All exam rooms should contain the following in
the bottom forms drawer:
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Pain Agreements (requires pt signature)
General Patient Information Sheets for Opioids
For more detail, precepting rooms contain:
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General Medicine Opioid Policies
General Opioid Prescribing Guidelines
Case Study
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Ms. B. is a 43 y.o. woman recently moved to the Bay area who
presents with a complaint of knee pain resulting from a MVA
10 yrs ago and pain in her joints. Physical examination is
unremarkable. She brings a record from an evaluation she had
at a pain treatment center several months ago which
recommended methadone treatment. You prescribe methadone
10 mg TID, but she returns complaining that her pain
continues. Gradually her dose increases to 80 mg daily, she
still requests more methadone. You decide to check the
California Prescription Monitoring Program and find that you
are one of 3 doctors prescribing methadone and that her daily
dose appears to be 260 mg. On query she admits that she is
seeing multiple physicians, but insists that her pain is
intolerable if she doesn’t have all of this medication.
What should you do?
Case Study
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The patient shows signs of methadone addiction. She is
requesting increasing methadone for relatively minor
complaints that cannot be verified with objective data, there is
evidence that she is doctor shopping, her total daily dose of
methadone is very high, but you note that she does not appear
intoxicated indicating high tolerance for the drug. Because of
the high dose of methadone, it would be very difficult to taper
the methadone in the primary care clinic. The patient would
best be served by referral to a methadone maintenance
program. In such a program she can be treated for her opioid
addiction; this would include either maintenance or gradual
taper. She is also not a candidate for buprenorphine because
her dose of methadone is too high to convert (she must be on
<40 mg methadone daily to be changed to buprenorphine).
Conclusions
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Prescription narcotic abuse and associated
addiction increasing
Consider non-opioid treatment options for
chronic pain
If chronic opioids are to be used:
Treatment Agreement/Informed Consent
 Good documentation of treatment plan and
responses
 Get releases at outset for other treatment
providers, family member(s) important to therapy
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Know the options for referral in your community
Effective pharmacotherapies and
psychotherapies available for substance use
disorders
Some available treatments make it possible to
treat medical/mental disorders and opioid
dependence (i.e.: buprenorphine)
References
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Maxwell, J.C. 2006. Trends in the abuse of prescription drugs. Gulf Coast Addiction
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Fishbain DA, Rosomoff HL, Rosomoff RS: Drug abuse, dependence, and addiction
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