Transcript Proper Prescribing Practices: Prevention, Pitfalls and Challenges

Center for Professional Health
Proper Prescribing Practices:
Prevention, Pitfalls and Challenges
Charlene M. Dewey, M.D., M.Ed., FACP
William H. Swiggart, M.S., L.P.C./MHSP
Co-Directors, Center for Professional Health
Vanderbilt University School of Medicine
Nashville, TN
Washington Hospital March 22 & 23, 2011
Center for Professional Health
Goals
The purpose of this session is to outline
proper prescribing practices to help
residents and practicing physicians avoid
misprescribing practices that could harm
patients or break rules resulting in loss of
licensure. Participants will learn:
1. The rules of proper prescribing (based on
the BME and the DEA) as well as internal
and external factors that result in risky
prescribing behaviors.
2. How SBIRT can help identify patients with
substance use issues.
Center for Professional Health
Objectives
Upon completing the training, participants should be
able to:
1.
2.
3.
4.
5.
6.
7.
Self-identify personal risk factors and categories
for misprescribing.
Identify at least 3 theories why physicians
misprescribe.
List the 12 steps to trouble and discuss ways to
improve practice behavior.
Discuss basic statistics around CPD abuse.
Define the difference between pseudoaddiction
and addiction.
List components of SBIRT.
Reflect on current practices and determine
improvements for proper prescribing practices.
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Agenda
1.
2.
3.
4.
5.
6.
Introduction
Theories
Medical Board/DEA
Cases
Q&A
Summary
Center for Professional Health
Ground Rules
•
•
•
•
Everyone's opinion counts
Respectful
Interactive discussion
All questions allowed – time at the
end
• Time
• Flexible
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Introduction
The story of the Starbuck’s Manager
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Introduction
“To write a prescription is easy, but to
come to an understanding with people
is hard.”
~Franz Kafka
A Country Doctor,1919
Center for Professional Health
Introduction
“It is not what you prescribe, but rather
how well you manage the patient's
care, and document that care in
legible form, that is important.”
~Released by the Minnesota BME 1990, adapted by both the North
Carolina and TN BME
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Theories:
Why Physicians Misprescribe Controlled
Substances:
– Family of origin
– Core personality
– Patient types
– Pharmacological knowledge
– Professional practice system
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Misprescribing
• Definition: Prescribing scheduled drugs
in quantities and frequency inappropriate
for the patient’s complaint or illness.
• E.g.:
–
–
–
–
Known alcoholic or drug addict
Large quantities/frequent intervals
Family members
For trivial complaints
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Twelve Steps to Trouble
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Step 1
• Ignore your pharmacist and
don’t return his/her calls.
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Step 1 - Lesson
1. Listen to your pharmacist. They
are a good source of information
about drug seeking patients. A
major cause of reports by
pharmacists to the BME is poor
collegial relations between the
pharmacist and the physician.
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Step 2
• If the BME sends an investigator to
audit your charts for scheduled drug
prescriptions, be rude and
uncooperative.
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Step 2 - Lesson
2. Cooperate: Hostility will only come
back to haunt you. The
investigator is only there to followup on a complaint about your
prescribing scheduled drugs for
certain patients. Your best
defense is a well-documented
chart and cooperation with the
investigator.
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Step 3
• Schedule large numbers of patients
daily.
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Step 3 - Lesson
3. Know your limits. Working long hours
for months or years with a daily
commitment to a large number of
patients greatly increases burnout and
the chance of a medical error. The CME
faculty is constantly amazed that
physicians put themselves under severe
pressure to see large numbers of
patients. The investigator of their
records cites them for poor or nonexistent documentation.
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Step 4
• Keep your
prescription pads in
plain view and
accessible at all
times.
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Step 4 - Lesson
4. Secure your prescription pad and
DEA number: You are responsible
for your DEA number and
prescription pad. Drug seeking
patients are constantly on the
lookout for unattended pads.
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Step 5
• Pretend addiction doesn’t exist.
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Step 5 - Lesson
5. Address Addiction: Chemical
dependency is a disease, which
responds to treatment. Early brief
interventions have shown to be
effective and saves health care
dollars.
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Step 6
• Never say no to
any request for
Schedule II
Drugs from a
patient or
colleague.
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Step 6 - Lesson
6. It’s OK to say NO: It is important to
document the need for Schedule II
drugs in the patient’s chart. Never
prescribe for a colleague or family
member.
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Step 7
• Never refer your
patients to a pain
clinic or suggest any
non-narcotic solutions
for chronic pain
management.
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Step 7 - Lesson
7. Refer when appropriate: Pain
clinics can be very helpful, though
not always easy to access. Ask for
their recommendations in writing
and include them in the medical
record.
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Step 8
• Rarely write anything
in your chart that is
legible or might
explain why you are
prescribing narcotics
or benzodiazepines
for a patient for
years.
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Step 8 - Lesson
8. Document: It is imperative that you
document your plan for the patient and
that it is legible. You will be unable to
defend yourself if the investigator cannot
read your writing or documentation is
absent. This is the most frequent cause
for an investigator reporting to the BME
that the physician should be cited for
inadequate prescribing practices.
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Step 9
• Do not have any
written office policy
regarding Schedule
II drug refills, pain
contracts, lost
medication, or
phone in
prescriptions.
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Step 9 - Lesson
9. Develop standards in your practice:
Clearly defined written policies and
pain contracts regarding schedule
drugs, etc. save time and energy.
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Step 10
• Ignore family members
concerns by not
returning their phone
calls or if you happen
to speak to them
remind them you are
the doctor and unable
to discuss potential
addiction in their loved
ones.
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Step 10 - Lesson
10. Include families if appropriate:
Family members can be important
allies, especially when addiction is
involved.
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Step 11
• Remain isolated from your peers
and never ask for help.
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Step 11 - Lesson
11. Keep up to date: Becoming
uninformed about addictive
potential of certain drugs is a major
cause of medical error. Recent
examples are OxyContin
(oxycodone HCL) and Ultram
(tramadol).
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Step 12
• Focus on the
negative aspects
of medicine today
such as managed
care and the loss
of income.
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Step 12 - Lesson
12. Focus on self-care: Malpractice
suits and medical errors often
occur in times of stress. Proper
self-care is an important way to
avoid these errors.
Remember why you went into medicine!
Center for Professional Health
Demographics
Center for Professional Health
Course Demographics
•
•
•
•
Total N = 771
Ave Age: 51
Male = 88%
Female = 11%
Jan. 1996 – Nov. 2010
31%
26%
241
202
22%
168
10%
1%
5%
77
2%
36
6
16
1940's 1950's 1960's 1970's 1980's 1990's 2000's
Medical School Graduation Year
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Practice Type
48%
350
34%
300
250
200
150
8%
100
9%
50
0
Solo
Partnership or
Group
Jan. 1996 – Nov. 2010
Hospital-Based
Other
Total N = 771
Specialty Types
62%
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Specialty Demographics
63%
441
16%
8%
7%
7%
3%
62
50
FP IM
Psy
Surgery
Jan. 1996 – Nov. 2010
23
ER
N = 771
3%
108
18
Dentist
Others
Center for Professional Health
Categories of Misprescribing
1. Dated – Fails to keep current
2. Disabled – failed judgment due to
impairment
3. Duped – fails to detect deception
4. Dishonest – personal or financial gain
5. Dismayed – Rx as quick fix due to time
limits
6. Dysfunctional – finds it hard to say NO
Center for Professional Health
Test Your Knowledge
Dr “V” is a young physician out of residency
training for three years. She attended a US
medical school with a heavy focus on
academics and research, scored well on her
family practice board exams and has had
no academic difficulty. She is opening a
solo practice in rural Louisiana. She has
experimented with marijuana while in
college but has not used any since then.
She drinks 1-2 glasses of wine in a week
with dinners. She had a father who was an
alcoholic and her mother suffered with
depression for many years.
Center for Professional Health
Test Your Knowledge
Dr. V’s demographic that is most associated
with misprescribing is which of the
following?
1)
2)
3)
4)
5)
6)
7)
8)
9)
Her female gender
Her experimentation with marijuana
Her risk of alcoholism
Her board scores
Her rural, solo practice
Her choice of family practice
Her consumption of ETOH
Her training in a US medical school
I don’t know
Center for Professional Health
Test Your Knowledge
From the list below select the two theories most
consistent with why physicians misprescribe
controlled substances.
a) Family of origin and professional practice
systems
b) Type of medical school attended and patient
types
c) Residency training location and US vs.
foreign training programs
d) Gender of the patient and knowledge of
pharmacology
e) I don’t know
Center for Professional Health
Test Your Knowledge
Dr X is on the last patient of the day. He is
trying to get to his daughter’s symphony
performance. The last walk-in patient
complains of back pain after he lifted a
dresser while moving 10 days ago. The
pain is improved but still bothering him
especially at night. The patient asks for
Percocet by name. Dr X did not have time
to ask about other pain control or complete
a full back and neurological exam. Dr X
provides a prescription for Percocet,
dispense #15 tabs with no refills before
leaving the clinic.
Center for Professional Health
Test Your Knowledge
This physician has misprescribed due to
being:
a)
b)
c)
d)
e)
f)
Duped
Dishonest
Dismayed
Dated
Disabled
I don’t know
Center for Professional Health
Controlled Prescription Drugs
Center for Professional Health
Controlled Prescription Drugs
• The problem:
– Substance abuse, including controlled
prescription medication, is the nation's
number one health problem affecting
millions of individuals.4
– Rate of controlled prescription drug
(CPD) abuse - ~ doubled from 7.8 mil to
15.1 mil in last decade (1992 - 2003)2
– Adults >18 is up by 81%
Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005. 2006 National Survey on Drug Abuse
and Health, SAMHSA
Center for Professional Health
Controlled Prescription Drugs
• New drug users of prescription
opioids = 2.4 million
– Marijuana (2.1 million); Cocaine (1.0 million)
• Total use is > those abusing
cocaine, hallucinogens, heroin, and
inhalants combined!
• “the most commonly used illicit
substance.”
DEA Practitioners Manual 2006 ed.; Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005.
Center for Professional Health
Controlled Prescription Drugs
• More “new users” tried opioids for nonmedical reasons in the past year than any
other illicit drug
• CDC:
– Opioid prescription painkillers cause more
drug overdose deaths than cocaine and
heroin combined
– Increased ER visits
– Increased accidental deaths
– Health care costs = millions of dollars
annually
DEA Practitioners Manual 2006 ed.; Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005.
2006 National Survey on Drug Abuse and Health, SAMHSA
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Controlled Prescription Drugs
• Rate has nearly tripled in the
teenage population2
• Children aged 12 -17 are abusing
CPD more than adults at a rate
estimated at 212% vs. adults
Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005. 2006 National Survey on Drug Abuse
and Health, SAMHSA
Center for Professional Health
Statistics on Illicit Opioid Use
• Americans = 4.6% of world’s
population
– Use 66% of world’s illicit drugs
– Use 80% of global opioid supply
– Use 99% of global hydrocodone
supply
2006 National Survey on Drug Abuse and Health, SAMHSA
Center for Professional Health
Controlled Prescription Drugs
• Prescription drug diversion is simply the
deflection of prescription drugs from
medical sources into the illegal market.18
• Physicians remain the #1 provider of CPD
• Sources:
•
•
•
•
•
•
doctor shopping
illegal internet pharmacies
drug theft
prescription forgery
illicit prescribing by physicians
family members
U.S. Department of Justice, Drug Enforcement Administration, Prescription Accountability Resource Guide,
September 1998, <http://www.deadiversion.usdoj.gov/pubs/program/rx_account/index.html > (5 January
2004).
Center for Professional Health
Controlled Prescription Drugs
• Up to 43% of physicians DO NOT ask
about CPD abuse in patient's history
• Only 19% received any MS training identify diversion
• Only 40% received training on identifying
CPD abuse and addiction5
• “Confrontational Phobia”- a term used
to describe physicians’ reluctance to say
“no” to a patient, thus making physicians
an “easy target for manipulation.”5
Bollinger et al, 2005
Center for Professional Health
Test Your Knowledge
The majority of scheduled drugs that find their way
to the street get there by physician prescribing
practices.
a) True
b) False
c) I don’t know
The majority of controlled drugs on the street are
obtained from family and friends from previous
prescriptions.
a) True
b) False
c) I don’t know
Center for Professional Health
The DEA & Medical Boards
What is the difference between the
medical boards and the DEA?
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Controlled Substances Act
(CSA)
•
•
CSA 1970: DEA assigned legal authority
for the regulation of controlled
substances (illicit and licit)
Responsibility is two-fold:
1. The prevention, detection, and investigation
of the diversion of controlled substances
from legitimate channels
2. Ensuring that adequate supplies are
available to meet legitimate domestic
medical, scientific, and industrial needs
Center for Professional Health
Controlled Substances Act
(CSA)
• Monitors:
– Diversion to Illicit Use
 Self
 Others
– Maintenance of addictions
– Iatrogenic addictions
• Five (5) schedules
Center for Professional Health
Controlled Substances Act
(CSA)
• Must be registered
• Registration can be suspended or
revoked by the Attorney General
upon a finding that the registrant:
• falsified any application filed
• been convicted of a felony
• had State license or registration suspended, revoked,
or denied by competent State authority
• committed acts as would render his registration
inconsistent with the public interest
• been excluded (or directed to be excluded) from
participation in a program pursuant to section 1320a7(a) of title 42.
Center for Professional Health
Test Your Knowledge
1. What constitutes schedule I or other
schedules assignments for drugs?
2. Identify the schedule for each of the
following:
•
Marijuana; morphine; heroin; codeine; LSD;
opium; amphetamine; cocaine;
hydrocodone
3. How often do you renew your DEA
registration and what happens if you
move?
4. Which schedules can be refilled?
5. Can scheduled II prescriptions be faxed?
DEA Practitioner’s Manual 2006; pg. 5-6 & 9-11 & 21-22
Center for Professional Health
Answers Q1: What constitutes schedule I
or other schedules assignments for drugs?
• Schedule I: no accepted medical use in
the US; therefore, cannot be prescribed,
administered or dispensed for medical
use; no evidence of safety; high potential
for abuse
• Schedule II-V: some accepted medical
use and can be prescribed, administered,
or dispensed for medical use; High
potential for abuse; descending order (II >
III > IV >V)
DEA Practitioner’s Manual 2006; pg. 5-6
Center for Professional Health
Answer Q1: (cont.)
• Schedule III:
– <15mg of hydrocodone (Vicodin® & Lortab®)
– <90mg of codeine
• Schedule IV:
– narcotics (propoxyphene) & benzodiazepines
• Schedule V:
– <200mg of codeine/100 ml or g (Robitussin
AC® & Phenergan with codeine®)
DEA Practitioner’s Manual 2006; pg. 5-6
Center for Professional Health
Answer Q2: Identify the schedule for each
of the following drugs.
• Schedule I:
– Marijuana
– Heroin
– LSD
DEA Practitioner’s Manual 2006; pg. 5-6
• Schedule II:
– Marinol (Dronabinol) medical marijuana
– Morphine
– Codeine (II-V)
– Opium
– Amphetamine
– Cocaine
– Hydrocodone (II-III)
Center for Professional Health
Answer Q3: How often do you renew your
DEA and what happens if you move?
• Renew DEA registration q3 years
– Sent 45 days prior to expiration
– Sent to address on file; will not be
forwarded
– If you don’t receive it w/in 30 days, call
800-882-9539
• Relocating: modify application online @: www.DEAdivision.usdoj.gov
DEA Practitioner’s Manual 2006; pg. 9-11
Center for Professional Health
Answer Q4: Which schedules can be
refilled?
• Schedules III-IV can be refilled on the
prescription
– Up to 5 times w/in 6 mo
• Scheduled II:
– Refilling a prescription for a controlled
substance listed in schedule II is prohibited
(Title 21 US Code $ 829(a))
– No federal timeline of must be filled from
signing
– No federal limit on quantity; some states limit
to 30 day supply
DEA Practitioner’s Manual 2006; pg. 19-22
Center for Professional Health
Answer Q5: Can scheduled II prescriptions
be faxed?
• Expedite filling:
– Schedule II prescriptions can be faxed but
pharmacist cannot dispensed until they have
original Rx.
• Emergencies:
– MD may call in schedule II by telephone
– Amount limited to treat during the emergency
period
– Original written/signed must be presented to
the pharmacist w/in 7 days
– Pharmacy MUST notify DEA if Rx is not
received
DEA Practitioner’s Manual 2006; pg. 20-21
Center for Professional Health
Test Your Knowledge
A patient from one of your colleagues calls on a
Saturday night complaining of pain in his abdomen.
He says that Dr “P” who usually sees him is out of
town. He would like some lortabs (hydrocodone/
acetaminophen) 10/500 mg because he has taken
this before. His pain is diffuse and he has chronic
constipation. It started this morning and he has not
taken anything for it. He has hypertension, diabetes
and coronary artery disease. He denies fevers,
chills, nausea or vomiting. He denies blood in the
stool or changes in stool patterns. He states that Dr
“P” usually gives him about sixty tabs when he has
these “flair ups.” You are covering for the weekend
and are not familiar with Dr “P”.
Center for Professional Health
Test Your Knowledge
What is the most appropriate statement for this
gentleman at this time?
a)
b)
c)
d)
e)
f)
g)
I am uncomfortable managing this disorder at
this time. You will need to go to the ER. I
cannot call in the medication at this time.
I am uncomfortable managing this disorder.
You must go to the ER now but I can call in the
medication after you have been evaluated.
I am concerned about your pain but can only
call in 30 tabs.
I am concerned about the pain and will call in
the amount requested.
I can understand your situation and will call in
the medications now.
I understand you are in pain but cannot call in
medications until Monday.
I don’t know
Center for Professional Health
Test Your Knowledge
Which of the following is a correct statement
regarding addiction to narcotics?
a)
b)
c)
d)
e)
f)
g)
More people are addicted to prescription controlled
substances than heroin, cocaine and other illicit
drugs combined
Controlled substance use accounts for more deaths
by overdose than does heroin and cocaine combined
Prescription controlled substances have a street
value of about $1.00/mg
Prescribed controlled substances are monitored from
production to distribution to dispensing
All of the above
None of the above
I don’t know
Center for Professional Health
Board of Medical Examiners
• Complaint driven
• Judge practitioners based on
behavior, not on patient outcome
• Distinguish between human error
and intentional reckless behavior
Center for Professional Health
Board Process
Complaint is filed and reviewed that evidence exists
of a possible violation:
1. An investigator is assigned to make an
inquiry
2. A “notice of complaint” is sent to the doctor
and an explanation may be requested
3. Investigator:
• Schedule a meeting or
• Just show up
4. An immediate suspension of the doctor’s
license can be issued if the public is deemed
at risk
Center for Professional Health
Management of Prescribing
• The Board DOES have the expectation
that the physician will create a record that
shows:
− Proper indication for the use of the drug
− Monitoring of the patient
− The response based on follow-up visits
− Rationale for continuing or modifying
therapy
Center for Professional Health
Test Your Knowledge
Which of the following are most correct with
regards to the key issues around medical boards
identifying misprescribing?
a)
b)
c)
d)
e)
Each state’s medical board has a defined definition
of misprescribing regarding quantity and frequency
of refills
Medical boards look at prescribing patterns
regardless of type of medication
Medical boards do not use complaints as a means
to recognize misprescibing
Medical boards identify misprescribing for those
physicians prescribing out of their scope of
practice
I don’t know
Center for Professional Health
Test Your Knowledge
From the list below, select the item(s) that
the DEA sanctions.
a)
b)
c)
d)
e)
f)
g)
Self prescribing scheduled drugs
Diversion of illicit drugs to others
Maintenance of addictions
Iatrogenic addictions
All of the above
None of the above
I don’t know
Center for Professional Health
Test Your Knowledge
The DEA has the authority to deny, suspend, or
revoke a DEA registration upon finding that the
registrant has:
a) Falsified a filed application
b) Committed an act that would render DEA
registration inconsistent with public interest
c) Been excluded from Medicare or Medicaid
program
d) Been convicted of a felony relating to a
controlled substance
e) All of the above
f) None of the above
g) I don’t know
Center for Professional Health
Proper Prescribing Practices
Center for Professional Health
United States Department of Justice
Drug Enforcement Administration
Office of Diversion Control
Practitioner’s Manual
An Informational Outline of the
Controlled Substances Act
2006 Edition
DEA remains committed to the 2001 Balanced Policy
of promoting pain relief & preventing abuse of pain
medications.
http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html
Proper Prescribing Practices
Center for Professional Health
Safeguards for Prescribers:
1. Keep all prescription blanks in a safe place where they
cannot be stolen.
2. Use electronic prescriptions when possible or use only
one prescription pad at a time.
3. Use ONLY tamper-resistant prescription paper
4. Never sign blank prescriptions.
5. DO NOT use prescription blanks for writing notes
6. Assist the pharmacist when they telephone to verify
information about a prescription order.
7. Contact the nearest DEA field office to obtain or to
furnish information regarding suspicious prescription
activities.
DEA Practitioners Manual 2006; pg. 15
Center for Professional Health
Proper Prescribing Practices
Example:
•
•
•
•
•
•
•
•
•
•
Patient: Wanna Feelgood
Address: 1 Skid Row Way
Today
2011
Name
Strength
Hydrocodone/Acetamenophin 5/500 mg
1 tab po q4 hrs PRN pain
Dosage form
Disp: #20 tabs (Twenty Tabs) – NO
Quantity
REFILLS
Suremakes M. Feelgood, M.D.
Dispense as written
Substitution
Indication
Directions
# of refills
Pt’s full name & address
Physician’s name, address & DEA #
Manually signed
Dr Suremakes Me Feel good
Any Practice, USA
1-800-cal-ford
DEA Practitioners Manual 2006; pg. 18
Center for Professional Health
Proper Prescribing Practices
Federal courts expect a “legitimate medical
purpose in the usual course of professional
practice.” Follow the general rules:
1. Avoid prescribing large quantities of
controlled substances.
2. Avoid large numbers of prescriptions issued
compared to other physicians.*
3. DO document history & physical
examination.
4. DO screen for substance abuse.
*Given your discipline
DEA Practitioners Manual 2006 ed.
Center for Professional Health
Proper Prescribing Practices
5. DO NOT warn patient to fill prescriptions at
different pharmacies.
6. DO NOT issue prescriptions to patients
known to divert drugs.
7. DO NOT issue prescriptions in exchange for
sexual favors or for money.
8. AVOID prescribing controlled drugs at
intervals inconsistent with legitimate
medical treatment.
9. AVOID prescribing drugs when there is NO
relationship between the drugs prescribed
and condition being treated.
DEA Practitioners Manual 2006 ed.
Center for Professional Health
Prescribing Boundaries
Center for Professional Health
Four Step Approach
Step 1 – Workup with appropriate screening measures
Step 2 – Implement full SBIRT – if a screen is positive
Step 3 – Develop appropriate plan of care &
reassessment criteria
Step 4 – Document, Document, Document!
Center for Professional Health
Test Your Knowledge
• Dr “V” is a young physician out of residency
training for three years. She attended a US
medical school with a heavy focus on academics
and research, scored well on her family practice
board exams and has had no academic difficulty.
She is opening a solo practice in rural Louisiana.
She has experimented with marijuana while in
college but has not used any since then. She
drinks 1-2 glasses of wine in a week with
dinners. She had a father who was an alcoholic
and her mother suffered with depression for
many years.
Center for Professional Health
Test your Knowledge
There are some preventive measures to help with
prescribing narcotics in your office. Based on the
scenario in question above, what is the best option
for this physician?
a)
b)
c)
d)
e)
f)
g)
Create an office policy of not prescribing schedule
drugs to new patients.
Recommend all refills be done over the phone.
Advise patients that they must list all other
physicians who prescribe narcotics for them.
Provide the nurses with signed, extra prescriptions to
refill only if the patient returns to the office.
All of the above
None of the above
I don’t know
Center for Professional Health
Test Your Knowledge
The definition for misprescribing controlled substances includes
prescribing drugs in quantities or frequencies inappropriate for
the patient’s complaint or illness. Please select the scenario(s)
below that constitute misprescribing?
a)
b)
c)
d)
e)
f)
g)
h)
Prescribing only large quantities and at frequent intervals
Prescribing to a patient with a history of ETOH addiction in
recovery for 6 months without accurate documentation of
addiction treatment plans
Prescribing to family members without documentation of
emergent situation
Prescribing for minor injuries without having tried nonnarcotic medications first
Prescribing for health care professionals in your office
setting
All of the above
None of the above
I don’t know
Center for Professional Health
Test Your Knowledge
Ms “B” is a 65 year old female with fibromyalgia
and depression. Her spouse died last week and
she presents to your office because her pain is
increased. The funeral is tomorrow and she needs
only a few Vicodin® to get her through the day. If
you prescribe the vicodin® for Ms “B”, you are
crossing what prescribing boundary?
a) Factitious disorders
b) Medicalization of social problems
c) Somatoform disorders
d) Circumscribed medical illness
e) I don’t know
Center for Professional Health
Use, Dependence and Abuse
“Addiction doesn’t come heralded by a brass band, it sneaks up
on you, and sometimes with extraordinary speed”
C. Everett Koop (former US Surgeon General), 2003
Center for Professional Health
Use, Dependence and Abuse
• Appropriate use of controlled
substances for pain control
• Temporary or long term
• DSM-IV: 2 opioid use disorders
1.Opioid Dependence
2.Opioid Abuse
Center for Professional Health
Dependence
• Physical Dependence: A state of
adaptation that is manifested by a drug
class specific withdrawal syndrome that
can be produced by abrupt cessation,
rapid dose reduction, decreasing blood
level of the drug, and/or administration of
an antagonist. (ASAM)
• Leading to clinically significant impairment
or distress upon ceasing - withdrawal
Center for Professional Health
Dependence
• Physical dependence necessitates the continued
presence of a drug in order to prevent a
withdrawal or abstinence syndrome.
• Substance dependence has several features in
common with diabetes and hypertension
− Chronic, relapsing
− Genetic vulnerability
− Physiologic brain changes
− Responds to chronic disease management strategies,
not short-term symptom relief
Center for Professional Health
Relapse Rates
Treatment Prevents Relapse
Center for Professional Health
Tolerance
• Tolerance: Tolerance is a physiologic state
resulting from regular use of a drug in which
an increased dosage is needed to produce a
specific effect, or a reduced effect is
observed with a constant dose over time.
• Tolerance may or may not be evident during
opioid treatment and does not equate with
addiction.
• Tolerance does not develop uniformly for all
actions of these drugs, giving rise to a number of
toxic effects.
• Tolerant users can consume doses far in excess
of the dose they took.
Center for Professional Health
Pseudoaddiction
• Pseudoaddiction: The iatrogenic
syndrome resulting from the
misinterpretation of relief seeking
behaviors as though they are drugseeking behaviors that are commonly
seen with addiction.
• The relief seeking behaviors resolve upon
institution of effective analgesic therapy.
Center for Professional Health
Dependence vs. Abuse
Physical dependence and tolerance are
normal physiological consequences of
extended opioid therapy for pain and are not
the same as addiction.
Use
Tolerance
Dependence
Pseudoaddiction
≠
Abuse
Addiction
Center for Professional Health
Abuse
• Abuse: Manifested by three of the
following within a 12-month period
− Tolerance – increased amounts for same
effect or diminished effect
− Withdrawal syndrome
− Larger amounts
− Can’t cut down
− Time spent in obtaining, using or recovering
− Social, occupational or recreational activities
are given up or reduced
Center for Professional Health
Addiction
• Addiction: Addiction is a primary, chronic,
neurobiologic disease, with genetic,
psychosocial, and environmental factors
influencing its development and
manifestations
• It is characterized by behaviors that include
the following:
− Impaired control over drug use, craving,
compulsive use, and continued use despite harm
= 4c’s (ASAM)
− Behavior is reinforcing; loss of control (NIDA)
Center for Professional Health
Suspect Drug-Seeking Behavior in
the Patient who…
Center for Professional Health
Drug Seeking Patients
1. Transient-passing through
2. Feigns physical or psychological
problems
3. Pressures the physician for a particular
drug or multiple refills of a prescription
4. Red flags in presentation and PE
findings
5. Assertive Personality, demanding,
overacting
Center for Professional Health
Drug Seeking Patients
6. Unwilling to provide references/medical
records
7. No PCP
8. Cutaneous signs of drug use
9. Has no interest in diagnosis
10. Rejects all forms of treatment that do not
involve narcotics
Center for Professional Health
Test Your Knowledge
• Case 1: Pt complains of 10 out of 10 pain
and calls frequently requesting increased
dose of medications on post-op day #2
Pseudoaddiction
• Case 2: Pt requests increased dose of
medication 6 weeks after treatment for
metastatic breast cancer with increased
bone mets
Tolerance
Center for Professional Health
Test Your Knowledge
• Case 3: Pt attempts to steal a
prescription pad from your office
Abuse
• Case 4: Pt traveled and ran out of
medications on day 4 of their 10 day
trip and is calling from out of town
because they are having flushing,
N/V/D, muscle pains and agitation
Withdrawal
Center for Professional Health
Cases
Center for Professional Health
SBIRT
S
Screening – Screening patients at risk for substance
abuse; inquiring about family history of addiction;
using screening tools such as the NIAA 1-question
screening tool for alcohol use, AUDIT, CAGE,
CRAFT for adolescents, etc.
BI
Brief Intervention - Establish rapport with pt; ask
permission; raise subject; explore pros/cons; explore
discrepancies in goals; assess readiness to change;
explore options for change; negotiate a plan for
change-(motivational interviewing)
RT Referral to Treatment – For patients responding
positively to the screening tests, refer to AA, drug
addiction clinic, pain clinic, counseling, etc.
Center for Professional Health
Case 1: “I’m calling the
Medical Board!”
Center for Professional Health
Screening
• Ask 3 questions:
1. Are you a current, former or never
tobacco user?
2. Do you sometimes drink beer, wine
or other alcoholic beverage?
3. In the past have you used any of the
following drugs (other than for
medical reasons): _________?
Center for Professional Health
Motivational Interviewing
•
•
Developed late 1970’ – Bill Miller &
Stephen Rollnick
“Motivational interviewing is a
directive, client-centered
counseling style for eliciting
behavior change by helping clients
to explore and resolve
ambivalence.”
http://www.motivationalinterview.org/clinical/interaction.html
http://www.motivationalinterview.org/clinical/whatismi.html
Center for Professional Health
Motivational Interviewing
• Compared with nondirective
counseling, it is more focused and
goal-directed.
• The examination and resolution of
ambivalence is its central purpose,
and the counselor is intentionally
directive in pursuing this goal.
• Focus is on “change talk”
http://www.motivationalinterview.org/clinical/interaction.html
http://www.motivationalinterview.org/clinical/whatismi.html
Center for Professional Health
Motivational Interviewing
• OARS:
– (1) Open-ended questions
– (2) Affirmations
– (3) Reflective listening
– (4) Summaries
http://www.motivationalinterview.org/clinical/interaction.html
http://www.motivationalinterview.org/clinical/whatismi.html
Center for Professional Health
Example - Summary
"Let me stop and summarize what we've
just talked about. Your not sure that you
want to be here today and you really only
came because your partner insisted on it. At
the same time, you've had some nagging
thoughts of your own about what's been
happening, including how much you've
been using recently, the change in your
physical health and your missed work. Did I
miss anything? I'm wondering what you
make of all those things."
http://www.motivationalinterview.org/clinical/interaction.html
http://www.motivationalinterview.org/clinical/whatismi.html
Center for Professional Health
Referral to Treatment
•
•
•
•
•
Addiction medicine specialist
AA
NA
Other community-based programs
Detox – inpt vs. outpt
Center for Professional Health
Example
http://www.ed.bmc.org/sbirt/cases.php
Center for Professional Health
Case 2: Nurse Betty
You are walking from your patient’s room heading
toward conference. One of your favorite nurses runs
up next to you as you walk and says, “Dr X I am so
glad I saw you. I am having an awful migraine HA.
Can you prescribe me some pain medication until I
get home to take my migraine medicine? Maybe
just 5-10 tabs of something strong like Percocet® or
Lortab®? My sister had some for her M-HA and
said they worked well for her.” You quickly write the
prescription and after conference you are paged
from the ER because nurse Betty just had a severe
allergic reaction and your name was on the bottle.
The sister, also a nurse, calls the medical board.
Center for Professional Health
Case 2: Nurse Betty
• Wrote Rx and RN had bad reaction
to it
• Proper prescribing issues
• Documentation
• Board investigations
Center for Professional Health
Test Your Knowledge
Most physicians who are sanctioned by the board for
misprescribing controlled substances are most often
sited for which of the following reasons?
a)
b)
c)
d)
e)
f)
g)
Poor documentation for indication and quantity of
controlled substances
Poor documentation of physical exam
Poor documentation of complaint and review of
systems
Prescribing for a family member without
documentation
Self-prescribing with clear documentation
Prescribing for a colleague with illegible writing
I don’t know
Center for Professional Health
Case 3: My Girlfriend’s Knee
You are a third year resident dating a biochemistry
graduate student. Over the weekend she fell
playing tennis. Her knee is obviously swollen, red
and tender to the touch. There are no open lesions
and no signs of infection. You are on call in the
hospital when she calls you. You suggest she
goes to the ER but she insists she has to get back
to the lab to run an important experiment before
Monday. She is in a lot of pain and can hardly
move it. She took two T-500 mg with only minimal
improvement. She asks you to call in something so
she can get back to the lab. You call in 10 tabs of
hydrocodone/acetaminophen to last through the
next two days and she leaves a message with her
PCP’s office to come in on Monday.
Center for Professional Health
Case 3: My Girlfriend’s Knee
• Is this a reportable issue?
• What is the best course of action?
Center for Professional Health
Test your Knowledge
A 55 year old woman stubbed her toe on the
bedpost two weeks ago. She went to the ER
after the event and her toe was buddy taped
after the foot films showed ligamentous
inflammation and soft tissue swelling without
acute fracture. She received ten (10)
hydrocodone/acetaminophen 5/500 tabs at that
time. She drops into your clinic for refills and
notes she is still anxious, depressed and upset
that she cannot sleep well and she slept better
on the hydrocodone. The toe hurts some but is
improved overall and she is back at work. The
swelling of the digit is resolved.
Center for Professional Health
Test Your Knowledge
What is the next best course of action?
a) Refill the hydrocodone for a longer period of
time
b) Refill the hydrocodone for the same amount
of time
c) Refill the hydrocodone for less tabs
d) Prescribe another narcotic instead of the
hydrocodone
e) Refill the hydrocodone but also address the
anxiety issue
f) Do not refill the hydrocodone
g) I don’t know
Center for Professional Health
Test Your Knowledge
1. List 5 characteristics of someone
who maybe drug seeking.
2. What is SBIRT?
3. Describe motivational interviewing.
Center for Professional Health
Test Your Knowledge
Pt “X” presents to your office as a walk-in from
Memphis, TN on Friday afternoon. He is new in
town and is asking for a refill of his Xanax and
hydrocodone. He says he is in between jobs and is
just passing through. He will leave for New Jersey
on Sunday morning for a Monday job interview. He
takes both medications for renal stones that he has
had for 5 years and they constantly irritate him.
The pain is an 8-9 out of 10 on the pain scale when
it is really bad and 5-6 daily. He does not have any
medical records with him and cannot recall the
doctor’s name in Georgia that gave him the last
prescription. He ran out yesterday and does not
have a prescription bottle with him. He cannot stay
to see a consultant because he is leaving on
Sunday.
Center for Professional Health
Test Your Knowledge
How many items in this history are red
flags for potential drug abuse?
a)
b)
c)
d)
e)
f)
g)
None
1
2
3
4
5 or more
I don’t know
Center for Professional Health
Test Your Knowledge
Questions in the CAGE assessment include
which of the following:
a)
b)
c)
d)
e)
f)
g)
Cut down on drinking
Alcoholism in the family
Guilty of a DUI
Elevated mood with substance
All of the above
None of the above
I don’t know
Center for Professional Health
Questions & Answers
Center for Professional Health
Summary
• Reflection and self-identification of
possible risk factors
• Familiarize yourself with DEA and
SMB rules and regulations
• Use proper prescribing practices
• Use SBIRT and identify at risk
patients
• Treat pain appropriately
Center for Professional Health
References
•
•
•
•
•
•
•
•
•
Manchikanti L, Whitfield E, Pallone F. Evolution of the National All
Schedules Prescription Electronic Reporting Act (NASPER): a public law
for balancing treatment of pain and drug abuse and diversion. Pain
Physician. Oct 2005; 8(4):335-347.
Substance Abuse: The Nation’s Number One Health Problem; Key
Indicators for Policy Update. The Robert Wood Johnson Foundation.
February 2001.
Bollinger LC. Under the Counter: The Diversion and Abuse of Controlled
Prescription Drugs in the U.S. The National Center on Addiction and
Substance Abuse (CASA). 2005.
Screening and Brief Intervention : Making a Public Health Difference (Join
Together) Robert Wood Johnson, 2008.
A Pocket Guide for Alcohol Screening and Brief Intervention. NIAAA 2005
Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000
Gelernter et al. Am J Hum Genet. 2006 May;78(5):759-69.
Drakenberg et al. Proc Natl Acad Sci U S A. 2006 Mar 7;103(10):3908-13
Web Pages
Center for Professional Health
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DEA webpage: http://www.justice.gov/dea/index.htm Last accessed 8-27-10
Rules of the TN State Board of Medical Examiners: http://www.state.tn.us/sos/rules/0880/0880.htm Last
accessed 8/27/10
TN State Board of Medical Examiners: http://health.state.tn.us/Boards/ME/index.htm Last accessed
8/27/10
TN State DEA Prescribing Monitoring Program: https://prescriptionmonitoring.state.tn.us
Federation of State medical Boards web page:
http://www.fsmb.org/pdf/2000_grpol_Professional_Conducts_and_Ethics.pdf Last accessed 8/27/0
FSBM: http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf Last accessed 8/27/10
KASPER website: http://chfs.ky.gov/os/oig/KASPER.htm
Practitioner’s Manual: An Informational Outline of the Controlled Substances Act 2006 Edition
http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html
http://www.justice.gov/dea/concern/narcotics.html
http://psyweb.com/Mdisord/jsp/subsd.jsp
http://www.justice.gov/dea/concern/narcotics.html
National Institute on Drug Abuse (NIDA)
National Survey on Drug Abuse and Health, SAMHSA
http://www.nida.nih.gov/about/organization/genetics/publications/2006_2007/briefing/opioid.html
http://www.webmd.com/mental-health/news/20040526/researchers-identify-alcoholism-gene
http://www.medicalnewstoday.com/articles/71475.php
http://www.motivationalinterview.org/clinical/interaction.html
http://www.motivationalinterview.org/clinical/whatismi.html
http://www.ed.bmc.org/sbirt/cases.php
MD Consult L.L.C. http://www.mdconsult.com Bookmark URL: /das/book/view/14899700/959/I366.fig/top
Screening Tools
Center for Professional Health
For (+) screen:
• Tobacco: 5-A’s
• ETOH: Several options
• NIAAA’s 1 Q approach:
− Do you drink beer, wine, or other alcoholic
beverages?
− Men: 5 or more drinks a day
− Women: 4 or more drinks a day
• CAGE: Cut down, Annoyance, Guilty, Eye
opener
• ASSIST: The Alcohol, Smoking, and
Substance Involvement Screening Test –
WHO; 8 Q
Center for Professional Health
Screening Tools
• Other screening tools for ETOH:
− AUDIT: 10 Q; reliable and valid tool;
>8=risk/harmful ETOH consumption
− MAST: Michigan Alcoholism Screening Test;
22 Q; ranks as no problem (<2); early or
middle (3-5), and more problem drinker (6 or
more)
− CRAFT: 6 Q mnemonic for adolescents; 2 or
more = problem drinking
− DAST: Drug Abuse Screening Test; 28 Q; >5
problem
− T-ACE: for pregnant women; adopted from
CAGE
See reference for “Join Together“ and NIAA pocket card