Engaging	
  the	
  Medical	
  
Community	
  
Brian	
  Fingerson,	
  RPh,	
  President,	
  
Kentucky	
  Professionals	
  Re...
Disclosure	
  
•  Brian	
  Fingerson,	
  BSPharm,	
  R.Ph.,	
  FAPhA,	
  
declares	
  no	
  conflicts	
  of	
  interest,	
 ...
Learning	
  Objec:ves	
  
1.  Describe	
  the	
  impact	
  of	
  changing	
  aQtudes	
  
concerning	
  Rx	
  drug	
  abuse...
Engaging	
  the	
  Medical	
  
Community	
  
24	
  April	
  2014	
  
Dallas	
  Gay	
  
Brian	
  Fingerson,	
  RPh	
  
Disclosure	
  
•  Brian	
  Fingerson,	
  BSPharm,	
  R.Ph.,	
  FAPhA,	
  
declares	
  no	
  conflicts	
  of	
  interest,	
 ...
Deadly	
  Epidemic:	
  Rx	
  Drug	
  
Overdoses	
  
•  In	
  the	
  past	
  11	
  years,	
  deaths	
  from	
  overdose	
  ...
Millions	
  of	
  Opioid	
  Prescrip:ons	
  
Go	
  to	
  'Doctor	
  Shoppers'	
  
•  Nearly	
  2%	
  of	
  all	
  US	
  op...
"But	
  Doc!	
  I	
  Really	
  Hurt!	
  “	
  
Dopamine Pathways – Pleasure pathways
nucleus
accumbens
hippocampus
striatum
frontal
cortex
substantia
nigra/VTA
cocaine
h...
Many Things Are Happening During
the Transition Between Voluntary
Drug Use and Addiction…
Compulsive
Drug Use
(Addiction)
Voluntary
Drug Use
Pain	
  Management	
  vs.	
  Pa:ent	
  
Management	
  
• Acute	
  Pain	
  
• Chronic	
  Pain	
  
• The	
  Pa5ent	
  with	
...
The	
  Interna:onal	
  Associa:on	
  for	
  the	
  Study	
  
of	
  Pain	
  
WHO	
  3-­‐step	
  ladder	
  
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± procedures
3 severe
2 mode...
"It	
  ain't	
  what	
  you	
  don't	
  know	
  
that	
  gets	
  you	
  into	
  trouble.	
  It's	
  
what	
  you	
  know	
...
Things	
  we	
  “know”	
  that	
  aren’t	
  so	
  
•  If	
  there	
  is	
  real	
  pain,	
  developing	
  opiate	
  
depen...
Risk	
  Factors	
  for	
  opiate	
  abuse	
  
•  History	
  of	
  alcohol	
  or	
  drug	
  abuse	
  
– History	
  of	
  ph...
Risk	
  Factors	
  for	
  opiate	
  abuse	
  
– Prior	
  failed	
  treatment	
  at	
  a	
  pain	
  
management	
  program	...
Sir	
  William	
  Osler	
  
“It is more important to know
what kind of patient has a
disease…
than what kind of disease
a ...
Defini:ons	
  
	
  Acute	
  Pain	
  
– Acute	
  pain	
  is	
  the	
  normal,	
  predicted	
  
physiological	
  response	
  ...
Acute	
  Pain	
  
•  Broken	
  bones	
  
•  Dental	
  “issues”	
  
•  Incisions	
  
•  Burns	
  
•  Kidney	
  Stones	
  
•...
SOMETIMES	
  YOU	
  THINK…	
  
• You	
  are	
  darned	
  if	
  you	
  do	
  and	
  	
  
• You	
  are	
  darned	
  if	
  yo...
As	
  a	
  healthcare	
  professional	
  
•  You	
  have	
  a	
  legal	
  and	
  ethical	
  responsibility	
  to	
  
uphol...
Office	
  staff	
  training	
  also:	
  
•  Train	
  staff	
  to	
  recognize	
  and	
  alert	
  you	
  to	
  
quesBonable	
  ...
Common	
  Characteris:cs	
  of	
  the	
  
Drug	
  Abuser:	
  
•  Unusual	
  behavior	
  in	
  the	
  waiBng	
  room;	
  
•...
Common	
  Characteris:cs	
  of	
  the	
  
Drug	
  Abuser:	
  
•  Reluctant	
  or	
  unwilling	
  to	
  provide	
  referenc...
What	
  You	
  Should	
  Do	
  When	
  Confronted	
  by	
  
a	
  Suspected	
  Drug	
  Abuser	
  
•  DO:	
  
•  perform	
  ...
What	
  You	
  Should	
  Do	
  When	
  Confronted	
  by	
  
a	
  Suspected	
  Drug	
  Abuser	
  
•  Do:	
  
•  call	
  a	
...
What	
  You	
  Should	
  Do	
  When	
  Confronted	
  by	
  
a	
  Suspected	
  Drug	
  Abuser	
  
DON'T:	
  
•  "take	
  th...
How	
  to	
  Discuss	
  Drug	
  Issues	
  with	
  
a	
  Pa:ent	
  
SuggesBons	
  from	
  Greg	
  Jones,	
  MD	
  
Medical	...
Why	
  bother?	
  	
  
The	
  paBent	
  is	
  the	
  
one	
  With	
  the	
  
problem	
  
Usual	
  Way	
  of	
  Discussing	
  Addic:on	
  
Issues	
  
•  	
  Never	
  ask-­‐	
  Probably	
  most	
  common	
  way	
 ...
“I’ve	
  never	
  had	
  a	
  problem	
  with	
  
drugs.	
  I’ve	
  had	
  problems	
  with	
  
the	
  police.”	
  
Keith	...
Dr.	
  Jones’	
  1st	
  law	
  of	
  Addic:on	
  
Medicine	
  
The	
  level	
  of	
  Denial	
  is	
  proporBonal	
  to	
  ...
Dr.	
  Jones’	
  2nd	
  law	
  of	
  Addic:on	
  
Medicine	
  
There	
  is	
  an	
  inverse	
  and	
  proporBonal	
  
rela...
So	
  what	
  on	
  Earth	
  am	
  I	
  
supposed	
  to	
  do!	
  
•  Ask	
  the	
  quesBons	
  	
  
•  And	
  in	
  the	
...
What	
  to	
  Ask	
  
•  Ask	
  do	
  you	
  drink?	
  Or	
  use	
  drugs?	
  
•  Ask	
  when	
  was	
  the	
  last	
  Bme...
Then….	
  
•  Do	
  you	
  recall	
  how	
  old	
  you	
  were	
  when	
  you	
  first	
  
used	
  alcohol	
  or	
  another...
What	
  if	
  they	
  complain	
  of	
  Pain?	
  
•  Ask	
  what	
  is	
  the	
  pain	
  prevenBng	
  them	
  from	
  doin...
Red	
  Flags	
  
•  The	
  “Call	
  Brand”	
  
•  AnyBme	
  they	
  menBon	
  or	
  ask	
  for	
  a	
  specific	
  
drug	
 ...
Get	
  A	
  KASPER	
  i.e.	
  Use	
  your	
  PDMP!	
  
•  How	
  many	
  classes	
  of	
  drugs	
  
•  How	
  many	
  pres...
Prescrip:on	
  Painkiller	
  Prescribing	
  Dropped	
  
Ader	
  New	
  Kentucky	
  Law	
  Implemented	
  
•  The	
  law	
 ...
So	
  you	
  are	
  fixin’	
  to	
  Rx	
  a	
  controlled	
  
substance	
  –	
  eyes	
  OPEN!	
  
And….	
  
•  UBlize	
  your	
  local	
  pharmacists	
  
•  Thank	
  you!	
  
For	
  further	
  informa:on:	
  
Brian	
  Fingerson,	
  RPh	
  
KY	
  Professionals	
  Recovery	
  Network	
  (KYPRN)	
  ...
April 22-24, 2014 | Atlanta, Georgia
Dallas Gay has no financial relationships
with proprietary entities that produce health
care goods and services.
1.  Describe the impact of changing
attitudes concerning Rx drug abuse.
2.  Define the roles clinicians play to
positively...
“PrescripBon	
   drug	
   safety	
  
educaBon	
  is	
  best	
  received	
  and	
  
understood	
   by	
   paBents	
   when	...
“Physicians	
   have	
   a	
   major	
   role	
  
to	
   play	
   in	
   reducing	
   the	
   supply	
  
of	
   unused	
  ...
  Make The Four Steps a part of every RX
  Put The Four Steps in the Rx bag
  Increase the availability of disposal sit...
  Expand Education Higher Education Programs
  Provide Resources and Education to Healthcare
Professionals
  Foster Imp...
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Education & Advocacy: Engaging the Medical Community - Brian Fingerson and Dallas Gay

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  1. 1. Engaging  the  Medical   Community   Brian  Fingerson,  RPh,  President,   Kentucky  Professionals  Recovery  Network   Dallas  Gay,  Co-­‐chair,   Medical  AssociaBon  of  Georgia   FoundaBon’s  “Think  About  It”  Campaign    
  2. 2. Disclosure   •  Brian  Fingerson,  BSPharm,  R.Ph.,  FAPhA,   declares  no  conflicts  of  interest,  real  or   apparent,  and  no  financial  interests  in  any   company,  product,  or  service  menBoned  in   this  program,  including  grants,  employment,   giOs,  stock  holdings,  and  honoraria   •  Dallas  Gay  has  no  financial  relaBonships  with   proprietary  enBBes  that  produce  health  care   goods  and  services.  
  3. 3. Learning  Objec:ves   1.  Describe  the  impact  of  changing  aQtudes   concerning  Rx  drug  abuse.     2.  Define  the  roles  clinicians  play  to  posiBvely  impact   this  epidemic.     3.  Demonstrate  programs  that  are  posiBvely  impacBng   the  clinical  community  regarding  opioids  use  and   abuse.    
  4. 4. Engaging  the  Medical   Community   24  April  2014   Dallas  Gay   Brian  Fingerson,  RPh  
  5. 5. Disclosure   •  Brian  Fingerson,  BSPharm,  R.Ph.,  FAPhA,   declares  no  conflicts  of  interest,  real  or   apparent,  and  no  financial  interests  in  any   company,  product,  or  service  menBoned  in   this  program,  including  grants,  employment,   giOs,  stock  holdings,  and  honoraria  
  6. 6. Deadly  Epidemic:  Rx  Drug   Overdoses   •  In  the  past  11  years,  deaths  from  overdose   increased  more  than  400  percent  among   women,  compared  with  a  265  percent  rise   among  men.   •  Americans  consume  80  percent  of  opiate   painkillers  produced  in  the  world,  according  to   the  American  Society  of  IntervenBonal  Pain   Physicians.  
  7. 7. Millions  of  Opioid  Prescrip:ons   Go  to  'Doctor  Shoppers'   •  Nearly  2%  of  all  US  opioid  prescripBons,  totaling  an  esBmated   4.3  million  prescripBons  each  year  and  4%  of  all  opioids  by   weight,  are  purchased  by  paBents  presumed  to  be  "doctor   shoppers,"  according  to  a  new  study.  In  the  first  naBonal   esBmate  of  opioid  medicaBons  obtained  in  the  United  States   by  the  doctor  shoppers  —  pa:ents  who  receive  painkiller   prescrip:ons  from  mul:ple  doctors  without  informing  the   doctors  of  their  other  prescrip:ons  —  researchers  found  that   they  obtained,  on  average,  32  opioid  prescrip5ons  per  year   from  10  different  prescribers.  
  8. 8. "But  Doc!  I  Really  Hurt!  “  
  9. 9. Dopamine Pathways – Pleasure pathways nucleus accumbens hippocampus striatum frontal cortex substantia nigra/VTA cocaine heroin nicotine amphetamines opiates THC PCP ketamine heroin alcohol benzodiazepine s barbiturates alcohol
  10. 10. Many Things Are Happening During the Transition Between Voluntary Drug Use and Addiction…
  11. 11. Compulsive Drug Use (Addiction) Voluntary Drug Use
  12. 12. Pain  Management  vs.  Pa:ent   Management   • Acute  Pain   • Chronic  Pain   • The  Pa5ent  with  the  Pain  
  13. 13. The  Interna:onal  Associa:on  for  the  Study   of  Pain  
  14. 14. WHO  3-­‐step  ladder   Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± procedures 3 severe 2 moderate A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine 1 mild ASA Acetaminophen NSAIDs
  15. 15. "It  ain't  what  you  don't  know   that  gets  you  into  trouble.  It's   what  you  know  for  sure  that  just   ain't  so."     Mark  Twain:  
  16. 16. Things  we  “know”  that  aren’t  so   •  If  there  is  real  pain,  developing  opiate   dependence  is  rare-­‐  Not  True!   •  If  is    a  legiBmate  Prescribed  Drug  it  is  safe-­‐  Not   True!   •  Even  if  they  had  past  issues  with  drugs  (or   alcohol)  if  they  need  it  then  they  ought  to  get   it,  just  be  careful-­‐  Haven’t  seen  this  work  too   well  
  17. 17. Risk  Factors  for  opiate  abuse   •  History  of  alcohol  or  drug  abuse   – History  of  physical/sexual  abuse   – History  of  depression/anxiety   – Current  chao:c  living  environment   – History  of  criminal  ac:vity  
  18. 18. Risk  Factors  for  opiate  abuse   – Prior  failed  treatment  at  a  pain   management  program   – Regular  tobacco  use   – Regular  alcohol  use   – MulBple  injuries  or  surgeries   – Family  history  of  drug  abuse  
  19. 19. Sir  William  Osler   “It is more important to know what kind of patient has a disease… than what kind of disease a patient has”
  20. 20. Defini:ons    Acute  Pain   – Acute  pain  is  the  normal,  predicted   physiological  response  to  a  noxious   chemical,  thermal  or  mechanical  s:mulus   and  typically  is  associated  with  invasive   procedures,  trauma  and  disease.  It  is   generally  :me-­‐limited.    
  21. 21. Acute  Pain   •  Broken  bones   •  Dental  “issues”   •  Incisions   •  Burns   •  Kidney  Stones   •  Childbirth   •  Damaged  or  disrupted  Bssue    
  22. 22. SOMETIMES  YOU  THINK…   • You  are  darned  if  you  do  and     • You  are  darned  if  you  don’t   • Write  that  Rx  
  23. 23. As  a  healthcare  professional   •  You  have  a  legal  and  ethical  responsibility  to   uphold  the  law  and  to  help  protect  society   from  drug  abuse.   •  You  have  a  professional  responsibility  to   prescribe  controlled  substances  appropriately,   guarding  against  abuse  while  ensuring  that   your  pa:ents  have  medica:on  available   when  they  need  it.  
  24. 24. Office  staff  training  also:   •  Train  staff  to  recognize  and  alert  you  to   quesBonable  paBent  demeanor.    
  25. 25. Common  Characteris:cs  of  the   Drug  Abuser:   •  Unusual  behavior  in  the  waiBng  room;   •  AsserBve  personality,  oOen  demanding  immediate   acBon;   •  Unusual  appearance  -­‐  extremes  of  either  slovenliness   or  being  over-­‐dressed;   •  May  show  unusual  knowledge  of  controlled   substances  and/or  gives  medical  history  with   textbook  symptoms  OR  gives  evasive  or  vague   answers  to  quesBons  regarding  medical  history;  
  26. 26. Common  Characteris:cs  of  the   Drug  Abuser:   •  Reluctant  or  unwilling  to  provide  reference   informaBon.  Usually  has  no  regular  doctor  and   oOen  no  health  insurance;   •  Will  oOen  request  a  specific  controlled  drug   and  is  reluctant  to  try  a  different  drug;   •  Generally  has  no  interest  in  diagnosis  -­‐  fails  to   keep  appointments  for  further  diagnosBc  tests   or  refuses  to  see  another  pracBBoner  for   consultaBon;  
  27. 27. What  You  Should  Do  When  Confronted  by   a  Suspected  Drug  Abuser   •  DO:   •  perform  a  thorough  examinaBon  appropriate   to  the  condiBon.   •  document  examinaBon  results  and  quesBons   you  asked  the  paBent.   •  request  picture  I.D.,  or  other  I.D.  and  Social   Security  number.  Photocopy  these  documents   and  include  in  the  paBent's  record.  
  28. 28. What  You  Should  Do  When  Confronted  by   a  Suspected  Drug  Abuser   •  Do:   •  call  a  previous  pracBBoner,  pharmacist  or   hospital  to  confirm  paBent's  story.   •  confirm  a  telephone  number,  if  provided  by   the  paBent.   •  confirm  the  current  address  at  each  visit.   •  write  prescripBons  for  limited  quanBBes.  
  29. 29. What  You  Should  Do  When  Confronted  by   a  Suspected  Drug  Abuser   DON'T:   •  "take  their  word  for  it"  when  you  are   suspicious.   •  dispense  drugs  just  to  get  rid  of  drug-­‐seeking   paBents.   •  prescribe,  dispense  or  administer  controlled   substances  outside  the  scope  of  your   professional  pracBce  or  in  the  absence  of  a   formal  pracBBoner-­‐paBent  relaBonship.  
  30. 30. How  to  Discuss  Drug  Issues  with   a  Pa:ent   SuggesBons  from  Greg  Jones,  MD   Medical  Director  at  the  KY  Physicians   Health  FoundaBon  
  31. 31. Why  bother?     The  paBent  is  the   one  With  the   problem  
  32. 32. Usual  Way  of  Discussing  Addic:on   Issues   •   Never  ask-­‐  Probably  most  common  way   •  Do  you  have  a  drinking  or  drug  Problem?   •  Or  You  don’t  have  a  drinking  or  drug   problem  do  you?   •  How  much  do  you  drink?   •  How  much  drug  do  you  use?  
  33. 33. “I’ve  never  had  a  problem  with   drugs.  I’ve  had  problems  with   the  police.”   Keith  Richards  
  34. 34. Dr.  Jones’  1st  law  of  Addic:on   Medicine   The  level  of  Denial  is  proporBonal  to   the  obvious  and  measurable  damage   done  by  their  drinking  or  drug  use.   *Corollary-­‐  Denial  increases  if   confronted  with  the  evidence  
  35. 35. Dr.  Jones’  2nd  law  of  Addic:on   Medicine   There  is  an  inverse  and  proporBonal   relaBonship  between  the  degree  of   convicBon  a  paBent  has  in  their  dx   and  the  likelihood  it    exists  
  36. 36. So  what  on  Earth  am  I   supposed  to  do!   •  Ask  the  quesBons     •  And  in  the  course  of  your  usual  Hx  taking   •  Any  hint  of  judgmental  or  disapproving   aQtude  and  the  useful  conversaBon  is  over  
  37. 37. What  to  Ask   •  Ask  do  you  drink?  Or  use  drugs?   •  Ask  when  was  the  last  Bme  you  ….   •  Are  you  concerned  about  your  drinking  or   drug  use?   •  Have  you  considered  doing  something   different  with  your  drinking  or  drug  use?   •  Ever  have  Bmes  you  drank  or  used  more  than   you  intended  too?  
  38. 38. Then….   •  Do  you  recall  how  old  you  were  when  you  first   used  alcohol  or  another  drug?   •  Do  you  recall  any  of  your  family  members   having  issues  with  alcohol  or  other  drugs?   •  “How  many  Bmes  in  the  past  year  have  you   had  X  or  more  drinks  in  a  day?”,  where  X  is  5   for  men,  4  for  women   •  Used  to  get  high?  
  39. 39. What  if  they  complain  of  Pain?   •  Ask  what  is  the  pain  prevenBng  them  from  doing?   Not  –  How  bad  is  the  pain?   •  Pain  scales  are  not  helpful.   •  Ask  about  things  they  are  able  to  do.   •  Ask  how  they  first  came  to  have  the  pain.   •  Ask  how  long  the  pain  has  been  present.   •  Ask  about  prior  evaluaBons.   •  Ask  about  prior  treatment.  
  40. 40. Red  Flags   •  The  “Call  Brand”   •  AnyBme  they  menBon  or  ask  for  a  specific   drug  by  name…   •  Having  more  than  one  doctor.   •  Having  more  than  one  pharmacy.   •  Being  on  more  than  one  class  of  controlled   substance.   •  They  brought  their  films.   •  Work  or  disability  related.  
  41. 41. Get  A  KASPER  i.e.  Use  your  PDMP!   •  How  many  classes  of  drugs   •  How  many  prescribers   •  Overlapping?   •  How  many  Pharmacies?   •  Amount  and  frequency?  
  42. 42. Prescrip:on  Painkiller  Prescribing  Dropped   Ader  New  Kentucky  Law  Implemented   •  The  law  requires  prescribers  to  register  with  the   state’s  prescripBon  drug  monitoring  database,  and   gives  law  enforcement  easier  access  to  it.   •  Rates  of  prescribing  for  oxycodone  and  hydrocodone   have  dropped.   •  Between  August  2012  and  May  2013,  the  number  of   hydrocodone  doses  decreased  by  9.5  percent,  and   oxycodone  doses  dropped  by  10.5  percent.  
  43. 43. So  you  are  fixin’  to  Rx  a  controlled   substance  –  eyes  OPEN!  
  44. 44. And….   •  UBlize  your  local  pharmacists   •  Thank  you!  
  45. 45. For  further  informa:on:   Brian  Fingerson,  RPh   KY  Professionals  Recovery  Network  (KYPRN)   202  Bellemeade  Road   Louisville,  KY  40222-­‐4502   O/H:  502-­‐749-­‐8385   Fax:  502-­‐749-­‐8389   Cell:  502-­‐262-­‐9342   kyprn@ax.net  for  email   www.kyprn.com   Ques:ons?  
  46. 46. April 22-24, 2014 | Atlanta, Georgia
  47. 47. Dallas Gay has no financial relationships with proprietary entities that produce health care goods and services.
  48. 48. 1.  Describe the impact of changing attitudes concerning Rx drug abuse. 2.  Define the roles clinicians play to positively impact this epidemic.
  49. 49. “PrescripBon   drug   safety   educaBon  is  best  received  and   understood   by   paBents   when   it   is   delivered   at   the   places   where  they  go  for  their  health   care.  Northeast  Georgia  Health   Systems   is   commixed   to   parBcipaBng   in   the   ‘Think   About   It’   prescripBon   drug   safety  educaBon  program.  We   believe   that   this   program   will   reduce   the   incident   of   drug   diversion   and   abuse   that   has   become   an   epidemic   in   our   country.”       -­‐Carol  Burrell   CEO  of  Northeast  Georgia  Health  Systems  
  50. 50. “Physicians   have   a   major   role   to   play   in   reducing   the   supply   of   unused   prescripBons   and   also   helping   their   paBents   understand   the   need   to   safeguard  their  medicines.    The   ‘Think   About   It’   program   has   caused   me   to   more   closely   evaluate   how   I   prescribe   to   paBents  in  order  to  reduce  the   supply   of   prescripBon   drugs   that   might   otherwise   be   diverted   from   their   intended   use  to  some  form  of  abuse.”         -­‐Dr.  Pierpont  F.  Brown,  M.D.,  F.A.C.S.  
  51. 51.   Make The Four Steps a part of every RX   Put The Four Steps in the Rx bag   Increase the availability of disposal sites   Display Rx safe storage boxes in stores
  52. 52.   Expand Education Higher Education Programs   Provide Resources and Education to Healthcare Professionals   Foster Implementation of Community Involvement   Advocate for Public Policy Changes

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