Prescription and Over-the Counter Drug Misuse and Abuse


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Prescription drug abuse is an epidemic in the Appalachian region that is impacting public health, education, economic development and family life. This talk will examine epidemiologic factors associated with prescription and over-the-counter drug misuse. Commonly abused prescription and over-the-counter drugs will be discussed and safe patient and prescriber factors that can increase the risk of prescription drug abuse will be compared. The strengths and limitations of prescription-drug monitoring programs will be explained. Session participants will discuss actions they have taken in their community to fight prescription drug abuse.

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  • There has been technology that the Fed know about that will stop this. However 38 states passed the NASPER Bill that is nothing more then placing our personal medical records on a WEBSITE! NASPER does not run in Real Time so the drug dealer gets his pills and makes his money. However We had had technology that will stop this on the spot! Close all Pill Mills and the Feds know this. 38 states use the NASPER database system that is backed by Purdue that makes Oxycontin??? Why. FAKE ID beats it and it's NOT a real time system. Until we use a database that runs in real time that something as easy as FAKE ID beats it our kids will keep dying and Purdue will keep making billions, the Feds will keep their jobs and everyone is happy but US! is a real time system that using a biometric finger scan that tells the doctor or pharmacy If this person is a doctor shopper. The BioScriptRx system works in Real Time and uses Biometrics so no one
    can use FAKE ID. Until we use biomedtrics and a real time system more pills will flow into the streets and our kids will pay the price. It's about job security. Get pissed! Please. Get pussed. will save billions of tax dollars and it's FREE so I ask why are we not using it? Again Job Security.
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Prescription and Over-the Counter Drug Misuse and Abuse

  1. 1. VRHA/VFC Annual Conference 2009 Prescription and Over-the-Counter Drug Misuse and Abuse Risk Factors, Red Flags, and Prevention Strategies Sarah T. Melton, PharmD,BCPP,CGP 2009 VRHA/VAFC Joint Meeting The Homestead Resort November 17, 2009 “The nonmedical use or abuse of prescription drugs is a serious and growing public health problem in this country. The elderly are among those most vulnerable to prescription drug abuse or misuse because they are prescribed more medications than their younger counterparts. Most people take prescription medications responsibly; however, an estimated 48 million people (ages 12 and older) have used prescription drugs for nonmedical reasons in their lifetimes. This represents approximately 20 percent of the U.S. population.” Nora Volkow, MD. Director, National Institute on Drug Abuse 2 Objectives At the completion of this presentation, the participant will be able to: 1. Examine epidemiologic factors associated with prescription and over-the-counter drug misuse and abuse in Virginia and Central Appalachia. 2. Discuss commonly abused prescription and over-the- counter drugs. 3. Compare and contrast safe patient and prescriber factors that can increase the risk of prescription drug abuse and describe prescribing practices that can limit abuse. 4. Explain the strengths and limitations of prescription- drug monitoring programs. Sarah T. Melton, PharmD,BCPP,CGP 1
  2. 2. VRHA/VFC Annual Conference 2009 Prescription drug misuse: A concerning trend While most people take prescription medications responsibly for the reasons in which the medications were prescribed, there has been an increasing trend in non-medical use of pharmaceuticals. Video and images of prescription drugs misuse and abuse are increasing as the media reporting on the popularizing of pharmaceuticals intensifies. Increase in Controlled Substance Abuse (1992-2003) Scope of the Problem 6.4 million (2.6%) of people aged 12 or older used prescription psychotherapeutic drugs for nonmedical reasons in the past month 4.7 million used pain relievers 1.8 million used tranquilizer 1.1 million used stimulants Nonmedical use of pain relievers and marijuana account for the largest number of first-time abuse Sarah T. Melton, PharmD,BCPP,CGP 2
  3. 3. VRHA/VFC Annual Conference 2009 Scope of the Problem (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007) Scope of the problem Source? 56.5% reported obtained free from friend or relative 18.1% reported obtained from one or more doctors 4.1% purchased from a drug dealer or stranger 0.5% bought from the internet Drug abuse related ED visits Drug abuse related emergency department visits involving narcotic analgesics and benzodiazepines (data from 2003 not available). Source: DAWN data. Sarah T. Melton, PharmD,BCPP,CGP 3
  4. 4. VRHA/VFC Annual Conference 2009 Drug/Poison Caused Death Rates by City/County of Residence, 2007 Office of the Chief Medical Examiner Annual Report, 2007. Prescription Drug Abuse in Appalachia Admission rates for the primary abuse of opiates and synthetic are higher in Appalachia than in the rest of the nation. Rates are rising across the nation and in Appalachia, the rate of increase in Appalachia is greater; particularly in Appalachian coal mining areas. National Opinion Research Center (NORC) at the University of Chicago and East Tennessee State University. An Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian Region Final Report August 2008 Prescription Drug Abuse in Appalachia Appalachian adolescents demonstrate similar use patterns for cocaine, marijuana and methamphetamine Non-medical use of psychotherapeutics Cigarettes Higher compared with rest of US Heavy alcohol use Highest rate of non-medical use of psychotherapeutics Distressed, at-risk Appalachian counties 10.6% in Appalachia, 8.7% outside Appalachia National Opinion Research Center (NORC) at the University of Chicago and East Tennessee State University. An Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian Region Final Report August 2008 Sarah T. Melton, PharmD,BCPP,CGP 4
  5. 5. VRHA/VFC Annual Conference 2009 Adolescents in Appalachia Past year nonmedical use of psychotherapeutics Painkillers Use in Past Year Coal Mining Status of Patient Location Sarah T. Melton, PharmD,BCPP,CGP 5
  6. 6. VRHA/VFC Annual Conference 2009 Trends in Use People use potentially addicting prescription or OTC medications in the following manner: For legitimate medical treatment As a substitute when drug of choice (DOC) is not available As a booster for a more intense high As an alternative when DOC has been eliminated from use by drug testing As an alternative addictive drug prescribed by physicians Lessenger JE, Feinberg SD. Abuse of prescription and over-the counter medications. J Am Board Fam Med over- 2008;21:45-54. 2008;21:45- Defining Abuse Appropriate use Use of controlled substance as prescribed for defined condition with no signs of misuse or abuse. Misuse/inappropriate use Use of controlled substance for reason other than that for which it was prescribed or in dosage different than that prescribed Abuse Use of controlled substance outside normally accepted standards of use, resulting in disability and/or dysfunction. Dependence and Tolerance Physical dependence does not equal abuse Dependence: abrupt cessation of intake of a substance leads to characteristic withdrawal symptoms Tolerance: state in which escalating doses must be ingested to attain the same effect Sarah T. Melton, PharmD,BCPP,CGP 6
  7. 7. VRHA/VFC Annual Conference 2009 Dependence, Addiction, and Pseudo-addiction Dependence Addiction Pseudo-addiction Person engages in drug-seeking behavior simply to obtain therapeutic and effective dosage of medication Pharmacologic Properties of Medications Likely to be Abused Rapid onset of action High degree of potency or intensity Brief duration of action High purity and water solubility High volatility Parran T. Prescription drug abuse: a question of balance. Med Clin North Am 1997;(81(4): 967-978. Characteristics of Abusers White Younger (stimulants) Tend to use opiates Tend to be women (sedatives) Tend to mix medications with alcohol Tend to use prescription and OTC meds in combination with alcohol to attempt suicide Obtain prescriptions from physicians or dentists, from friends, or purchase on the black market Lessenger JE, Feinberg SD. Abuse of prescription and over-the counter medications. J Am Board Fam Med over- 2008;21:45-54. 2008;21:45- Sarah T. Melton, PharmD,BCPP,CGP 7
  8. 8. VRHA/VFC Annual Conference 2009 Lucrative Black Market Quality and potency are guaranteed Obtaining from health professional less than cost on the street Oral products perceived to be “safer” Drugs can be traded on the street for other drugs of choice Values for Commonly Prescribed Substances Hydromorphone (Dilaudid) $30/tab Morphine (MSIR, Roxanol) $20/tab Meperidine (Demerol) $15/tab Oxycodone (Percocet, Tylox) $7-10/tab Methadone (Dolophone, Methadose) $9/tab Diazepam (Valium) $8/tab Methylphenidate (Ritalin) $6/tab Hydrocodone (Vicodin, Lortab) $3-6/tab Oxycodone ER (Oxycontin) $1/mg State Police Drug Diversion Unit for average prices, 2005 Opioids Hydrocodone is the most commonly prescribed drug in the United States Opioids are second most commonly abused drug, falling after marijuana and before cocaine 20-40% of patients taking opioids for chronic pain have UDS positive for marijuana, alcohol or unprescribed controlled substance Estimated number of ED visits involving narcotic abuse rose 117% from 1994 to 2002 Drug Abuse Warning Network Report Sarah T. Melton, PharmD,BCPP,CGP 8
  9. 9. VRHA/VFC Annual Conference 2009 Opioids More people died from drug overdoses in Western Virginia in 2006 than from homicides, house fires and alcohol-related automobile accidents combined. The region had 264 fatal drug overdoses in 2006 22 percent increase from 2005 294 percent increase from a decade ago. Methadone (combined with benzodiazepines) most fatal drug Where pain relievers are obtained Opiate Use (1997-2006) Source: Based on data from US Drug Enforcement Administration. Automation of Reports and Consolidated Orders System (ARCOS); Sarah T. Melton, PharmD,BCPP,CGP 9
  10. 10. VRHA/VFC Annual Conference 2009 Opioids : Increased Risk of Abuse Significantly more dramatic, euphoric reaction the first time they use them Tobacco use Criminal record Presence of mood disorder History of emotional, physical, sexual abuse Wilson J. Strategies to stop abuse of prescribed opioid drugs. Ann Int Med 2007;146(12):897-900. Retail Sales of Opioid Medications (grams) Source: Opioid Risk Stratification Tools Screening Instrument for Substance Abuse Potential (SISAP) Opioid Risk Tool The Screener and Opioid Assessment for Patients with Pain (SOAPP) Drug Abuse Screening Test (DAST) The Current Opioid Misuse Measure (COMM) Prescription Opioid Misuse Index Sarah T. Melton, PharmD,BCPP,CGP 10
  11. 11. VRHA/VFC Annual Conference 2009 Stimulants Misuse most frequently involves immediate- release methylphenidate and dextroamphetamine Past year use is more prevalent among person aged 25 years or younger Peak use in mid-1990s, annual prevalence of amphetamine use has fallen in all age categories since that time 2.8% percent of all 12th graders reported they had used Adderall®. Amphetamines rank fourth among 12th graders for past-year illicit drug use. Kroutil LA, Van Brunt DL, Herman-Stahl MA, et al. Nonmedical use of prescription stimulants in the Herman- the United States. Drug and Alcohol Dependence 2006;84: 135-143. 135- Stimulant abuse 545 subjects (89.2% with ADHD) 14.3% abused stimulants 79.8% abused short-acting agents 17.2% abused long-acting agents 2% abused both 1% abused other agents Adderall® 40% Adderall® XR 14.2% Ritalin® 15% Most common method of abuse was crushing pills and snorting (75%) Bright GM. Abuse of medications employed for the treatment of ADHD: results from a large-scale ADHD: large- community survey. Medscape J Med 2008;10(5):111. Benzodiazepines Rarely sole or preferred drug of abuse High doses used to enhance the euphoria effects of opioids; boost methadone or heroin fixes; temper cocaine highs; augment the effects of alcohol; ease the effect of withdrawal from other drugs Sarah T. Melton, PharmD,BCPP,CGP 11
  12. 12. VRHA/VFC Annual Conference 2009 Benzodiazepines Benzodiazepine use, abuse and dependence higher in psychiatric treatment settings/substance-abuse populations Short-acting BZs are preferred Diazepam (lipophilic, crosses BBB quickly) Lorazepam, alprazolam (more potent and reinforcing) Less reinforcing effects Oxazepam, clorazepate, chlordiazepoxide Muscle relaxants Soma® (Carisoprodol) Centrally acting Active metabolite is meprobamate (C IV) Higher doses cause euphoria, impaired hand- eye coordination and balance Tolerance exists Withdrawal syndrome Atypical Drugs of Abuse Seroquel® (quetiapine) Quell, Suzie Q, baby heroin, Q-ball (with cocaine) Abused intranasally Abuse is related to sedating effects Problematic in prisons Neurontin® (gabapentin) Sedating effects with a “high” similar to marijuana Reduces cravings for alcohol Can cause withdrawal Sarah T. Melton, PharmD,BCPP,CGP 12
  13. 13. VRHA/VFC Annual Conference 2009 Antiretroviral agents Norvir® (ritonovir) Booster for other protease inhibitors Unintended effect of heightening effects of illicit drugs Methamphetamine Ecstasy PCP Diazepam Inciardi JA, Surmatt Hl, Kurtz SP, et al. Mechanisms of prescription drug diversion among drug-involved club- and drug- club- street-based populations. Pain Medicine 2007;8(2):171-183. street- 2007;8(2):171- Medications for Erectile Dysfunction Viagra® (Sildenafil) Drug seeking behavior in homosexual and heterosexual men and women Often mixed with recreational drugs Now recognized as a “club drug” Increasingly popular among ecstasy users Prescription Drug Abuse in the Elderly Overall prevalence of prescription abuse is difficult to estimate 11% of older women misuse/abuse (Simona-Wastila, 2006) As baby boom cohort ages, extent of alcohol and medication misuse is predicted to significantly increase Factors associated with drug abuse in older adults Female gender Social isolation History of substance abuse History of mental illness Medical exposure to prescription drugs with abuse potential Culberton JW, Ziska M. Prescription drug misuse/abuse in the elderly. Geriatrics 2008; 53(9): 2008; 22-26, 31. 22- Sarah T. Melton, PharmD,BCPP,CGP 13
  14. 14. VRHA/VFC Annual Conference 2009 OTC Substance Abuse Intentional use of a commercially available substance to experience its psychoactive effects instead of use of that product for its intended purpose. Legal, inexpensive, easily concealed, convenient, uncontrolled availability 1 in 10 American teens has abused OTC medications Antihistamines/sleep aids, caffeine, NRT, DXM Dextromethorphan Dex, DXM, Robo, Skittles, Triple-C, Tussin Semisynthetic morphine derivitive Drug of choice is Coricidin HBP® 30 mg of DXM, comes in tablet form Plateaus of response 8 tablets – euphoria 16 tablets- dissociation Abuse has increased 300% from 2000-2003 in 13-19 year olds Effects begin within 30 minutes after ingestion, and persist 6 hours Dextromethorphan Clinical presentation Mood changes, giggling, euphoria, dissociation, dreamlike experience, warm feelings for others Tachycardia, hypertension, diaphoresis, vomiting, mydriasis, altered tactile sensations, Hallucinations, “zombie,” ataxic gait Withdrawal is manifested by a profound depression Combination with other ingredients Guaifenesin – intense nausea and vomiting Acetaminophen – hepatic injury Chlorpheniramine – classic anticholinergic symptoms Pseudoephedrine – diaphoresis, hypertension Lab testing Useful to identify concomitant ingestion Can ask specifically for testing for DXM Sarah T. Melton, PharmD,BCPP,CGP 14
  15. 15. VRHA/VFC Annual Conference 2009 Antihistamines and Sleep Aids Doxylamine, cyclizine, chlorpheniramine, dimenhydrinate Most ingestions are intentional Used to induce hallucinations and euphoria Tachycardia; warm, dry, flushed skin; dry mucosa; mydriasis; delirium; urinary retention; arrhythmias Dimenhydrinate/diphenhydramine OTC anti-emetic compound of diphenhydramine and 9-chlorotheophylline Acute effects of euphoria and hallucinations Psychiatric patients abuse because of anti-anxiety effects Tachycardia, anticholinergic syndrome, agitation, tremor, hallucinations, convulsions, delirium, coma Withdrawal results in sedation and memory impairment Caffeine Psychoactive methylxanthine alkaloid Widely available in beverages, analgesics, weight loss supplements, stimulants Children are vulnerable to caffeine effects Dependence and withdrawal Intentionally abused in up to 23% of children and teens Doses > 200 mg Anxiety, nervousness, GI upset Sarah T. Melton, PharmD,BCPP,CGP 15
  16. 16. VRHA/VFC Annual Conference 2009 Nicotine Replacement Therapy Up to 5% of adolescents report trying or using nicotine gum or patches 2% of students who have never smoked admit to having tried NRT Lower abuse potential than tobacco containing products Cost Side effects IV epinephrine 19 year-old male who injected 1.1 mg epinephrine Removed the drug from an OTC bronchodilator used for asthma History of IV cocaine and amphetamine abuse Headache, nausea, numbness of hands/feet, chest pain, palpitations Hall AH, Kulid KW, Rumak BH. Intravenous ephinephrine abuse. Am J Emerg Med. 1987 Jan;5(1):64- 65. Jan;5(1):64- Preventing prescription drug abuse/misuse Prescription drug abuse prevention is a is an important part of patient care. Nearly 70 percent of Americans (191 million people) - visit a health care provider, such as a primary care physician, at least once every 2 years. Accurate screening and increases in medication should be careful monitored by physicians as well as the patient receiving the medication. (National Institute on Drug Abuse [NIDA], 2001) Sarah T. Melton, PharmD,BCPP,CGP 16
  17. 17. VRHA/VFC Annual Conference 2009 Assessing Prescription Drug Abuse: Four Simple Questions Have you ever felt the need to Cut down on your use of prescription drugs? Have you ever felt Annoyed by remarks your friends or loved ones made about your use of prescription drugs? Have you ever felt Guilty of remorseful about your use of prescription drugs? Have you Ever used prescription drugs as a way to “get going” or to “calm down?” Adapted from Ewing, JA. “Detecting Alcoholism: The CAGE Questionnaire.” JAMA 252(14):1905-1907, 1884. Questionnaire.” 252(14):1905- Red Flags for Drug-Seeking Behavior More concerned about the drug than the problem Report multiple medication sensitivities Say they cannot take generic drugs Refuse diagnostic workup or consultation Sophisticated knowledge of drugs “You are the only one who can help me” “Lost” prescriptions Patterns of Use Indicating Risk Escalating use of a substance without consultation with a physician Use of a substance for effects independent of a defined medical condition Continued use of a substance despite negative consequences Preoccupation with obtaining the substance Using opioids to relieve anxiety Abnormal results from a urine drug screen Sarah T. Melton, PharmD,BCPP,CGP 17
  18. 18. VRHA/VFC Annual Conference 2009 Patterns of Use Indicating Risk Unauthorized emergency department visits Resisting changes in therapy or use of alternative therapies Having been discharged from another clinician’s practice for noncompliance Prescription forgery Injecting oral formulations Overdose Altering route of administration Common Scams Spilled the bottle… Lost the prescription… It is the only thing that works… Stolen from my home… But you filled it before… Prescription stealing or altering… Washed the prescription in the laundry… “We have met the enemy…” Editorial by Dr. Ron Pawl, published in May 2008 in Surgical Neurology Discusses the dramatic rising prescription rates of opioids for non-disease based pain Emphasizes the lack of evidence supporting use of narcotics to treat psychological-based chronic pain “…part of our medical leadership in pain medicine, some of the practitioners of pain medicine and the pharmaceutical industry all have contributed to the increased use of narcotic medications and unprecedented rise in narcotic drug abuse. We have met the enemy and they are ourselves.” Sarah T. Melton, PharmD,BCPP,CGP 18
  19. 19. VRHA/VFC Annual Conference 2009 4 D’s and Other Physician/Pharmacist Factors Dated Duped Dishonest Disabled “Medication mania” “Hypertrophied enabling” “Confrontation phobia” Strategies to Prevent Prescription Drug Abuse Screen for alcohol and drug abuse before prescribing controlled substances Be knowledgeable about controlled substances Be familiar with anxiety, depression, and pain syndromes Document all prescription drugs in medical record Adopt safe prescribing practices Strategies to Prevent Prescription Drug Abuse Use controlled-substance contracts Learn “antiscam” techniques Just say no Turn the tables Collaboration between pharmacists - prescribers Clarify cross-coverage policies Sarah T. Melton, PharmD,BCPP,CGP 19
  20. 20. VRHA/VFC Annual Conference 2009 Safe Prescribing Practices Use EMR and fax/electronically send prescriptions If handwriting prescriptions, keep blanks in secure location Use watermark paper or prescription pads Choose long-acting opioids and opioids of lesser street value Limit quantity to no more than 30-day supply No refills Use letters and numbers to document quantity and strength Allow only the patient to pick-up prescriptions Office Practice Standards Office-wide controlled substance policy Office visit documentation templates Opioid risk tools Controlled Substance Agreement Monitoring tools Office visits for periodic reassessment Prescription drug monitoring program data Pharmacy records Urine drug screens Pill counts Safe Prescribing Practices Perform a thorough physical examination and document the results Document the questions asked of the patient and his or her responses Request identification and social security number. Photocopy these documents and include them in the patient’s record Confirm a telephone number at which the patient can be contacted During each visit, confirm the patient’s current address Sarah T. Melton, PharmD,BCPP,CGP 20
  21. 21. VRHA/VFC Annual Conference 2009 Safe Prescribing Practices Ensure that there is clear clinical indication for the drug Define the therapeutic end point Do not prescribe controlled substances on the first visit Obtain all medical records and review before prescribing any controlled substance State your refill policy up front Avoid prescribing multiple substances Avoid giving multiple refills without office visits Train staff to respond to suspicious phone calls Safe Prescribing Practices Never telephone prescriptions for an unfamiliar patient; insist the patient make an appointment to be seen. Trust your instincts! Take precautions when you are suspicious. Never prescribe drugs simply to get rid of a drug- seeking patient. Ensure that all prescribing and dispensing of controlled substances are conducted within the scope of practice and part of a valid practitioner- patient relationship. Characteristics of Fraudulent Prescriptions Prescription looks “too good” Quantities, directions or dosages differ from the usual medical usage Appears to be “textbook” prescriptions Prescription appears to be photocopied Directions written in full without abbreviations Prescriptions written in different color inks or in different handwriting Sarah T. Melton, PharmD,BCPP,CGP 21
  22. 22. VRHA/VFC Annual Conference 2009 Types of Fraudulent Prescriptions Legitimate prescription pads stolen from physician office and written for fictitious patients. Alteration of the physician’s prescription. Change call-back number on prescription Computers used to create prescriptions from nonexistent prescribers or to copy legitimate prescriptions. Types of Fraudulent Prescriptions: ? Legitimate Use Prescriber writes significantly more prescriptions (or larger quantities) compared with other prescribers in the area. Patient appears to be returning too frequently. Prescription written for antagonistic drugs (uppers and downers) at the same time. Prescriptions written in the names of other people. A number of people appear simultaneously, or within a short time, all bearing similar prescriptions from the same physician. Prevention Techniques Know the prescriber and his/her signature; Know the prescriber’s DEA registration number; Know the patient, and; Check the date on the prescription order. With any question: CALL THE PRESCRIBER! Request proper identification. Sarah T. Melton, PharmD,BCPP,CGP 22
  23. 23. VRHA/VFC Annual Conference 2009 Prevention Techniques If you believe you have a forged, altered or counterfeit prescription --- don’t dispense it! If you have discovered a pattern of prescription abuses, contact the State Board of Pharmacy or your local DEA office. Disposal of Medications Patients may have hundreds of tablets on hand Take unused, unneeded or expired drugs out of their original containers and throw in trash, but first…. Mix with coffee grounds or kitty litter and put in impermeable cans or bags will ensure the drugs are not diverted Prescription Monitoring Programs (PMPs) Education and Information Public Health Initiatives Intervention and prevention Investigation and law enforcement Protection and confidentiality Mission: To promote the appropriate use of controlled substances for legitimate medical purposes while deterring the misuse, abuse, and diversion of controlled substances. Sarah T. Melton, PharmD,BCPP,CGP 23
  24. 24. VRHA/VFC Annual Conference 2009 Prescription Monitoring Programs Prescription Monitoring Programs Electronic data base of controlled substances dispensed in pharmacies Used to track individual patients Allows healthcare providers to feel more comfortable prescribing and dispensing controlled substances Better able to identify patients at risk for abuse Intervene in problematic cases to minimize risk Katz N, Housel B, Fernandez KC, et al. Update on prescription monitoring in clinical practice: a survey study of prescription monitoring program administrators. Pain Med 2008;9(5): 587-594. NASPER National All Schedules Prescription Electronic (NASPER) Act of 2005 (through Health and Human Services) Provides for establishment of controlled substance monitoring program in each state Communication between state programs Goals Physician/pharmacist access to monitoring programs Monitoring of Schedule II – IV drugs Information sharing across state lines Sarah T. Melton, PharmD,BCPP,CGP 24
  25. 25. VRHA/VFC Annual Conference 2009 Case One: In the Clinic A 46 YO female is seen in clinic for the first time for evaluation of chronic migraine headaches. She states she has just moved to the area and she does not provide any old medical records. While getting her history, you discover she has a long history of generalized anxiety and depression. She reports adverse effects to valproic acid, codeine, propoxyphene, tramadol, and sumitriptan. She states that a neurologist saw her years ago but that “he did not help her at all.” After completing your physical exam, the patient requests prescriptions for a month’s supply of Lortab 10/500 mg tablets QID and diazepam 5 mg TID because “those are the only things that work.” Case One: In the Clinic Discuss red flags that alert you to the possibility of prescription drug abuse. Describe strategies you could employ to prevent prescription drug abuse. Case Two: In the Pharmacy A disheveled appearing man approaches the pharmacy counter ten minutes before closing time and presents a prescription to the technician. He is speaking in a loud voice and demands immediate attention. The prescription is from a physician in a town approximately 45 minutes away. The prescription is written for Vicodin, 1 tab po Q6h prn pain #30 with 4 refills. It is dated one month ago. He tells the technician that he must have the brand name Vicodin and that he does not “do well” with the generic. He states he has no insurance and then he proceeds to pace in front of the pharmacy. Sarah T. Melton, PharmD,BCPP,CGP 25
  26. 26. VRHA/VFC Annual Conference 2009 Case Two: In the Pharmacy What are some red flags that alert you to possible diversion? How would you handle this situation? What are precautions you should use on a regular basis in the pharmacy? Conclusion Statistics show that prescription drug abuse is escalating, especially in Appalachia, with increasing ED visits and unintentional deaths due to prescription controlled substances. Several patient and physician factors increase risk for prescription drug abuse. Recognition of these factors and implementation of prevention strategies can allow physicians to prescribe controlled substances in a safe, effective manner and pharmacists to limit diversion in the pharmacy. QUESTIONS? Sarah T. Melton, PharmD,BCPP,CGP 26