Prescription Drug Epidemic: Pills, Addictions, Deaths. What To Do About it

The Prescription Drug Epidemic:
Pills, Addictions, Deaths.
What To Do About it?

Michael M. Miller, MD, FASAM, FAPA

33rd Annual Behavioral Health &
Addictive Disorders Conference
U.S. Journal Training, Inc.
February 14, 2012

mmiller@rogershospital.org

Medical Director, Herrington Recovery Center (HRC)
Rogers Memorial Hospital
Oconomowoc, Wisconsin

Associate Clinical Professor
University of Wisconsin School of Medicine and Public Health
Associate Clinical Professor
Medical College of Wisconsin, Dept of Psychiatry & Behavioral Health
Past President and Board Chair
Wisconsin and American Societies of Addiction Medicine
At-Large Director
American Board of Addiction Medicine

Rogers treats children, adolescents
and adults with:
• Anxiety disorders
• Mood disorders
• Eating disorders
• Substance-use disorders

800-767-4411
rogershospital.org

Psychiatry (MD, DO)

(General, Adult, Child/Adolescent, Geriatric, Forensic, Addictio
n)

A medical specialty of physicians devoted to the diagnosis
and treatment of mental disorders, using
psychotherapy, medications, and other somatic therapies

Clinical Psychology (PhD, PsyD)

A mental health discipline in which individuals with a doctoral
degree in psychology from an accredited professional school
of psychology (the scientific study of the behavior of
individuals and their mental processes) evaluate and treat
children, adolescents, and adults using clinical
interviews, psychological testing, and various
individual, group, couples and family therapies.

Addiction Medicine:

The specialty of medicine devoted to
diagnosis, treatment, prevention, education, epidemiology, res
earch, and public policy advocacy regarding addiction and
other substance-related health conditions

How to Identify a Physician Recognized for
Expertise in the Diagnosis and Treatment of
Addiction and Substance-related Health
Conditions (ASAM Public Policy Statement)
www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

www.asam.org/HowToIdentifyaPhysicianRecognized
forExpertness.html

• Completion of a residency/fellowship in Addiction
Medicine or Addiction Psychiatry
• Certification in Addiction Medicine by the American Society
of Addiction Medicine (ASAM)
• Subspecialty certification in Addiction Psychiatry by the
American Board of Psychiatry and Neurology (ABPN)
• A Certificate of Added Qualification in Addiction Medicine
conferred by the American Osteopathic Association (AOA)
• Board Certification in Addiction Medicine by the
American Board of Addiction Medicine (ABAM)

Scope of Practice for Addiction Medicine
Physicians (ABAM)
The addiction medicine physician provides medical care within
the bio-psycho-social framework for persons with addiction,
for the individual with substance-related health conditions,
for persons who manifest unhealthy substance use, and for
family members whose health and functioning are affected by
someone‘s substance use or addiction.

Scope of Practice for Addiction Medicine
Physicians (ABAM)
The addiction medicine physician is specifically trained in a
wide range of prevention, evaluation and treatment modalities
addressing substance use and addiction in ambulatory care
settings, acute care and long-term care facilities, psychiatric
settings, and residential facilities.

Addiction medicine specialists often offer treatment for
patients with addiction or unhealthy substance use who have
co-occurring general medical and psychiatric conditions.

Prelude

• Pain and addiction are both commonly experienced
conditions.
• General medical physicians, e.g. those in primary care or in
emergency department settings, are called upon to treat
patients with pain complaints and/or with substance use
disorders—but they have had inadequate training in
medical school and residency to address these
presentations.

Prelude

• There was great concern in the 1990s that physicians were
overly/unnecessarily hesitant to prescribe opioid
analgesics, even to patients with cancer, even to patients
who were terminal.
• A response was a public policy initiative to work with
professional societies, licensure boards, and accreditation
agencies to promote ‗balance‘ in opioid prescribing.

Prelude

• A result was a major increase in recognition of pain as a
focus of clinical care, but also a major increase in the
number of opioid prescriptions written
• Pain Medicine has expanded as a medical specialty, but
specialists/subspecialists are unable to meet the demand
for care—thus, patients on chronic opioid analgesic therapy
present to emergency departments and 1° care, presenting
new kinds of challenges

Prelude

• There has also been an increase in recognition of
substance use issues as a focus of clinical care
• Addiction Medicine has expanded as a medical
specialty, but specialists/subspecialists are unable to meet
the demand for care; there has been a push to train
generalists to become prescribers of buprenorphine and
naltrexone, and patients methadone, Suboxone®
(buprenorphine) and Vivitrol® (naltrexone) present to
emergency departments and primary care—presenting new
kinds of challenges

Prelude

• Physicians who specialize in the treatment of pain and
those who specialize in the treatment of addiction have
been struck with how under-recognized these conditions
have been in general medical settings – in response, there
have been efforts to improve the recognition of these
treatable states, so that suffering can be minimized and
functioning enhanced, for individuals and for populations.

Inadequacy of docs to evaluate/
manage pain

• Too few specialists in Pain Med
• Inadequate training on basic concepts of management
• Many patients
• Docs flooded with ‗demand‘ and ‗entitlement mentality‘

Inadequacy of docs to evaluate/
manage addiction

• Too few specialists in Addiction Med
• Inadequate training on basic concepts of management
• Many patients – most unrecognized
• Docs flooded with ‗med-seeking patients‘ and patients with
‗dysfunctional behaviors‘
• Docs, like the public, often don‘t distinguish between
addiction and ‗unauthorized substance use‘

Under-responding to pain…

• Comprehensive Cancer Center, UW-Madison
• Pain Policy Project – UW-Madison
• Survey of cancer patients, domestically and internationally
• Survey of State Medical Board practice
• Attention to ―opioiphobia‖ on the part of docs
• Education to docs re: pain and pain meds
• Policy changes at FSMB and JCAHO – a call for ―balance‖

Joint Commission Standard PC.01.02.07 ―The hospital
assesses and manages the patient's pain‖

Rationale for the Standard:
• Patients can expect that their health care providers will ask
them about whether they have pain. When pain is identified
the individual is assessed based on his or her clinical
presentation and in accordance with the
care, treatment, and services provided by the organization.

Joint Commission Pain Standard

Evidence of Performance:
1 The hospital conducts a comprehensive pain assessment that is
consistent with its scope of care, treatment, and services and the
patient‘s condition. (See also PC.01.02.01, EP 2; RI.01.01.01, EP 8)
2 The hospital uses methods to assess pain that are consistent with the
patient‘s age, condition, and ability to understand.
3 The hospital reassesses and responds to the patient‘s pain, based on
its reassessment criteria.
4 The hospital either treats the patient‘s pain or refers the patient for
treatment.

There have been efforts
to improve the case-finding
by docs of cases of pain

The Joint Commission Standard
―Pain as the 5th vital sign‖

PAIN ASSESSMENT: THE FIFTH VITAL SIGN
California Assembly Bill 791 was signed into law by Governor Gray
Davis, to be effective January 1, 2000.

Section 1254.7 was added to the Health and Safety Code (HSC) as part
of this bill. HSC 1254.7 reads:
(a) It is the intent of the Legislature that pain be assessed and treated
promptly, effectively, and for as long as pain persists.
(b) Every health facility licensed pursuant to this chapter shall, as a
condition of licensure, include pain as an item to be assessed at the
same time as vital signs are taken. The health facility shall insure that
pain assessment is performed in a consistent manner that is
appropriate to the patient.
The pain assessment shall be noted in the patient‟s chart in a manner
consistent with other vital signs.

PAIN ASSESSMENT: THE FIFTH VITAL SIGN
California Assembly Bill 791 was signed into law by Governor Gray
Davis, to be effective January 1, 2000.

This legislative mandate is consistent with state and federal concerns regarding
appropriate pain management for all persons. The Veterans Administration has
adopted similar policies, referring to pain as the fifth vital sign.

In 1994, the BRN adopted a pain management policy for RN practice and pain
management curriculum guidelines for nursing programs. Both of these
documents include a standard of care for California RNs of assessing pain and
evaluating response to pain management interventions using a standard pain
management scale based on patient self-report. Nursing programs need to
integrate pain as the fifth vital sign into their curriculum and health facilities
need to educate staff regarding pain management. It is now required that all
health care staff record pain assessment each time that vital signs are recorded
for each patient.

Measuring Pain as the 5th Vital Sign Does
Not Improve Quality of Pain Management

• Mularski RA, White-Chu F,Overbay D, Miller, L, Asch
SM, Ganzini L.
• Journal of General Internal Medicine 21(6): 607–612.
(2006)

Over-responding to pain…

• Joint Commission standard: a ―right‖ to pain mgmt?
• Proliferation of interventional pain clinics
• Proliferation of opioid prescribing and ―pill mills‖
• Under-attention to non-interventional approaches, non-
opioid pharmacotherapy, non-pharmacological therapy
• Expanding incidence of
diversion, misuse, overdose, mortality, and cases of
addiction

How did we get here?

• More prescribers
– Explosion of prescribing by primary care
• More milligrams
– Availability of new drug formulations: MS
Contin, OxyContin, fentanyl in patch form
• More patients
– Aging population: more aches/pains
– Successful expansion of markets by direct-to-consumer
advertising

Increasing Use of Prescribed Opioids

Manchikanti & Singh 2008
Slide thanks to Marv Seppala, MD, Hazelden Foundation

Retail Sales of Opioid Medications
(grams of medication 1997-2005)

1997 2005 % of Change
Methadone 518,737 5,362,815 933%
Oxycodone 4,449,562 30,628,973 588%
Fentanyl Base 74,086 387,928 423%
Hydromorphone 241,078 781,287 244%
Hydrocodone 8,669,311 25,803,544 198%
Morphine 5,922,872 15,054,846 154%
Meperidine 5,765,954 4,272,520 -26%
Codeine 25,071,410 18,960,038 -24%

http:www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html
Table thanks to Marv Seppala, MD, Hazelden Foundation

Annual Numbers of New Nonmedical Users of
Psychotherapeutics: 1965-2000

2001 National Household Survey on Drug Abuse
http://www.oas.samhsa.gov/NHSDA/2k1NHSDA/vol1/toc.htm#v1

Thanks to Marv Seppala, MD, Hazelden Foundation

Scope of the Problem
• Between 1992 and 2003:
– U.S. population increase of 14%
– No. people abusing controlled prescription drugs jumped 81%
2x > than marijuana 5x > than cocaine 60x > than heroin
• Prescription pain medications (Opioids) are now the 4th most abused
substances in the U.S.
– Behind marijuana, alcohol, and tobacco
• Misuse of painkillers represents 3/4 of the overall problem of
prescription drug abuse
• Prescription medications are now the leading cause of accidental
death for ages 18-34
Drug Enforcement Administration www.justice.gov/dea

Thanks to Marv Seppala, MD, Hazelden Foundation

Persons Admitted for Addiction Treatment are
More Often Having Diagnoses of Opioid Use Disorder

• The proportion of all SUD treatment admissions where
opioid analgesic abuse or dependence is
mentioned, increased more than four-fold between 1998
and 2008.
• The proportion of SUD treatment admissions for persons
ages 12-24 where opioid analgesic abuse or dependence is
mentioned, increased more than eight-fold between 1998
and 2008.

Emergency Department Visits

DAWN Data 1995 - 2005

Treatment Admissions for Pain Medications

• The proportion of all substance abuse treatment
admissions (that reported any pain medication abuse)
increased more than four-fold between 1998 and 2008.
• The increase in those age 12-24 increased approximately
eight-fold.

―Non-Medical Use‖ of Prescription Opioids
• Where are these medications coming from?
How many patients who had an overdose ever had a legitimate
prescription for the medication they overdosed on?
• What do persons report is the source of the prescription opioids
that they‘re using?
– Their own doctor?
– A family member who got it from their own doctor?
– A friend who got it from their own doctor?
– A dealer?
– Multiple sources?

The ―One Doctor‖ Source for
Prescription Drugs
• According to NSDUH 2008 data, only 1 in 20 nonmedical
users (4.3%) of prescription pain relievers got them from a
drug dealer.
• In most cases, prescription drugs obtained for nonmedical
purposes originated from a single doctor – rather than from
multiple sources (the Rx could have been written for
them, or could have been obtained from a different
―legitimate patient‖ of a single prescriber who authorized it
in the course of routine medical/dental practice)

JAMA Article April 2011 plus editorial by
Volkow and McLellan
From 1991 to 2009, prescriptions for opioid analgesics
increased almost threefold, to over 200 million. According to
the Drug Abuse Warning Network system, which monitors
drug-related emergency department visits and drug-related
deaths, emergency room visits related to the nonmedical use
of pharmaceutical opioids has doubled between 2005 and
2009.

Volkow and McLellan
• The sample included 79.5 million prescriptions dispensed in
the United States during 2009, which represent almost 40
percent of all the opioid prescriptions filled nationwide.
• Most abusers report getting these medications from friends
and relatives who had been prescribed opioids, or they are
abusing their own medications.
• The records show that approximately 56 percent of
painkiller prescriptions were given to patients who had filled
another prescription for pain from the same or different
providers within the past month.

Volkow and McLellan
• Nearly 46 percent of opioid prescriptions were given to
patients between ages 40 and 59, and most of those
were from primary care providers.
• Nearly 12 percent of opioids prescribed were to young
people aged 10-29. Dentists were the main prescribers
for youth aged 10-19 years old.

It‘s not just diversion and misuse
It‘s O.D.s and Overdose Deaths

Accidental Deaths Due to Prescribed Opioids

• Between 1999 and 2002:
– The number of opioid analgesic poisonings on death
certificates increased 91.2%
– Heroin poisonings increased 12.4%
– Cocaine poisonings increased 22.8%
• 2007: The second leading cause of injury/death (after motor vehicle
accidents)
• 2009: The number of deaths secondary to prescription drugs was 4
times the number due to illicit drugs.

Machikanti 2007 MMWR 7/8/11
Slide thanks to Marv Seppala, MD, Hazelden Foundation

Opioid Deaths are #1 Rx Drug Deaths
Prescription Opioid O.D. Deaths Outpace Heroin Deaths

The CDC used death certificates to determine that there were 45,000
traffic accident deaths in 2006 and about 39,000 drug-induced deaths—
pooled US data

Responding to the epidemic
• Return to restrictive prescribing practices and opiophobia
• Training of prescribers re: reasonable limits on numbers of
doses/refills authorized
• Recognition of data on efficacy: what really is ‗best
practice‘?
• Making medication formulations more safe
• Practices to better manage supplies in the community
– Lock Your Meds, Take Back your meds, safe disposal of
medication supplies


The White House Office of National
Drug Control Policy (ONDCP)

―EPIDEMIC: RESPONDING TO AMERICA‘S PRESCRIPTION
DRUG ABUSE CRISIS‖

http://whitehousedrugpolicy.gov/publications/pdf/rx_abuse_plan.pdf

ONDCP Strategy on PDA

• Education: patients, parents, youth, and health care
professionals
• Monitoring: Prescription Drug Monitoring Programs
(PDMPs), multi-state data-sharing
• Rx Disposal
• Enforcement

• Controlled Substances Workgroup (CSW), Prevention
Committee, Wisconsin State Council on Alcohol and Other Drug
Abuse (SCAODA)
• California
http://www.adp.ca.gov/Director/pdf/Prescription_Drug_Task_Force.pdf
• Ohio
http://www.odh.ohio.gov/features/odhfeatures/drugod/drugoverdose.aspx
• Maryland
http://www.oag.state.md.us/Reports/PrescriptionDrugAbuse.pdf
• Washington State
• Medical Society of Georgia Foundation

ONDCP Strategy on PDA:
Health Provider Education
• Work with Congress to amend Federal law to require practitioners
(such as physicians, dentists, and others authorized to prescribe)
who request DEA registration to prescribe controlled substances to
be trained on responsible opioid prescribing practices as a
precondition of registration. This training would include assessing
and addressing signs of abuse and/or dependence.
(ONDCP/FDA/DEA/SAMHSA)

• Require drug manufacturers, through the Opioid Risk Evaluation and
Mitigation Strategy (REMS), to develop effective educational
materials and initiatives to train practitioners on the appropriate use
of opioid pain relievers. (FDA/ONDCP/SAMHSA)

Health Provider Education
• Federal agencies that support their own healthcare systems will
increase continuing education for their practitioners and other
healthcare providers on proper prescribing and disposal of
prescription drugs. (VA/HHS/IHS/DOD/BOP)

• Work with appropriate medical and healthcare boards to
encourage them to require education curricula in health
professional schools (medical, nursing, pharmacy, and dental)
and continuing education programs to include instruction on the
safe and appropriate use of opioids to treat pain while
minimizing the risk of addiction and substance abuse

Prescription Drug Monitoring Programs
(PDMP)
• The National All Schedules Prescription Electronic Reporting
(NASPER) Act, was signed into law on August 11, 2005
– Authorized $60 million to establish or improve state-run
Prescription Drug Monitoring Programs (PDMP) which analyze
prescription data
– The Department of Justice and SAMHSA continue to fund grants
• PDMP can identify individuals, physicians, or pharmacies that have
unusual patterns suggesting drug diversion, abuse, or doctor
shopping

Prescription Drug Monitoring Programs
(PDMPs)

• The National All Schedules Prescription Electronic Reporting
(NASPER) Act, was signed into law on August 11, 2005
– Authorized $60 million to establish or improve state-run
Prescription Drug Monitoring Programs (PDMP) which analyze
prescription data
– The Department of Justice and SAMHSA continue to fund grants
• PDMP can identify individuals, physicians, or pharmacies that have
unusual patterns suggesting drug diversion, abuse, or doctor
shopping

PDMPs
1. What is a prescription drug monitoring program (PDMP)?
According to the National Alliance for Model State Drug Laws
(NAMSDL), a PDMP is a statewide electronic database which collects
designated data on substances dispensed in the state. The PDMP is
housed by a specified statewide regulatory, administrative or law
enforcement agency. The housing agency distributes data from the
database to individuals who are authorized under state law to receive the
information for purposes of their profession.

2. Does the Drug Enforcement Administration (DEA) oversee PDMPs?
The DEA is not involved with the administration of any state PDMP.

Q&A on webpage of DEA‘s Office of Diversion Control
http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm

PDMPs
3. What are the benefits of having a PDMP?
The overview provided by NAMSDL clearly identifies the benefits of a
PDMP: as a tool used by states to address prescription drug
abuse, addiction and diversion, it may serve several purposes such as:
– support access to legitimate medical use of controlled substances,
– identify and deter or prevent drug abuse and diversion,
– facilitate and encourage the identification, intervention with and
treatment of persons addicted to prescription drugs,
– inform public health initiatives through outlining of use and abuse
trends, and
– educate individuals about PDMPs and the use, abuse and diversion of
and addiction to prescription drugs.

PDMPs
4. Which states currently have a PDMP?
According to the Alliance of States with Prescription Monitoring
Programs, (www.pmpalliance.org) as of October 16, 2011, 37 states have
operational PDMPs that have the capacity to receive and distribute
controlled substance prescription information to authorized users. Eleven
states) and one U.S. territory (Guam), have enacted legislation to establish
a PDMP, but are not fully operational.

PDMPs

• In 1992 only 10 states had a PDMP
– In 1998, California created its Controlled Substance Utilization
Review and Evaluation System (CURES). 7500 pharmacies and
158,000 prescribers report information and can review patient
medications.
• Now 43 states have operational PDMPs in place
• Only 3 states – Kentucky, Nevada & Utah – routinely
provide their information proactively to physicians
• Rarely is data from Methadone Clinics (Opioid Treatment
Programs, OTPs) included in a state‘s PDMP database!

Proper Drug Disposal
• While the administrative process to establish the DEA medication disposal
rule is underway,19 DEA and other Federal agencies shall conduct
additional take-back activities. Information about the take-back events shall
be distributed to local anti-drug coalitions and other organizations (chain
pharmacies, boards of pharmacies, boards of medicine, environmental
agencies, etc). (DEA/ONDCP)
• Once DEA regulations on controlled substance prescription drug disposal
have been established, develop and execute a robust public education
initiative to increase public awareness and provide education on new
methods of safe and effective drug return and disposal. (ONDCP/
EPA/DEA/FDA/CDC/HHS/SAMHSA/NIDA)
• Once DEA regulations have been established, engage PhRMA and others
in the private sector to support community-based medication disposal
programs. (ONDCP/FDA/DEA/HHS/CDC/ SAMHSA/EPA)

Public Eduation

Partnership for a Drug Free America
www.drugfree.org

Preventing Teen Abuse of Prescription Drugs
• FACT SHEET

Wisconsin State Council on AODA

SCAODA Prevention Committee
Controlled Substances Workgroup (CSW)
http://scaoda.state.wi.us/docs/prevandspfsig/FINAL01032012
CSWReport.pdf

Responding to the epidemic: Wisconsin State Council
Controlled Substances Workgroup Recommendations

Priority Area: Fostering Healthy Youth
• Recommendation 1: Support communities to foster healthy
youth.

Priority Area: Community Engagement & Education
• Recommendation 2: Launch a public outreach and education
campaign.
• Recommendation 3: Support community coalitions as the vehicle
through which communities will successfully prevent and reduce
prescription drug diversion, abuse and overdose deaths.


Priority Area: Health Care Policy and Practice
• Recommendation 4: Mandate education and training health care
professionals.
• Recommendation 5: Ensure that chronic pain sufferers have safe and
consistent access to care.
• Recommendation 6: Establish standard prescribing practices for urgent
care and emergency departments.
• Recommendation 7: Develop standard screening methodologies for
drug-testing labs to use in detecting the presence of drugs to include all
commonly misused opioids, benzodiazepines, psychostimulants, and
related agents, and assure that drug-testing methodologies used in
clinical settings and in post-mortem settings (including the State Crime
Lab system) are aligned in order to generate the most consistent and
useful data.


Priority Area: Health Care Policy and Practice
• Recommendation 8: Develop a standard set of treatment protocols
for Opioid Treatment Programs (OTPs).
• Recommendation 9: Establish guidelines to reduce the diversion of
prescription drugs by those who handle prescription medications in
the course of their daily work.
• Recommendation 10: Equip health care providers and first
responders to recognize and manage overdoses.
• Recommendation 11: The Wisconsin Dental Association and
Wisconsin Dental Examining Board should endorse the findings of
the Tufts Health Care Institute Program on Opioid Risk Management
and the School of Dental Medicine, Tufts University.


Priority Area: Prescription Medication Distribution
• Recommendation 12: Convene a work group to develop
recommendations to increase security measures in the dispensing of
prescriptions for controlled substances.
• Recommendation 13: Implement a system to ensure that, for
controlled substance prescriptions, patients are identified in a
manner similar to photo identification as required to obtain
pseudoephedrine.
• Recommendation 14: Support a system that increases security and
traceability of controlled substances from manufacturer to patient.


Priority Area: Prescription Medication Disposal
• Recommendation 15: Establish a coordinated statewide system for
providing secure, convenient disposal of consumer medications from
households.
• Recommendation 16: Integrate medication collection with the
Wisconsin Drug Repository.
• Recommendation 17: Create an infrastructure for the destruction of
drugs in compliance with state and federal environmental regulations.
• Recommendation 18: Identify the causes for prescription drug waste
and implement proactive solutions.


• Recommendation 19: Identify a sustainable means for funding
collection and disposal in cooperation with key stakeholders including
pharmaceutical producers, local governments, law enforcement,
waste management companies, health care providers, pharmacies
and consumers.
• Recommendation 20: Establish a system for effective disposal of
consumer medications in all care programs and facilities which
complies with state and federal waste management laws.


• Recommendation 21: Establish regulations that would permit
registered nurses employed by home health agencies and
hospices to transport unused medications, including controlled
substances, to designated drug drop-off and disposal facilities, so
that when patient medications are no longer needed, such nurses
are allowed by law to assist in their safe destruction.


Priority Area: Law Enforcement and Criminal Justice
• Recommendation 22: Build bridges between law enforcement and
community-based prevention efforts.
• Recommendation 23: Make drugged driving a priority issue.
• Recommendation 24: Support drug courts.


Priority Area: Surveillance System
• Recommendation 25: Design and implement an electronic
Prescription Drug Monitoring Program (PDMP).
• Recommendation 26: Develop a community early warning and
monitoring system that tracks use and problem indicators at the local
level.
• Recommendation 27: Develop a community monitoring and early
warning and monitoring system that tracks overdoses at the local
level.
• Recommendation 28: Improve consistency in reporting drug use and
abuse across the state.


Priority Area: Early Intervention, Treatment & Recovery
Across Lifespan
• Recommendation 29: Establish guidelines to screen for
substance use in all health care settings.
• Recommendation 30: Promote and support evidence-based
screening and early intervention for mental health and substance
abuse.


Priority Area: Early Intervention, Treatment & Recovery
Across Lifespan
• Recommendation 31: Integrate high quality medication
management and psychosocial interventions for substance use
disorders so that both are available to consumers as their
conditions indicate.
• Recommendation 32: Make addiction treatment and recovery
support services available both on a stand-alone and integrated
basis with primary health care services, as well as in other
relevant community settings.


• Community Coalitions (CADCA, others)
• Education of Patients by Prescribers
• Education of Prescribers re: best practices
• Better Data
– Mortality statistics
– Accurate death certificates
– Accurate toxicology at time of death; aligning drug testing
procedures for the living and the dead


• Better disposal of unused supplies
– If they‘re there, keep ‗em locked
– If they‘re not needed, bring them to safe collection site
– Change laws/procedures to allow for well-recognized legal
collection sites

What about ―going upstream‖ from
treatment, to PREVENTION?

• Reducing availability of prescription drugs for diversion
(and misuse, and overdose)?
• By educating physicians and dentists to prescribe less
often, to authorize smaller supplies, to have fewer
refills, and to monitor all patients on such medications?
• By educating parents as to their role in keeping drug
supplies locked away and safe?

Prevention Strategies: “Lock Up Your Meds”
• ―You are the Key‖
• National Family Partnership: www.nfp.org

The responsible parties are:
• PARENTS and GRANDPARENTS
• PHYSICIANS who can educate parents about their role

www.nfp.org
• Affiliates Alert
• TVAds
• Radio Ads
• Multimadia Slide Show
• Communication Gap
• MEDucation Kit
• Logos
• Leave Behind Card
• Sponsor solicitation slides
• Parent Guide Brochure

http://mccrearyrecord.com/x316477008/
Are-you-an-Accidental-Dealer
Are you an ‗Accidental Dealer‘?
• Operation UNITE launches prescription awareness
campaign
• By JANIE SLAVEN News Editor The McCreary County Record
Tuesday January 25, 2011, 01:05 PM EST
• WHITLEY CITY — A University of Kentucky study has shown
rural teenagers in Kentucky are 26 percent more likely to abuse
prescription drugs than those living in urban areas.

The CDC is Paying Attention
Data from the National Vital Statistics System Mortality File:
• From 1999 through 2006, the number of fatal poisonings
involving opioid analgesics more than tripled from 4,000 to
13,800 deaths.
• Opioid analgesics were involved in almost 40% of all poisoning
deaths in 2006. .
• In about one-half of the deaths involving opioid
analgesics, more than one type of drug was specified as
contributing to the death, with benzodiazepines specified with
opioid analgesics most frequently.
• In 15 states, opioid deaths exceed highway traffic deaths

New Policy Initiative: Washington State
• Interagency Guideline on Opioid Dosing for Chronic Non-
Cancer Pain
• The Washington State Medical Quality Assurance
Commission (MQAC)
• http://www.wsma.org/medical_professionalism/clinicalresou
rces.cfm#painPain_Management_Guidelines
• Effective 7.1.11 for DOs, DPMs, DDSs, nurses and
osteopathic PAs
• Effective 1.2.12 for MDs and their PAs

―Washington State Guidelines‖
• Requirements re: patient evaluation and periodic review
• Requirements re: signed informed consent, written
treatment plans, and written ―treatment agreements‖
• Mandatory consultation for any patient that is receiving >
120 mg morphine equivalent dose (MED), with certain
exemptions

Equivalent Dose (mg) Chart
Doses equal to Dose (mg) per 24 hr
Morph 10mg IM IV/IM PO/PR

Codeine 130 200
Fentanyl 0.1 N/A
Fentanyl Patch* (mcg/hr*) = *16.7
Hydrocodone N/A 30
Hydromorphone 1.5 7.5
Levophanol 2 4
Meperidine 75 300
Methadone 10 20
Morphine 10 20
Nalbuphine 10 N/A
Oxycodone N/A 30
Pentazocine 60 180
Propoxyphene N/A 130
Sufentanil 0.01-0.02 N/A
Tramadol N/A (?) 150

Summary: the POLICY side

• States and their Medical Licensing Boards are involved, as
well as the FSMB
• The CDC is involved
• The federal treatment agencies are involved
(SAMHSA/CSAT)
• The federal research agencies are involved (NIDA)
• The federal policy agencies are involved
(the White House ―Drug Czar‘s Office‖)

CDC

http://www.cdc.gov/media/pressrel/2010/s100603.htm?s_cid=media
rel_s100603
• CDC Statement Regarding the Misuse of Prescription Drugs
(Press Release, June 3, 2010)
• November 2011
http://www.cdc.gov/vitalsigns/PainkillerOverdoses/
Prescription Painkiller Overdoses in the US

CDC Vital Signs, November 2011
Related Pages
• Vital Signs: Overdoses of Prescription Opioid Pain Relievers–United States, 1999–
2008 (link to come): Morbidity and Mortality Weekly Report (MMWR)
• CDC Feature- Prescription Painkiller Overdoses in the U.S.
• Prescription Painkiller Overdoses in the U.S. – What You Need to Know
[PODCAST - 1:15 minutes]
• Sobredosis de medicamentos recetados para el dolor en los EE. UU.: Lo que usted
necesita saber [PODCAST - 1:39 minutes]
• Prescription Painkiller Overdoses in the U.S. – What You Need to Know [PSA - 0:60
seconds]
• Policy Impact: Prescription Painkiller Overdoses
• Unintentional Poisoning
• Home and Recreational Safety

CDC Vital Signs, November 2011
Related Pages: On Other Web Sites
• The White House - Office of National Drug Control Policy
• SAMSHA – Substance Abuse and Mental Health Services
Administration
• Drug Enforcement Administration – Office of Diversion Control
• National Institute on Drug Abuse – Prescription Medications
• U.S. Food and Drug Administration - Drugs Information
• MedlinePlus - Pain Relievers
• MedlinePlus - Prescription Drug Abuse

The Interface of Policy and Practice
• If not enough pain is recognized, and not enough pain is
treated, is that an ―imbalance‖?
• If regulators/criminal justice are trying to control supplies
and penalize physicians, is that ―imbalance‖?
• If not enough addiction is recognized, if he addictive
potential of prescription drugs is under-appreciated, is that
―imbalance‖?

What can we do in the meantime?
• There are patients with pain
• There are patients who engage in ―non-medical use‖ of
pain meds
• There are patients who develop addiction

What can happen in the clinical world to restore balance …
and so that we won‟t have “more pain patients” becoming
translated into “more addiction patients” and “more coroners‟
cases”?

So, what would ―real balance‖
in clinical care look like?

• Clear understanding of pain
• Clear understanding of addiction and the range of substance
use conditions
• Balance in prescribing practices--no one is
stigmatized, excluded, under-treated
• Improved pharmacotherapy of pain and pharmacotherapy of
addiction


• Clear understanding of addiction and the range us
substance use conditions
• Balance in prescribing practices
• Improved pharmacotherapy of pain and pharmacotherapy
of addiction

Pain: Clinical Definition

―Whatever the patient states it is unless proven
otherwise by poor adherence to the agreed
upon medical regimen.‖

– Fishman, et al, Journal of Pain and Symptom
Management, Vol. 20 (2000)

Acute Pain vs. Chronic Pain
• Acute Pain
– Sudden onset, usually sharp in quality
– Serves as a warning of disease or a threat to the body
– Multiple causes: Broken bones, cuts, burns, surgery, infection…
• Chronic Pain
– Persists, lasting longer than 3-6 months
– Serves no useful purpose; may continue after healing of an injury
– Assumes control of the individual

(Slide thanks to Marv Seppala, MD, Hazelden Foundation)

Chronic Pain Syndrome

• Intractable pain of more than 6 months duration
• Marked alteration in behavior, restriction in daily activities
• Excessive use of medication and medical services
• No clear relationship to organic disorder - multiple
nonproductive tests/treatments/surgeries

Office of Disabilities, Social Security Administration

Chronic Pain by the Numbers

• 116 million people in the U.S. suffer from chronic pain
• Low back pain is the most common type, affecting 28% of
the population
• Knee pain is second at 20% of the population

IOM Report
Relieving Pain in America

Characteristics of Patients
Referred to Pain Management
(or is this a list of characteristics of patients referred for
Addiction Management?)
• Report high level of psychological distress
• Display high levels of psychopathology
• Report high levels of functional impairment
• Have work / M.V.A. related injuries
• Frequent use of health care system
• Complain of constant pain
• Have had prior surgery (ies) for pain
• Are using narcotic medications

Chronic Pain Syndrome:
Common Presentation
• Mood disturbance
(irritable, depressed, anxious, angry)
• Sleep disturbance
• Physical deconditioning
• Work, vocational, financial, legal issues
• Weight changes
• Psychiatric illness
• Alcohol or other drug misuse/addiction
Slide: courtesy of Marv Seppala, MD, Hazelden Foundation

Pain Complaints

• The pain is an appropriate/legitimate response to
injury/illness/pathophysiology.
• The complaint has a legitimate/organic bases but is an
amplification of appropriate/legitimate distress.
• The complaint represents a psychiatric disorder rather than
somatic injury/illness
• The complaint is a manifestation of an addictive disorder.

Psychiatric States in which Pain Complaints
can be Manifest
• Major depression with somatization
• Major depression with psychosis
• Conversion disorder
• Psychogenic pain disorder
• Somatization disorder
• Anxiety disorder
• Borderline personality, histrionic personality, narcissistic
personality, antisocial personality
• Munchausen‘s syndrome (factitious disorder)

Manifestation of an addictive disorder
• Addiction—out-of-control use; deterioration of functioning
over time; continued substance use despite adverse
consequences; the substance becomes the central
reinforcer in the person‘s life; use in order to experience
euphoria or too feel ―normal‖
• Often diagnosed longitudinally in the pain patient (the more
meds you give, the worse the patient looks and gets, cf.
pain disorder where the more meds you give, the better the
patient functions (ideally)
• Withdrawal—often seen in addiction, but sometimes
present without addiction; ‗normal‘ physiological process

Is it Addiction or Pseudoaddiction?

• Pseudoaddiction: a syndrome of maladaptive behavior
indicating not true addiction, but at attempt on the part of
the patient to obtain relief of under-treated pain
• Preoccupation, seeking supplies, phone calls between
refills, ER visits, and even doctor-shopping and securing
illicit supplies, can indicate pseudoaddiction

Is it Addiction or Pseudoaddiction?

• Addiction: taking more meds leads to decrease in
function
• Pseudoaddiction: taking adequate dose of opioids
improves function and ends pattern of maladaptive
behaviors

REMEMBER: it’s not the medication that’s pathological;
opioids are not intrinsically evil!

Addiction vs. Pseudoaddiction

• Addiction is diagnosed prospectively: Aberrant behavior
worsens despite the best attempts at a rational treatment
plan by the physician

• Pseudoaddiction is diagnosed retrospectively: Aberrant
behavior normalizes with a rational treatment plan.

Pathological Pattern of Use =
Misuse, Non-Medical Use
• Stealing scripts, forging scripts, altering scripts, calling in
scripts
• Using via alternate route of administration
• Using for an indication other than the intended, e.g., for
relief of depression/ anxiety/insomnia/‘stress‘ vs. pain
• Amplifying or fabricating symptoms in order to obtain
additional supplies

Medication Seeking

• Conscious manipulation of healthcare professional
– For others
– For sale
– For self - cases of opioid addiction
• Seeking supplies for ―relief use‖
― Treatment of anxiety
― Treatment of depression
― Treatment of withdrawal

Medication Seeking

• Seeking supplies for treatment of general medical condition
not actually present
– Somatization disorder
– Psychogenic pain disorder
• Pseudo addiction – seeking medication because of under
treatment of legitimate injury/illness

Aberrant Drug-Related Behaviors
More Predictive Less Predictive
• Selling Prescription Drugs • Aggressive complaining about the
• Prescription forgery need for higher doses
• Stealing or ―borrowing‖ drugs from • Drug hoarding during periods of
another patient reduced symptoms
• Injecting oral formulations • Requesting specific drugs
• Obtaining prescription drugs from non- • Prescriptions from other physicians
medical sources • Unsanctioned dose escalation
• Concurrent abuse of related illicit drugs • Unapproved use of a drug
• Multiple, unsanctioned dose • Reporting psychic effects not intended
escalations by the physician
• Repeated episodes of lost
prescriptions Portenoy 1996

Assessing Aberrant Behavior
What does it mean?
• Aberrant behavior may mean out of control use of a drug,
which is a symptom of addiction
• Aberrant behavior may suggest inadequate pain
management
• ―Aberrant Behavior‖ by a pain patient is not, in and of itself,
not diagnostic; it must be interpreted and addressed in the
clinical context

True ―Medication Seeking‖
• Patient demands one agent only, claims nothing else
works.
• Patient is impatient and speaks only of meds—not of non-
medication approaches, not even of his/her symptoms
• Patient returns again and again seeking early supplies, with
odd stories (lost/missing).
• Patient requests more of the agent even when manifesting
impairment from use (sedated, ataxic, incoherent).

Danger Signs of Abuse / Addiction
Ask: ―Have you ever….‖
• Had a problem with prescription drug use?
• Been treated for addiction to prescription drugs?
• Taken __ in doses greater than your doctor ordered?
• Taken __ in a way [route of admin.] different than Rx‘d?
• Taken any __ even if it was [impairing your function]?
• Taken __ for a reason other than what the medicine was
intended for, e.g., a pain med for anxiety/sleep?
• Gotten a ‗high‘ from taking __, and then taken it in order to get
that high? [can be energy boost not just euphoria]

Danger Signs of Abuse / Addiction
Ask: ―Have you ever….‖
• Used some __ from a friend/family member‘s supplies?
• Obtained __ from more than one doctor at once, without the
other doctor‘s knowledge/permission?
• Made up a symptom in order to get a prescription?
• Over-stated a symptom in order to get a prescription?
• Bought any supplies from a non-medical source?
• Taken any __ from someone‘s medicine cab./ purse?
• Altered a prescription? Forged /called in a Rx?
• Stolen any __? Stolen a prescription pad?

―Red Flags‖ to look for

Check the patient‘s chronic pain management history for
these ―Red Flags‖ that might point to potential problems:
• Excessive use of medications
• Lack of progress in physical therapy
• Diagnosis of addictive illness including nicotine
• Prior injuries/chronic pain condition
• Failure to follow up on or irregular attendance with
providers for therapy or medical appointments

There are various types of pain,
and various terms to describe them
• Somatic or visceral pain
– Eudynia
• Neuropathic pain
– Maldynia
• Acute pain and chronic pain
– Acute injury/inflammation
– Pain associated with terminal conditions
– Chronic non-cancer pain

There are various types of pain,
and various terms to describe them
• Psychological pain
• Physical pain
• Nociceptive pain
• Other pathological pain states
– Hyperalgesia
– Allodynia
– Phantom-limb pain

How to approach

• Somatic/visceral/nociceptive pain:
– Responds well to opioids, NSAIDS, ASA/Tylenol, and probably
sedatives
• Neuropathic pain:
– Responds poorly to opioids, well to tricyclics, anticonvulsants
(gabapentin, carbamazepine), Lyrica, Cymbalta
• Depression with physical symptoms:
– Responds well to SSRIs, TCADs, anticonvulsants, and somewhat
to anxiolytics

How to approach

• Hyperalgesia responds well to reducing opioids
• Psychogenic pain/somatoform disorders require
psychotherapy and a long-term relationship; they do not
respond well to opioids or other general pharmaco-
therapies, and patients are at risk as well for overuse of
benzo‘s
• Patients with borderline personality, histrionic personality
may have somatic pain


• Clear understanding of addiction and the
range us substance use conditions
of addiction

Range of Conditions
Or, looked at another way:
• Use • Use
• Misuse
• Risky Use • Unhealthy Use
• Problem Use – ‗heavy drinking‘
– ‗non-medical use‘
• ‗Abuse‘
– ‗use despite consequences‘
• Addiction
– ‗binge drinking‘
• Disability – ‗harmful use‘ (IVDU)
• Death
• Addictive Use

Addiction is only one of the
Substance-Related Disorders
• Addiction (DSM-IV Substance Dependence)
• Problem Use (DSM-IV Substance Abuse)
• Intoxication States
• Withdrawal States
• Substance-Induced Medical Problems
• Substance-Induced Psychiatric Problems
• Health Problems linked to Secondary Use

Terminology is complicated
and not consistent
Addiction vs. dependence

Addiction vs. pseudoaddiction

Dependence vs. abuse

Physical vs. psychological

―Physical Dependence‖ =
Tolerance and Withdrawal
Repeated administration of opioids that activate the mu
receptor results in dose-dependent physical dependence and
opioid tolerance
Physical dependence and tolerance manifest as characteristic
withdrawal signs and symptoms (the opioid withdrawal
syndrome) upon (1) reduction or cessation of opioid
use/administration or (2) the administration of an antagonist or
a partial agonist in a person with established tolerance

What is Addiction?
• Substance use (= reward, relief, from alcohol/drugs/behaviors)
• Use behaviors and procurement behaviors persist despite problems
due to use
• Return to use after periods of abstinence, despite previous problems
• Inability to consistently control use
• Preoccupation with use/procurement; salience of use-related
behaviors
• Cognitive changes (over-valuation, de-valuation, minimization/denial)
• Enhanced cue responsiveness via conditioning and generalization

The Definition of Addiction
(ASAM, AAPM, APS – 2001)

• Addiction: a primary, chronic, neurobiological disease, with
genetic, psychosocial, and environmental factors influencing its
development and manifestations. It is characterized by
behaviors that include one or more of the following: impaired
control over drug use, compulsive use, continued use despite
harm, and craving.

• 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.

Addiction

Its onset and progression (genesis and pathogensis)
result from genetic, psychosocial, and environmental/
cultural influences

Addiction

New Definition from
American Society of Addiction Medicine

www.asam.org/DefinitionofAddiction-LongVersion.html

Addiction

Results from interactions among
• Agents
• Biology
• Context
»Substances
»Hosts
»Environments

Opioids don‘t cause opioid addiction

Addiction arises due to interactions among agents
(e.g., opioids), vulnerable hosts (persons with increased
genetic risks or psychiatric comorbidities), and
environments (stresses, drug availability, cultural issues).

Prescription Opioid
Use/Misuse/Addiction
Nathaniel Katz, MD,
Tufts University School of Medicine
Presentation at APA Meeting 2006

Katz‘s data
• 33-45% of persons with opioid use disorder report that their first
supply was a prescription from a physician
• Rates of co-morbid SUD in chronic pain patients is 20-40%
• Most prescription opioid abusers obtain drugs from either their own
prescriptions or from prescriptions written for family members of
friends
• A significant minority of prescription opioid abusers were not at
apparent high risk prior to first exposure
• Katz, in Clinical Journal of Pain 18:S76 2002: 21% of persons with
no ‗aberrant behaviors‘ have a urine drug test positive.

Katz‘s data
We are lacking data so we can have a more intelligent discussion.
Data submitted for publication by Katz et al.:
• Opioids dispensed per year USA: 190 mil prescriptions, 9.5 billion
doses
• Non medical users in last year (NSDUH) = 11 million people
• 430 million non-medical use days
• Minimum of 430 million abused doses (only 1/day)
• Ratio of Non-medical use days to Medical use days = 0.22.

Why a Person with Addiction Would Seek
Drugs for Their Own Use

• To produce euphoria

• To manage an acute opioid withdrawal syndrome

• To relieve post-acute opioid withdrawal symptoms



of addiction

Clinical Management:
So, how DO we prescribe ‗properly‘?

Management

• Treat acute pain as acute pain
• Give thoughtful consideration to the likelihood that a non-
opioid (e.g., NSAID) may be effective
• If authorizing an opioid write for only a reasonable number
of doses, and if you have no established relationship with
the patient, no refills

Management

• If it‘s chronic pain, are you sure that opioids will make a
long-term difference?
• Might we all change our thinking, and if we do use opioids
when ‗chronic pain‘ is clearly the problem, might we
envision only a short-term trial and make this clear to the
patient?
• Place the prescribing of opioids into a context, including
treatment agreements and monitoring

Management

• Is there a ―treatment agreement‖ or ―pain contract‖ in
place?
– Are you operating within the parameters of the treatment
agreement?
– Are you operating outside of the parameters of the treatment
agreement?
• What is the patient ―being held to‖ and what is the
prescriber ―being held to‖

Provider Obligations
• Keep clear records of # of pills authorized per office visit, number
of refills, date that the authorization is expected to last until
• Monitor clinical progress: keep clear records of the patient‘s
response to treatment
– Symptom reduction
– Functional impairment
• Utilize collaterals to validate patient self-reports
• Monitor adherence and non-adherence via drug testing
• If the patient violates the contract, do you do what the contract
says you will do in response to that?

Management
• ‗Lost supplies‘
– listen to story; your response is a judgment call
– fill for 1-2 days only: get management back in the hands of the
regular Rx-er
• ‗Violated contract / loss of provider‘
– listen to story; your response is a judgment call
– fill for 1-2 days only: get management back in the hands of the
PCP
– you don‘t have to given an opioid; you can respond to the
patient‘s loss of regular / legitimate opioid supplies, and offer to
manage any acute withdrawal

Management:
Tips for Prescribers

• Maybe the most therapeutic thing you
can do is not to give an opioid
• RECALL: the WAY you do this is a key
• Be THERAPEUTIC: You are a
Physician, not a prosecutor or jail deputy
!



• Improved pharmacotherapy of pain
and pharmacotherapy of addiction

Managing Acute Pain without Opioids

• NSAIDs
• Acetaminophen
• Flexeril / Skelaxin / Baclofen
• Think before prescribing Fiorinal
– it‟s not a „pain medicine‟, it‟s a BARB

Managing Chronic Pain without Opioids

• TCAD‘s
• Cymbalta
• Lyrica
• Neurontin and other anticonvulsants

Managing Pain With Opioids

Short-acting, adequate potency
Long-acting (Levodromeran)
Methadone for Pain

Methadone

• Excellent pain control, long acting
• Increasingly used because of low cost (Medicare Part D;
any managed pharmacy benefit plan)
• Can be LETHAL
• Must ―start low, go slow‖
• Starting dose in methadone clinics / OTP‘s
• Starting dose in pain practice / primary care

Managing Opioid Withdrawal without focusing
on managing pain

• Maybe the acute problem isn‘t the underlying pain
condition, but the symptoms resulting from a cutting off of
opioid analgesic supplies
• Traditional methods: clonidine and supplemental agents;
Ultram® can be used but that is associated with drug-
linking and diversion among addicts

Do treat acute pain

• Even if patient has history of addiction

• Even if patient is on methadone

• Even if patient is on Suboxone (this probably requires use
of fentanyl)
– But the first intervention should be to divide the dose of Suboxone
or methadone

• Even if the patient is on naltrexone (Vivitrol)

Do your best to not use opioids to treat
‗psychic pain‘
• Is it really depression you‘re treating?

• Is it really anxiety you‘re treating?

• Is it really a somatoform disorder you‘re treating?

Buprenorphine

• OBOT—office based opioid treatment
• Special DEA registration of the provider
• Clinics are not regulated, prescribers are
• Sublingual tablets, but use of new ―film‖ can reduce
diversion

Buprenorphine

• It IS AN OPIOID – it is a ―partial agonist‖ at the mu opioid
receptor (the ―morphine‖ receptor)
• Thus, it can treat pain, in the absence of addiction
– Buprenex
– Butrans
– Suboxone, Subutex
• While special DEA registration is required of the provider
who prescribes for addiction, no special DEA registration is
required when prescribing for pain management only
• It can treat pain and addiction in the patient who has both

Intrinsic Activity: Full Agonist (Morphine), Partial
Agonist (Buprenorphine), Antagonist (Naloxone)
100

90 Full Agonist
(Morphine)
80

70
Intrinsic Activity 60
Partial Agonist
50 (Buprenorphine)
40

30

20

10
Antagonist (Naloxone)
0
-10 -9 -8 -7 -6 -5 -4

Log Dose of Opioid

Responding to the Epidemic

• Treat Opioid Addiction with Buprenorphine!
Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone
Treatment for Prescription Opioid Dependence
A 2-Phase Randomized Controlled Trial
Roger D. Weiss, MD; Jennifer Sharpe Potter, PhD; David A. Fiellin, MD; Marilyn Byrne, MSW; Hilary S.
Connery, MD, PhD; William Dickinson, DO; John Gardin, PhD; Margaret L. Griffin, PhD; Marc N.
Gourevitch, MD, MPH; Deborah L. Haller, PhD; Albert L. Hasson, MSW; Zhen Huang, MS; Petra
Jacobs, MD; Andrzej S. Kosinski, PhD; Robert Lindblad, MD; Elinore F. McCance-Katz, MD; Scott E.
Provost, MSW; Jeffrey Selzer, MD; Eugene C. Somoza, MD, PhD; Susan C. Sonne, PharmD; Walter
Ling, MD

Arch Gen Psychiatry. Published online November 7, 2011.
doi:10.1001/archgenpsychiatry.2011.121

Now available in a sublingual film

• Generic buprenorphine is available, but not recommended
• Still, many hurdles to overcome re: stigma,
misunderstandings, discrimination
• Limitations of access
– ‗off formulary‘
– ‗caps‘ on daily doses, monthly doses, duration of therapy, via
Medicaid and private insurers/PRMs

Pharmacotherapy Approaches to Opioid
Dependence
Agonist Maintenance Treatment
• Methadone (full agonist)
• Buprenorphine (partial agonist)

Antagonist Maintenance Treatment
• Naltrexone (oral = ReVia®)
• Naltrexone (long-acting injectable = Vivitrol®)

Thank you!

Medical Director
Herrington Recovery Center

262-646-1056
mmiller@rogershospital.org

Prescription Drug Epidemic: Pills, Addictions, Deaths. What To Do About it

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