Prescription Drug Abuse in Family Practice Patients Kristin Rhodes, RN, MSN, FNP-C

Family Nurse Practitioner Newport Family Medicine

Objectives • Define bio-psycho-social model of addiction • Identify 3 categories of direct stimulators that lead to

addiction • Identify signs & symptoms of intoxication from various

addictive substances • Identify criteria requiring admission for detox • Demonstrate how drugs effect neurotransmitters of

mood • Discuss abuse among various populations • List referral resources for outpatient management • Identify methods to support recovery and limit risk of

enabling

Why Important

• Hot Topic – CNN Report – LA Times, Orange County Register – FDA recommendations- Ambien, Vicodin

• Addiction • Death • Loss of License

• For every 1 overdose death from prescription painkillers there are

– 10 treatment admissions for abuse – 32 emergency department visits for misuse or abuse – 130 people who abuse or are dependent – 825 people who take prescription painkillers for

nonmedical use • Enough prescription painkillers were prescribed in 2010

to medicate every American adult around-the-clock for one month.

Why Increased Use? • Misperception of safety • Increased availability 1991-2010 5- 45 million of stimulants

75.5 – 209.5 million for opioid analgesics- • Varied motivations for abuse: get high, reduce anxiety,

induce sleep, cognitive enhancement, reduce pain • “Pain as the 5th Vital Sign” campaign

– Benefiting pharmaceutical industry • Education of ER patients

– Minor MVA d/c’d home w/ moderate severe pain more likely given opioids if lower education and socioeconomic status

• Fear of addiction • Others feel provider mistrusts their pain or anxiety

Platts-Mill, 2012

Prevalence

• 120 million (51%) were current drinkers • 71.5 million (29.5%) used tobacco • 8.7% of population (22.5 million

Americans) older than 12 y.o. abused psychotherapeutic drugs – 14.8 percent of high-school seniors used a

prescription drug nonmedically in the past year

– Increasing in Baby Boomers

Prescription Drug Abuse • Most people prescribed narcotic

analgesics, sedative-hypnotics, and/or stimulants use responsibly

• Street value of Prescription Meds 2nd to Cocaine – Trade more value than generic – Polydrug users will start with street drugs and

progress to prescription • Medical Boards punitive for MDs for

overprescribing

DSM-IV Criteria for Substance Abuse

1.Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).

2.Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).

3.Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct).

4.Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).

Disease Concept

• Alcohol and other drug (AOD) use can lead to addiction – Abuse – use of a substance other than for

which it is intended or more than which it is prescribed

– Dependence- chronic use of substance that if use was stopped leads to withdrawal symptoms

– Addiction- compulsion to use despite negative consequences

• Addiction is a Brain DISEASE

Intoxication

• Intoxication- symptoms that occur at time of use

• Repeated episodes of substance intoxication substance abuse or dependence

• One or more episodes of intoxication does not define abuse or dependence

4 A’s of Opioid Treatment

• sufficient Analgesia to engage in Activities of daily living while avoiding Adverse events and Aberrant medication-related behaviors

Pseudoaddiction

• Undertreated chronic pain • Reversible • Patient behaves erratically but improves

once pain is treated

Pleasure Principle

• Dopaminergic receptors are throughout the brain

• When triggered, things feel good so we keep doing them to receive pleasure – Sex, food, laughter, exercise, drugs and

alcohol • Positive reward- we do it because it feels

good • Negative reward- we do it to make us feel

better aka self-medication • Habit- conditioned reinforcement of either

Direct Stimulators

• The locus coeruleus if stimulated directly or indirectly, leads to pleasure

• Direct stimulators are drugs that lead to addiction

• Three types – Opiates – Sedative-hypnotics – Stimulants

Oxycontin

• Oxycodone – 10-160 mg; time release – Higher potency than Tylox or Percodan

• “Oxy”, “O.C.”, “killer” • Crush and ingest, snort, or inject • Patients will sell prescription for profit

– 40 mg pill = $4 except on street $20-$40 – 4 out of 12,000 become addicted

MMWR, 7/6/12

Methadone

• Higher rates of overdose related deaths due to methadone, of which majority not enrolled in heroin addiction programs

• No clinical use for mild or acute pain, breakthrough pain or as needed

• Should not be primary drug of choice for insurers and prescribers for chronic non-cancer pain – Not prescribed for opioid naïve nor with those using

benzodiazepines

Risk Factors • personal or family history of drug or alcohol abuse or

addiction • cigarette smoking • history of a mood disorder, especially uni-polar

depression • younger age • history of childhood sexual abuse • history of drug-related legal problems, and a • history of driving under the influence

Individual Risk Factors

• Conduct Disorder – Highly r/t substance use disorder, not just use

• Psychiatric Disorder- HIGH – Mood, anxiety disorders (internal) – Conduct & impulsivity disorders (external)

• Executive Cognitive Function • Academic Failure • Self-esteem- probable • Social Skills deficit- peer rejection

Environmental Risk Factors

• Family • Home • Poor parental monitoring • Peers

– Greater influence from individual risk factors than peers

Protective Risk Factor

• Intelligence • Problem solving ability • Social facility • Positive Self-esteem • Supportive Family Relationships • Positive Role Models • Affect Regulation

Longo et al (2000)

Drug-Seeking Patients • Scam- patient generated pressure to prescribe

w/ your feeling of hesitancy – “I’m feeling pushed by you to write a prescription

today that is not medically indicated and thus I’m concerned about you. We should talk about your alcohol (or drug) use.”

• Fear of avoidance- patients have stronger relationship w/ drug than you

• Countertransference – Anger, guilt, wish to disengage, pity, revulsion

• Codependency- fear anger and abandonment

Longo et al (2000)

Characteristics of Overprescribing

• Dated • Duped • Dishonest • Disabled

Risk Management • Maintain current knowledge base • “Write Right”

– Prescribe enough until next appt – Write out number dispensed – Telephone only to one pharmacy

• Consultation • Informed consent • Document decision-making process • Duty to warn • Avoid prescribing meds in isolation from other

therapy

Opioids

• 26 studies w/ 4893 patients for long term use for chronic non-cancer pain- most case series, noncontrolled studies – Most fell out due to side effects (22.9%) – Ineffective pain relief (10.3%) – 0.27% addicted – 44% had 50% pain relief

Warner, 2012

Referring to Pain Management Specialist

• Screens high risk for abuse potential • Untreated mental health disorder • High dose requirements > 100-120

morphine equivalent dose/day • Lack of response to treatment • Lack of improvement • Diagnosis is uncertain • Alternatives desired

Mersey, D.(2003). American Family Physician

“Red Flag” Complaints

• Frequent absences from school or work

• Hx frequent trauma or accidental injuries

• Depression or anxiety • Labile hypertension

• GI symptoms – Epigastric distress – Diarrhea – Weight changes

• Sexual dysfunction • Sleep Disorders

SAMHSA Tip 11

Substance Abuse and Medical Illnesses

• Malnutrition • Liver damage • Falls and injuries • Cardiac arrest (cocaine) • Tuberculosis • STI/HIV/Hep B and C • Infective endocarditis • Pneumonia • Skin & soft tissue infections

Screening

• Identify those at risk or having substance abuse problems

• Identify those who need further assessment to diagnose and develop treatment plan

• Negative screen also provides opportunity for health promotion

• Ask and accept responses without judgment

• Document screening and response

Screening Prescription Drug Use

• "In the past year, how often have you used alcohol (4+/5+ drinks in a day, depending on gender), tobacco products, prescription drugs for nonmedical reasons, or illegal drugs?" – never, once or twice, monthly, weekly, or

daily/almost daily

Screening Prescription Drug Use

• Do you see >1 health care provider regularly? Why? Have you changed providers recently? Why?

• What Rx drugs are you taking? Any problems?

• Where do you fill your Rxs? Do you go to more than 1 pharmacy?

• Do you use other OTC meds? What? How much? How often? Since when?

NM-ASSIST

• NIDA-modified Alcohol, Smoking, and Substance Involvement Screening Test (NM-ASSIST – www.drugabuse.gov/nmassist – ..\NMASSIST.pdf

Drug Withdrawal

• Reverse of direct pharmacological effect of drug – Opiates

• dysphoria, pain, anxiety, diarrhea – Benzodiazepines

• Rebound anxiety

TIP 24- SAMHSA

Intervention

• Nondependent but problematic users do well with counseling and brief intervention efforts.

• If use is creating problems in one or more areas of their lives, assessment and intervention should be done

Brief Intervention

• Assessment and direct feedback • Negotiation and goal setting • Behavioral modification techniques • Self-help directed bibliotherapy • Follow-up and reinforcement

Motivational Interviewing

• Phases – Build motivation to change Strengthen

commitment to change • Principles

– Express empathy – Develop discrepancy – Roll w/ resistance – Support self-efficacy

Early Intervention

• Intrinsic motivation – Positive acceptance of personal responsibility

• Extrinsic motivation – Social pressure

• Goals of motivation – Treatment (short term) – Remaining abstinent (medium/long term) – Lifestyle changes (long term)

Categories of Resistance

• Arguing – Challenging – Discounting – Hostility

• Interrupting • Denying • Ignoring

SAMHSA Tip 24/Tap 11

Referring a Patient for Treatment

• Goals – Attain & maintain abstinence – Maximize Health – Preventing reducing frequency/severity of

relapse • For those who cannot or will not stop their

use of alcohol or drugs without the help of a specific program

SAMHSA Tip 24

Treatment Models

• Some combination Medical/Psychological/Sociocultural

• Minnesota Model • Drug-free Outpatient • Methadone Maintenance

SAMHSA Tip 24

6 D’s of Treatment

For Dually diagnosed • Diagnosis • Dosage • Duration • Discontinuation • Dependence Development • Documentation

SAMHSA Tip 24

Psychosocial Interventions

• Group therapy • Marital/Family therapy • Cognitive behavioral therapy • Behavioral contracting or contingency

management • Relapse prevention • Self-Help Groups

Behavior Oriented Treatment

• Patient must assume primary responsibility to change

• Have to accept they have a problem • Need to learn how to deal with cravings

without relapse – Motivational enhancement therapy – CBT – Contingency contracting – Exposure treatment

Principles of Detoxification • Detox alone not adequate treatment for

dependency • Use protocols when using pharmacology • Inform patient if procedure used not established

as safe and effective • Control access to meds during detox • Individualize initiation of withdrawal • Substitute long-acting for short-acting drugs of

addiction • Do best to reduce s/s of withdrawal • Patient and family participation ASAP

Detoxification

• Young people with AOD dependence less than 1 year “unrealistically optimistic” regarding long term abstinence

• Outpatient for mild to moderate alcohol withdrawal

• Patient’s crisis is opportunity for intervention – Drug-related seizure, arrest, family illness,

death

Toxicology Screen • Urine

– Checks for metabolites within 2-3 d of use • Saliva (Bennett, 2002)

– 12-24 hours of last use – Respects dignity – Nervousness creates dry mouth – Specific/sensitivity

• Cocaine 96/92%; opiates 100-94/99-86% (similar urine) • Not for benzodiazepines

• Serum- most specific, expensive • Hair

Dimoff, T. www.sacsconsulting.com

Altering Drug Tests

• Adulteration – Add substance to urine

• Substitution – Pass off as own

• Dilution – Drink water

• Check specific gravity and creatinine

Goals of Detoxification

• Provide safe withdrawal from drug(s) of dependence and enable to live drug free

• Provide humane withdrawal and dignified • Prepare for ongoing treatment

Detoxification

• Chemical Detox – 4-8 hours- brain goes through withdrawal and

puts body in a “panic of activity” – 48-72 hours- peak of acute withdrawal – 3-5 days- detox complete

SAMHSA Tip 24

Psychopharmacology Purpose Treatment Goal Examples Detoxification Enable patients to be safely

withdrawn from their drug of dependency

Clonidine or methadone for opiate withdrawal Phenobarbital or valproate in benzodiazepine withdrawal

Relapse Prevention Make drinking alcohol aversive

Disulfiram (Antabuse)

Block reinforcing effects of opiates

Naltrexone (ReVia)

Treat underlying or drug-induced psychopathology that may cause relapse to drug use

Antidepressants, mood stabilizers (e.g., lithium or valproate)

Opioid Maintenance Reduce the medical and public health risks of heroin use

Methadone LAAM Buprenorphine*

SAMHSA Tip 24

Benzodiazepine Detox • Withdrawal highest > 65 y/o

– Rapid catatonia – Always consult w/ addiction specialist

• Carbamazepam and valproate • Abrupt discontinuation

– Seizures, psychosis, severe anxiety, intense nightmares, and insomnia

• Withdrawal- psychosis, parathesias, irritability, phono/photosensitivity, acute anxiety, insomnia

SAMHSA Tip 24

Opioid Detoxification

• Mild craving and anxiety to 3 grades – Grade 1

• Yawning, sweating, tearing (lacrimation), rhinorrhea

– Grade 2 • Mydriasis (dilated pupils), piloerection, muscle

twitching, anorexia – Grade 3

• Insomnia, increased pulse, increased respirations, elevated BP, abdominal cramps, vomiting, diarrhea, weakness

SAMHSA Tip 24

Stimulant Detoxification

• No pharmacological intervention needed • Withdrawal

– Agitated – Appear depressed – Difficulty sleeping

• Can use chlordiazepoxide

SAMHSA Tip 24

Other Drugs

• Barbiturates, carbamates, chloral hydrate – W/drawal based on half-life

• Peak 24-72 hours for pentobarbital, secobarbital, oxazepam, alprazolam

• 5-8 days- diazepam, chlordiazepoxide – Higher risk of seizure

• Marijuana – No withdrawal syndrome

Detoxification

• Cognitive Recovery – 14-28 days: Unable to think clearly or

process information as quickly. • Short term effect of withdrawal

– 6-18 months: Long term effect; recovery of most cognitive functioning

– 3-5 years: Return to pre-drinking/pre-drug use mental state

Postdetoxification

• Some enter detox to satisfy family, work, or courts

• Family suffer consequences – Lost income – Domestic violence – Divorce – Maladaptive behavior from children – Lack of trust

Brain Dysfunction • Thinking

– Unable to abstract or conceptualize; poor memory; activated by increased stress

• Emotional management – Easily excitable; over react

• Memory • Stress Related Illnesses

and disease • Accident Prone

– Poor psycho-motor performance

Frustration

Stress Sleep Problems

Memory loss

Dual Diagnosis

• Comorbidity • Intoxication psychiatric symptoms that

resolve w/ abstinence • Substance use can mask, exacerbate, or

ameliorate psychiatric symptoms in mentally ill

SAMHSA Tap 11

Special Populations

• Pregnancy – Opiates/cocaine- intrauterine growth

retardation, premature delivery, birth defects, CV problems, neuro-behavioral/physical dysfunction

– OB care, pediatric care, child dev’t, parenting skills, economic security, housing, birth control

– May be on methadone, not disulfiram or naltrexone

SAMHSA Tap 11

Special Populations

• Women – More likely to have depression, anxiety, PTSD from

past/current physical or sexual abuse, codependency – Need help with child care, parenting skills, health

relationship, avoid sexual exploitation, preventing HIV/STI, and enhance self-esteem

• AIDS – 69% of female AIDS cases r/t drug use – Needle sharing – ETOH inhibit judgment unsafe sex and drug use

practices

SAMHSA Tap 11

Special Populations

• Adolescents – Ask annually about ETOH, nicotine, illicit drugs, OTC

and prescriptions including anabolic steroids – High rates of depression, eating disorders, and hx of

sexual abuse – Need peer-oriented treatment

• Elderly – 10% males; 2% females alcohol and Rx drugs – Unexplained falls, confusion and inadvertent

overdose

Orange County Grand Jury 2010-2011

• ~500,000 residents > 60 • 65 and older are 13% of US population yet

receive 1/3 of all medications prescribed • More likely to take long term and multiple drugs

leading to unintentional use • Prescription drug abuse 12-15% of US seniors • 63% undetected in those over 60 • Recommend further study focusing on seniors,

routine screening in county clinics et al

Jones (2003)

Working with the Recovered

• Record sobriety date and confirm at each visit

• Non judgmental • Document use of support • Review all meds including OTC and herbs • Those in recovery are more likely to be

adhere • Encourage family and friends to participate

in 12-step programs

Jones (2003)

Working with Recovered • Many fear use of medication will lead to relapse

– Promote Lifestyle therapy • Stress reduction • Relaxation • Heat, ice, rest, elevation • PT, acupuncture, biofeedback

• Pain Management – No early refills – Collaborate with addiction specialists – May need higher doses – Keep pain diary

Rationale for Total Abstinence

• Other drugs and alcohol can cause cravings

• Others use – makes more difficult to resist cravings – Lead to irresponsible and inappropriate

behavior – Grows out of control – Disrupts development of coping skills – Encourages to continue being w/ high risk

people, places, and things – Impairs judgment

Prescription Drug Monitoring Program

• CURES • 25% unaware or didn’t have access • Time or complexity to access information

• http://oag.ca.gov/sites/all/files/pdfs/pdmp/brochure.pdf

Resources

• Diversion Program – 1-800-522-9198

• http://findtreatment.samhsa.gov – 1-800-662 HELP

• http://www.drugabuse.gov/nidamed-medical-health-professionals

• CURES https://oag.ca.gov/cures-pdmp

Confidentiality

• Alcohol and drug abuse patient records protected by federal law

• 1987- patient records from general medical setting and hospitals are not covered unless treating provider has primary interest in substance abuse treatment

• Handle information with discretion • Need written consent to release

information

The good news is…

Drug Abuse is a preventable behavior

and

Drug Addiction is a treatable disease