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Use, Abuse, Misuse & Disposal of Prescription Pain Medication Time Tool
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USE, ABUSE, MISUSE, AND DISPOSAL OF PRESCRIPTION
PAIN MEDICATION
TIME TOOL
A Resource from the American College of Preventive Medicine

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A TIME TOOL FOR CLINICIANS
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals.Please refer to the Use, Abuse, Misuse, and Disposal of Prescription Pain Medication Clinical Reference for more information.

The "Perfect Storm” – Treat pain aggressively or choose calm waters
Adequate pain control is a fundamental right of every patient and the consequences of not treating pain are significant. However, physicians are challenged to deal with the "perfect storm”—a confluence of pain control versus risk of abuse and misuse of prescription medications, and combined use of prescription with over-the-counter (OTC) medications. The problem cannot be ignored because abusers face significant complications, including:

  • Overdoses
  • Addiction and dependence
  • Adverse effects
  • Drug interactions
  • Economic, family, and social dysfunction
  • Legal consequences

Misuse and Abuse of Prescription Drugs is Epidemic
The past two decades have witnessed an expansion of analgesic use, especially opioid use for patients who have chronic noncancer pain.

  • 7 million people abuse/misuse prescription drugs every month; pain relievers = 5.3 million
  • Rates of prescription drug abuse are higher than cocaine, inhalant, hallucinogen, and heroin use combined

Nonmedical use of Prescription drugs is the defining drug problem of the new century
Prevalence of prescription use, misuse, and abuse varies among clinical settings and by definition of misuse or abuse.

  • Pain Patients
    • Opioids are the most abused drugs in the chronic pain setting
    • The prevalence of lifetime substance use disorders ranges from 36% to 56% in patients treated with opioids for chronic back pain

We live in "a pill for every ill” culture
The increase in diversion of prescription drugs is fueled by:

  • Increased advertising and advocacy
  • Easy access and availability
  • Stronger motivations to get high (such as to deal with problems, or work harder and longer)
  • Safety perception that prescription drugs are less harmful than illicit street drugs
  • Normalization of abuse of prescription drugs in teen culture
  • Limited liability
  • Lack of education
  • High street value

The economic figures are startling
Close to half a trillion U.S. dollars are spent on expenses associated with medical, economic, social, and the criminal impact caused by the use and abuse of addictive substances:

  • In 2002, abuse of prescription drugs costs were nearly $181 billion; a significant amount of these dollars were attributed to opioid abuse
  • Direct health care costs for opioid abusers = $15,884 compared with $1,830 for nonabusers
  • Common Prescription Drugs of Abuse and Street Value

Physicians play a pivotal role in curbing abuse
Primary care physicians are well poised to recognize substance use in their patients and to take steps to address the issue before use escalates.

  • Less than 40% of physicians receive training in medical school to identify prescription drug abuse or recognize the warning signs of drug diversion
  • More than 40% of primary care physicians report difficulty in discussing the possibility of prescription medication abuse with patients
  • More than 90% fail to detect symptoms of substance abuse
  • Patients may have multiple physicians prescribing medications, without a physician assessing possible interactions between medications prescribed through multiple providers, and OTC medications that might also be used

Significant changes in medical practice are needed
Barriers to appropriate prescribing:

  • Conflicting (or absent) evidence on effective pain management
  • Dual, conflicting roles for prescribers
  • Regulatory requirements
  • Inadequate time to develop and coordinate an integrated or multidisciplinary treatment plan
  • Availability of unused medications at a patient’s home

Strategic practice patterns create a balance between appropriate pain relief while reducing risk of abuse

FERRET OUT DIVERSION TACTICS

  • Doctor shopping
  • Deception
  • Forged or altered prescriptions
  • Corrupt physicians
  • Drug theft
  • Recurrent medication loss
  • Early refills
  • Obtaining refills from multiple sources (e.g. Emergency Departments, urgent care)
  • Improper prescribing
  • Family sharing

JUDGE PATIENT RISK

  • Be alert to warning signs
  • Use screening tools with everyone at the beginning of treatment e.g. the Opioid Risk Tool

MANAGE PATIENTS AT HIGHER RISK(See Resources in Clinical Reference for samples)

  • Regular use of medication agreements
  • Document every encounter
  • Obtain informed consent
  • Require random urine drug screens
  • Consider periodic pill counts
  • Do not provide automatic refills
  • Require office visits at least every 1-3 months
  • Do not prescribe scheduled substances after-hours or on weekends
  • Consider universal precautions
  • Prescribe with caution
  • Ensure clinical benefit from medications or taper down
  • Offer short-term prescriptions of opioids medications for acute issues
  • Violations of medication agreements result in discontinuation of all scheduled substance prescriptions
  • No scheduled medications for new patients ("no opiates/benzodiazepines on the first visit”)
  • Require records from other providers before assuming prescribing of chronic opiates
  • Have the patient use a single pharmacy for all prescriptions

TREAT ADDICTIONS

  • Treat addiction as you would any other medical condition; specifically, become skilled with Screening, Brief Intervention, Referral and Treatment (SBIRT) guidelines
  • Refer patients with complex issues
  • Teach coping skills
  • Become skilled in the use of buprenorphine for office-based treatment of opioid addiction and get a DEA waiver to use buprenorphine for this purpose

REPORT NONMEDICAL DRUG USE

  • Become familiar with your state’s Prescription Drug Monitoring Program (PDMPs) requirements
  • Be prepared to report and access information regarding the abuse of prescription drugs in your area

STAY ABREAST OF CHANGE

  • Attend educational seminars; become familiar with relevant practice guidelines (e.g., SBIRT, use of buprenorphine for office-based addiction treatment, and VA/DoD Clinical Practice Guidelines for both Substance Use Disorders and Chronic Pain Management)
  • Read current literature on strategies to minimizes drug abuse
  • Visit various web sites dedicated to the topic for the latest updates (See Resources in Clinical Reference)
  • Become empowered to respond to patients appropriately

"Medication mania” is not the best response for every patient complaint
Knowing that > 40% of physicians have difficulty discussing substance abuse, including abuse of prescription drugs, the following "conversation openers” will help with patient/physician communications:

When patients are fearful of scheduled drugs (Additional Scripts found in Clinical Reference)

  • "Yes, these medications do have the potential for addiction but relatively few pain patients become addicted to their medication.”
  • "Addiction is a very loosely used term. Often patients become physically dependent on pain medication because they are in pain. While tolerance builds to the pain medication, this is not necessarily a psychological addiction.”
  • "As part of my normal treatment approach, I will routinely monitor your use and see how well the pain is controlled on minimal doses.”
  • "I will continue to be your doctor and can work with you if either physical dependence or psychological addiction becomes a problem.”

When patients misuse medication (Additional Scripts found in Clinical Reference)

  • "It seems like you are running out of medication early. Let’s talk about how much pain you are in.”
  • "During this check-up, I want you to fill out this brief questionnaire. It will help me with your treatment plan.”
  • "Talk to me about the types of OTC and herbal medications you take and any other drugs.”

When abuse is suspected (Additional Scripts found in Clinical Reference)

  • "It is my choice to not prescribe at this time.” (Be clear and short)
    • Provide a referral, possibly to detox program
    • Use SBIRT (See Resources in Clinical Reference)
  • "It is clinic policy to not prescribe these types of drugs.” (Chose language so the patient has no room to maneuver)

Throw it? Trash it? Flush it? Burn it?
A dilemma exists around the storage and disposal of pain medications and there are no uniform guidelines or protocols for the safe, environmentally acceptable disposal of unused drugs. The Office of National Drug Control Policy recommends that drugs be taken out of their containers, mixed with undesirable substances, (e.g., cat litter, used coffee grounds) and put into a disposable container with a lid or into a sealed bag before putting in the trash. Advise patients to remove any personal information by covering the information with black marker, or duct tape, or by scratching it off.

What physicians can do

Modifying their Practice:

  • Consider writing prescriptions in smaller amounts understanding that the patient’s insurance may only fill one prescription in 30 or 90 days forcing the patient to pay more out of pocket
  • Refer patients to Take-Back Programs

During a Patient Consult:

  • Educate patients about safe storing and disposal practices
  • Ask patients not to advertise that they are taking controlled substances and to keep medications secure
  • Refer patients to community "take back” services for disposal

A Final Thought
It is universally acknowledged that pain is often suboptimally managed. Physicians are challenged with adequately managing pain while being keenly alert for misuse and abuse. Physicians can maintain a balance by staying educated, attending peer workshops, using screening tools, employing careful patient selection when prescribing controlled substances, and following consensus guidelines for pain management. Knowledge of the prevalence of the problem, impact and burden will help clinicians stay abreast of current trends, demographics, risk factors, and clinical characteristics of the prescription drug abuse epidemic. These can be applied in clinical practice to improve screening and clinical management skills that may reduce nonmedical use and abuse of prescription medications without compromising patient care and access to needed prescription medications.


Supporting references and additional information:

Download printable versions of these resources:

Taking medication as directed to prevent misuse and abuse is addressed in other ACPM Time Tools. To read more go to Medication Adherence and Over-the-Counter Medications



The American College of Preventive Medicine acknowledges Purdue Pharma L.P. for its support of this resource through an unrestricted educational grant.

 

For other information and useful links, visit the American College of Preventive Medicine website at www.acpm.org.




Recommended Citation

ACPM recommends using the following citation when referencing this educational program.

Excerpted with permission from the American College of Preventive Medicine. Use, Abuse, Misuse, and Disposal of Prescription Pain Medication Time Tool: A Resource from the American College of Preventive Medicine2011. Retrieved from http://www.acpm.org/?UseAbuseRxTimeTool.

To better serve our membership and other constituents, we would like to know how information from our website is being used.  Please send a short email to info@acpm.org with a short description of what information you are citing and for what purpose.
 


Copyright 2011. American College of Preventive Medicine. All Rights Reserved.

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