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Prescription Drug Misuse

Introduction

“Prescription drug misuse and abuse is the intentional or unintentional use of medication without a prescription, in a way other than prescribed, or for the experience or feeling it causes. Results from the 2014 National Survey on Drug Use and Health (NSDUH) indicate that about 15 million people aged 12 or older used prescription drugs non-medically in the past year, and 6.5 million did so in the past month. This issue is a growing national problem in the United States. Prescription drugs are misused and abused more often than any other drug, except marijuana and alcohol.1

Prescription drug misuse occurs when a patient requests a prescription for a legal drug that they then sell, give to others or use for non-medical reasons. Prescription drugs can be obtained through pharmacy theft, prescription forgery or street sales; however, the vast majority of misused prescription drugs are obtained by legal means.

“The reasons for the high prevalence of prescription drug misuse vary by age, gender, and other factors, but likely include ease of access.”2 Even if the medication was not prescribed to the individual, it is perceived as safer than a street drug. Prescription drugs are more desirable for several reasons including the fact that their possession is not illegal, they have a higher street value than illegal drugs and they are more easily recognizable as the real thing. Also their quality, dose and effects are ensured since they are manufactured under federal regulations. Lastly, cost can be a factor; if the patient has medical insurance they may be able to obtain the drug at a lower cost or at no cost.5

Providers play an important role in identifying and preventing prescription drug abuse. Their role is complex and at times difficult. As the misuse and abuse of controlled substances continues to grow, providers must be vigilant when prescribing these drugs.

Prescription Drug Monitoring Programs

Prescription drug monitoring programs (PDMPs) are statewide mechanisms that collect, monitor, and analyze prescribing and dispensing data related to controlled substances. These programs allow providers and pharmacists to track prescriptions and help identify patients who are "doctor shopping" for the purpose of obtaining prescriptions for non-medical use. The AMA supports up-to-date interoperable, at the point-of-care PDMPs that are integrated into a provider’s workflow.

Providers should be familiar with their state prescription monitoring program and follow all requirements of their state’s program. Failure to follow these requirements could lead to board action. When a provider or pharmacist becomes aware of a patient who might be abusing or misusing prescription medications, they must take appropriate steps to address the situation

Specifics of New Hampshire, Vermont and Maine PDMPs can be found at the links below:

New Hampshire: http://newhampshirepdmp.com/

Vermont: http://www.healthvermont.gov/alcohol-drugs/professionals/vermont-prescription-monitoring-system-vpms

Maine: http://www.maine.gov/dhhs/samhs/osa/data/pmp/index.htm

In the Physician Office Practice

It can be difficult to differentiate between patients with legitimate health issues and patients who are seeking drugs for misuse. The following questions might be helpful in determining if the patient is attempting to obtain prescription drugs for non-medical reasons.

  • Does the patient have frequent visits to the office?
  • Has the patient recently moved, but refuses to give the name of his/her previous physician?
  • Is the patient paying cash for the visit?
  • Is the patient very familiar with prescription drugs and states only a specific drug is effective?
  • Does the patient report allergies to multiple prescription painkillers?
  • Is the patient specific about providers they want or do not want to see?
  • Does the patient report loss of medications?
  • Does the patient see multiple providers or have prescriptions filled at multiple pharmacies?

If the answers to these questions raise concerns that the patient might be abusing or diverting medications, the provider should take steps to address these concerns.

Providers must be familiar with their state regulations around prescribing controlled substances. While requirements differ from state to state, most include some variation of the following:

  • Document history and physical
  • Preform a risk assessment to determine patient’s appropriateness for opioids
  • Document opioid prescription and rationale
  • Develop a treatment plan that includes consideration of non-pharmacological modalities and non-opioid options for pain
  • Document informed consent discussion with patient
  • Query your state’s PDMP
  • Ensure patient has been provided information on risks of side effects, including addiction and overdose resulting in death
  • Consider patient’s risk for opioid misuse, abuse, diversion and prescribe the lowest effective dose for shortest duration
  • Develop a written treatment agreement which includes:
    • Goals of treatment in terms of pain management
    • Restoration of function
    • Consideration of non-pharmacological modalities and non-opioid therapy
    • Requirement of one pharmacy/one provider
    • Provisions for periodic drug testing
    • Instances where no further prescribing of controlled substances will be done
  • Educate patients on the risk of keeping unused medications and options for safely securing and disposing of unused medications
  • Re-evaluate treatment plan and re-check PDMP
  • Conduct random and periodic drug testing as required by state regulations and explain potential cost to the patient
  • Consider consultation with appropriate specialist for patients receiving high doses of medication, at high risk for abuse or with co-morbid psychiatric disorders

Medical Mutual's practice tip, Opioids and Chronic Pain Control: Avoiding Risks When Prescribing Medication Therapy in the Primary Care Practice also provides recommendations for treating patients with chronic pain.

It is crucial that providers monitor patients for signs of abuse. Providers can address prescription drug abuse by staying up to date on methods to manage chronic pain, anxiety, and insomnia, including methods that do not include medications with a high risk for abuse. Providers should be familiar with drug treatment programs, so they can make referrals to these programs when they encounter patients they believe are abusing medications.

When patients are attempting to obtain prescription medication they can be very persistent. These patients may use guilt, shame and other manipulative tactics to deceive you. It is important for providers to build up their resistance to manipulation. While it might be easier to give in and provide the patient with a prescription, this behavior usually backfires. When a provider prescribes liberally, word spreads thereby increasing the provider's encounters with these patients. Also, it might be difficult to justify your actions if the patient's medical record was audited by the Drug Enforcement Administration (DEA).

Providers should be compassionate yet firm when dealing with patients they believe are attempting to divert drugs. Learning to combat manipulative behavior and being current with treatment alternatives as well as drug treatment programs available can help physicians deal with these patients.

According to the CDC, unused drugs in the home contribute to prescription drug abuse, with teens being particularly prone to misuse of unused prescription medication left in medicine cabinets. Patients should be reminded not to share their medication. They should understand that the practice is not only unsafe, but also illegal. Patients need to be educated on the safe storage and disposal of prescription medication. When providers prescribe medications, particularly medications with a potential for abuse, they should encourage patients not to store medication in medicine cabinets, to keep medicines locked up and to keep track of their pills. It is especially important to have this conversation with patients who might have children living or visiting their homes.

Patients should be instructed on the proper disposal of unused medications, since improper disposal poses a threat to the environment. Medications should not be flushed down the toilet or put down the drain, as this raises serious public health concern of our water being contaminated with prescription drugs. Patients now have options at the state and local level for disposal of unused medications. Providers should familiarize themselves with the options available in their community and be sure their patients are aware of these options.

As a healthcare professional, providers share responsibility for minimizing prescription drug abuse and drug diversion. Providers can also protect themselves and their practice by adopting the following procedures:

  • Use e-prescribing to maximize safe opioid prescribing practices
  • Never sign an incomplete prescription
  • Keep all hard copy prescription blanks in a safe place where they cannot be stolen
  • Use tamper-resistant prescription pads that cannot be photocopied
  • Write the quantity and the strength of drugs in both letters and numbers. If only a number is on the prescription, it is easier to alter
  • Refer to the DEA’s Practitioner's Manual for detailed information on providers' responsibilities when prescribing controlled substances
  • Participate in your state's PDMP
  • Follow state and federal guidelines and regulations around prescribing controlled substances

In the Emergency Department

Individuals seeking to divert drugs for non-medical purposes oftentimes target emergency departments for several reasons including: they are always open, the visit might be brief and might not include an attempt to verify the patient's history, and it is likely that frequent visits might go unnoticed. For emergency department physicians, encounters with patients exhibiting drug-seeking behavior can be all too common. These patients present to the ED with multiple alleged allergies to narcotics, stories of lost or stolen medications or other reasons stated to secure the medications they desire.5 Often when they encounter resistance to prescribing controlled substances, these patients will become angry and threatening.

EMTALA: After a provider has several encounters with a patient they believe is drug seeking, it might be tempting to either refuse to see them or give them an abbreviated exam before discharging them. Federal regulations require that all patients presenting to an emergency department receive an appropriate medical screening exam (MSE) to determine if they have an emergency medical condition. If an emergency medical condition exists the hospital is obligated to provide treatment until the patient is stable or to transfer the patient to another facility following the regulation's requirements. Not performing an appropriate MSE is a violation of EMTALA regulations. If the MSE does not support a prescription for narcotics, the provider should provide a treatment plan that is appropriate for the presentation. It is important to document the complete MSE and the provider's conclusions.

Emergency Department providers should be aware of state requirements around opioid prescribing and must show documentation in the patient’s medical record that these requirements were followed.

If a provider is concerned that the patient is requesting a medication that is not appropriate they should educate the patient about why the medication is not appropriate. Providers with knowledge about pain management, chemical dependence, anxiety and insomnia can offer alternative treatments for the presenting complaint. If the patient continues to insist on the medication, the provider should explain in a direct, firm, and non-judgmental fashion that the medication is not appropriate. If necessary, the provider should make a referral to an appropriate treatment program. The provider should document all discussions with the patient regarding the appropriateness or inappropriateness of specific prescription narcotics and the patient's level of understanding.

Flagging patients with drug-seeking behaviors: There are several ramifications associated with noting "drug-seeking behavior" in a patient's medical record. These include a defamation claim, a patient claim of interference with insurance coverage and possibility of misdiagnosis. Medical Mutual generally discourages documenting this in the medical record and instead encourages providers to document the facts of the encounter including the patient's request for specific medications, requests to replace lost medications, etc.

Maine, New Hampshire and Vermont all have specific requirements around prescribing controlled substances. Providers should be familiar with the requirements in their state and must show through their documentation that they have followed these requirements. State requirements can be found through the following links:

Maine Medical Association: https://www.mainemed.com/pain-management-government-resources

Vermont Medical Society: http://www.vtmd.org/opiate-prescribing-substance-use-disorder-information

New Hampshire Medical Society: http://www.nhms.org/resources/opioid

Reportable Acts

Questions frequently arise regarding what constitutes a reportable act and when law enforcement should be notified about a patient's possible illegal activity. Information gained as a part of the patient/physician relationship, including disclosure of possible criminal acts, remains confidential. However, a patient who attempts to use a provider to perpetrate illegal acts, such as acquisition of drugs or selling those drugs, should be reported to the DEA or local law enforcement agency.

If the Medicaid program insures a patient engaging in questionable conduct, a report on the matter should be provided to Medicaid Surveillance.

Be aware that health information obtained through Substance Abuse Treatment Programs fall under federal law, CFR 42 Part 2. Under this law it is a crime to disclose health information obtained from a Substance Abuse Treatment Program. Prior to disclosing this information to authorities, take steps to assure that your program or practice does not meet the federal definition of a Substance Abuse Treatment Program.

Consult with an attorney or your state medical association for further recommendations on reporting illegal behavior.

References:

  1. SAMHSA: Prescription Drug Misuse and Abuse https://www.samhsa.gov/topics/prescription-drug-misuse-abuse
  2. Misuse of Prescription Drugs: National Institute on Drug Abuse https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/summary
  3. Women Dying of Opioid Overdose at Unprecedented Rates, Medscape Medical News, July 2, 2013, Megan Brooks.
  4. Dealing with Drug-Seeking Patients in the Emergency Department, AHC Media, LLC.
  5. AMA: Prescription Drug Misuse, Overdose and Death https://www.ama-assn.org/delivering-care/prescription-drug-misuse-overdose-death
  6. National Quality Foundation Opioid Stewardship Action Team: http://www.qualityforum.org/National_Quality_Partners_Opioid_Stewardship_Action_Team.aspx
  7. Although Relatively Few, “Doctor Shoppers” Skew Opioid Prescribing https://www.drugabuse.gov/news-events/nida-notes/2014/05/although-relatively-few-doctor-shoppers-skew-opioid-prescribing
  8. SAMHSA’s Efforts to Fight Prescription Drug Misuse and Abuse https://www.samhsa.gov/prescription-drug-misuse-abuse/samhsas-efforts
  9. CDC: Prescription Painkiller Overdoses: https://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html