Prescription Drug Abuse and Drug Seekers. IDN Summit Brian Fingerson, RPh

Transcription

1 Prescription Drug Abuse and Drug Seekers IDN Summit Brian Fingerson, RPh

2 What is Prescription Drug Abuse? Prescription drug abuse (PDA) is the intentional misuse of a medicine outside of the normally accepted standards for its use

3 When used appropriately, prescription drugs are invaluable in treating a wide variety of debilitating disorders Make complex surgical procedures are possible Relieve pain for millions of people Enable many individuals with chronic medical conditions to control their symptoms and lead productive lives

4 But When used non-medically, they can be dangerous, addicting and even deadly! And for many it is illegal!

5 Prescription Drug Abuse is a Growing Problem Approximately 14.7 million people used prescription drugs non-medically in National Household Survey on Drug Abuse Data

6 National Center on Addiction and Substance Abuse (CASA) Exhaustive national study of the diversion and abuse of prescription drugs on the Internet Americans are abusing prescription drugs at alarming rate February 2004

7 CASA s Study: The problem was judged so severe that they released a White Paper Report: You ve Got Drugs Prescription Drug Pushers on the Internet

8 CASA s Study & Findings: Snap shot in time between Jan 15-22, 2004 Identified 495 sites offering prescription drugs

9 CASA s Findings: 41% of the Sites did not require a prescription 49% offered an online consultation 4% required that a prescription be faxed 2% required that a prescription be mailed 4% made no mentions of prescriptions

10 Example of an Online Pharmacy: Q: Do I need a prescription? A: Instead of a traditional physical exam by a physician, the patient is allowed to decide for himself depending on the symptoms what s right for him.

11 Some of the PD s available on the Internet are: Percocet Percocet Lortab Lortab Lortab OxyContin OxyContin Dilaudid Dilaudid Tylox Tylox Valium Valium Vicodin Vicodin Fentanyl Fentanyl Ritalin Ritalin

12 Online Pharmacy Example: Orlando DEA Task Force purchased OxyContin over the Internet w/o a prescription Site requested them to check a box that said: medical records would be sent but charged the credit card and sent the Oxy w/o receiving the records One month later this online pharmacy charged the credit card and sent a refill order w/o a request

13 CASA s Findings: Internet provides wide-open channel of prescription drugs distribution Ease of availability has enormous implications for public health No mechanism in place to block youth or drug pushers from purchasing these drugs

14 Particular concern of PDA for: Adolescents Most dramatic increase in new users: 12 to 17 yr. olds and also in 18 to 25 yr. olds National Survey on Drug Use and Health

15 Particular concern of PDA for: Women 12 to 17 yr. old girls were more likely to use prescription drugs than boys Women are twice as likely to become addicted National Survey on Drug Use and Health

16 Particular concern of PDA for: Older adults 17% of 60 + yr. olds are affected by prescription drug abuse Less compliant, more vulnerable to problems: falls, injuries from impairments National Survey on Drug Use and Health

17 Why are Prescription Drugs so Popular? Easy to obtain Cheaper Legal Safer & non-addictive

18 Why are Prescription Drugs Safer: so Popular? Easily identity and less stigma than street drugs I m not a heroin addict but Higher purity and less risky but Safer because it's a prescription drug : Grandma's pills might not be so safe!!!

19 Why are Prescription Drugs Safer: so Popular? Easier to use, no IV injecting but what about tolerance Less HIV or hepatitis risk but Individual may not use IV injection but drug use impairs judgment and risk of sexuallytransmitted disease may remain high

20 Why do People Become Prescription Drug Abusers? 1. Some people who abuse PD s do so intentionally from the outset 2. For others, what began as prescribed use escalates over time

21 2. For these others. Started using on their own, self-medicate: to take care of their own anxiety, depression, pain, This misuse may escalate over time to abuse and addiction

22 Identify Patients as: Use (Low risk) Non-users Misuse (At risk) Abuse (Problem) Addiction IOM Continuum Model alcohol use

23 Misuse vs. Abuse Substance misuse - use of a drug that varies from a socially or medically accepted use Substance abuse - any use of drugs that causes physical, psychological, economic, legal or social harm to the individual user or to others affected by the drug user s behavior

24 Identify Patients as: Use (Low risk) Non-users Misuse (At risk) Abuse (Problem) Addiction IOM Continuum Model alcohol use Brain gets hijacked The brakes of brain stop functioning properly

25 Identify Patients as: Use (Low risk) Non-users Misuse (At risk) Any use of other drugs is misuse Abuse (Problem) Addiction IOM Continuum Model for other drug use

26 Health Professionals Have An Excellent Opportunity To: Identify/screen for alcohol and other drug use in patients Give drug use prevention messages to patients Do brief interventions on patients who are misusing and abusing drugs

27 Health Professionals have an Excellent Opportunity to: Refer addicted patients for assessment and/or treatment Support/monitor addicted patients during their recovery Minimize relapse in recovering patients

28 Identify Patients as: Use (Low risk) Non-users Misuse (At risk) Abuse (Problem) Addiction What s happening in the brain?

29 Pleasure Center Nucleus Accumbens Stimulates NAc NAc Dopamine Normal pleasure response

30 Reward Pathway Drugs act on the Pleasure Center (NAc) The Wow!!! is a big reason people take drugs but other things also happen Dopamine surge!!! NAc Wow!!! VTR Drugs

31 Reward Pathway Areas Emotional & behavioral learning Dopamine surge!!! Wow!!! Control of body movement Early learning and memory processing Drugs Attention states and automatic function

32 Reward Pathway Frontal Cortex A molecular switch is thrown in the brain Wow!!! Compulsive drug seeking behavior Loss of control over drug use Triggers Addiction Drugs

33 Reward Pathway Frontal Cortex Wow!!! Addiction is a Brain Disease Opiates Alcohol Cocaine Amphetamines Marijuana

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35 Addiction A disease characterized by continued use and abuse of a drug despite recurring negative consequences in a person s life Loss of control over taking a substance

36 DSM IV: Diagnosis of Substance Dependency (3 out of 7) 1. Tolerance 2. Withdrawal Loss of Control: 3. Used more and longer than planned 4. Unsuccessful attempts to quit or control use 5. Excessive time spent obtaining, using, or recovering from use 6. Important activities given up 7. Continued use despite adverse consequences

37 American Society of Addiction Medicine and National Council on Alcoholism and Drug Dependency Disease Definition of Chemical Dependency

38 Chemical dependency is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.

39 The disease is progressive and fatal.

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41 Denial from Knots by R.D. Lang There must be something the matter with him because he would not be acting as he does unless there was. Therefore he is acting as he is because there is something the matter with him.

42 Denial continued: He does not think there is anything the matter with him because one of the things that is the matter with him is that he does not think that there is anything the matter with him. Therefore we have to help him realize that, the fact that he does not think there is anything the matter with him is one of the things that is the matter with him.

43 HCP good at cover up and if confronted will deny Denial is not just a river in Egypt Paranoia and irritability Depression Use of large quantities of alcohol more than normal or more than others present Blackouts

44 Blackouts - Once a person has had one Fr Vernon Johnson 1) You can never tell how much of the chemical it will take to put you into the blackout again. 2) You can never tell how long the blackout will last. 3) There is no connection between our value system and what we will do in a blackout.

45 Problems continued: Slurred speech frequent drunkenness Personal problems Parenting problems Sexual dysfunction or promiscuity Insomnia Having ONLY friends who like to party

46 Problems continued: Frequent promises to cut back Avoiding social functions unless altered Memory problems Mood swings Blaming of behavior on others Withdrawal into isolation

47 Problems continued: Legal problems e.g. DUI Health problems or injuries due to accidents Attempted suicide

48 Impairment signs/symptoms in the workplace: Changes in the manner in which patients and colleagues are treated Deterioration of personal appearance and hygiene Loss of interest in work, or. Super Pharmacist or Super whatever

49 Workplace continued: Poor record keeping Problems with concentration Treatment errors or whatever Absenteeism or tardiness, esp. on day following days off Pattern of frequent job changes

50 Clinical Implications to Identifying Drug Abusers 3% of alcoholics and other drug dependent patients can be easily recognized 97% either deny or are unaware of the extent of their problem and continue to maintain social and work relationships These factors make identification challenging

51 Beliefs and attitudes can also interfere with our ability to identify alcohol and other drug problems

52 Barriers to recognizing a drug problem Belief that persons with drug problems fit a specific stereotype The image of a skid-row bum

53 Other barriers to recognizing a drug problem Discomfort in asking personal questions about drug problems 46.6% of physicians find it difficult to discuss prescription drug abuse with their patients A tendency to treat specific complaints without checking to see if they are related to drug problems

54 Health Professionals Have An Excellent Opportunity To: Identify/screen for alcohol and other drug misuse and abuse Give drug use prevention messages to patients who are misusing and abusing drugs

55 Health Professionals have an Excellent Opportunity to: Refer dependent patients for assessment and/or treatment Support/monitor dependent patients during recovery Minimize relapse in recovering patients

56 However There will always be a certain number of patients who present to you as a practitioner who are drugseeking.

57 How do people get these drugs? Percocet Percocet Lortab Lortab Lortab OxyContin OxyContin Dilaudid Dilaudid Tylox Tylox Valium Valium Vicodin Vicodin Fentanyl Fentanyl Ritalin Ritalin

58 How do people get these drugs? Thefts and break-ins from pharmacies and warehouses Accosting customers in drugstore parking lots Breaking into homes of patients who use these drugs Employees stealing from hospitals

59 How do people get these drugs? Inappropriate prescribing by physicians Unscrupulous physicians selling drugs Patients with legitimate prescriptions selling the pills

60 How do people get these drugs? Smuggling of pharmaceutical drugs Illegal sales & distribution over the Internet

61 How do people get these Doctor shopping drugs?

62 Profile of Drug Seeking Behaviors Patient Becomes Doctor Emotional Tactics Out of Town Patient Telephone Scams Addiction Confessions

63 How do people get these drugs? Altering and forging prescriptions Tampering, forging and counterfeiting prescriptions Photocopying or designing form Ask doctor for another drug and soak off ink and rewrite script Tamper proof prescription pads

64 Alteration of Prescriptions

65 Drug-Seeking Behavior Individual claims to be from out of town and to have lost prescription, forgotten to pack medication, or saying that it was stolen I flushed them down the toilet by accident The dog ate them

66 Drug Scams Person reads obituaries and contacts prescriber for prescription, posing as an out-of-town relative of the deceased Practitioner prescribes for fictitious patient and then picks up medication for personal abuse Scams are only limited by the imagination of the drug seeker

67 Kentucky All Schedule Prescription An electronic data monitoring system Electronic Reporting

68 National Initiative Being Implemented by States States with Monitoring Program Oklahoma Massachusetts Hawaii Nevada Utah Indiana Rhode Island West Virginia Michigan New Mexico Kentucky California Illinois Texas Washington Idaho New York Many states have reporting programs for at least one class of controlled substance Additional states are coming on-line with programs

69 Goals of Electronic Monitoring Designed to be: a source of information for practitioners and pharmacists an investigative tool for law enforcement GOALS Decrease doctor shopping

70 Kentucky Officials Launch MethCheck In November 2005 Kentucky officials launched a pilot program called MethCheck, in which an electronic database is used--in lieu of written logs- -to monitor pseudoephedrine (PSE) product sales in an attempt to curtail local methamphetamine production.

71 So what can we do? Learn all we can about a disease that impacts more people than diabetes. Left unrecognized and untreated the prognosis is jails, institutions, or death.

72 Questions? - Thank you Thank you Thank you Thank you