Substance Abuse & Diversion in Palliative Care

Substance Abuse & Diversion in Palliative Care Screening Survey Tools Select the right tool(s) for your purposes and practice Patient self-administers vs Clinician interview Length vs Thoroughness Substances assessed Initial Assessment vs Ongoing monitoring Validation for your general patient population and that individual patient Purpose of the tool s findings understand the interpretation Ease of scoring No conclusions should ever be made from a single screening tool Low-risk patients can still become addicted and high-risk patients may never become addicted Opioid Risk Tool (ORT) [www.partnersagainstpain.com/printouts/opioid_risk_tool.pdf] Short, only 5 questions Easily scored and adaptable to electronic health records Self-administered and can easily be incorporated into paperwork for new patients Validated in male and female pain patients, although not validated in non-pain patients Excellent in differentiating high- vs low-risk for future abusive drug-related behavior (c > 0.8) May be susceptible to intentional deception Revised Screener & Opioid Assessment for Patients with Pain (SOAPP-R) [www.painedu.org/soapp.asp] Moderately long (24 questions) Easily scored Self administered Validated and cross-validated in chronic noncancer pain patients Screens for high-risk for future aberrant drug-taking behaviors (91% sensitivity) Less susceptible to overt deception compared with original SOAPP Diagnosis, Intractability, Risk, and Efficacy Score (DIRE) [www.emergingsolutionsinpain.com/content/tools/esp_9_instruments/pdf/dire_score.pdf; also available as free iphone app] Short (7 total questions) Physician interview Well-suited for documentation in electronic medical records Good inter-rater reliability Predicts compliance with 94% sensitivity and 87% specificity with long-term opioid treatment Pain Medication Questionnaire (PMQ) Long (26 questions) but thorough Self administered Good for ongoing monitoring Apparently only available for purchase from wiley Prescription Opioid Misuse Index (POMI) [www.oasas.ny.gov/admed/fyi/pomifyi.cfm] Short (8 or 6 question versions) Physician interview Good for ongoing monitoring and easily documented in electronic medical records Validated in chronic pain patients with good sensitivity and specificity, although small study Attempts to incorporate behaviors driven by addiction rather than uncontrolled pain 2013 AAHPM & HPNA Assembly

2 of 8 Restricted Medication Agreements Introduces the concept of multimodality and/or multidisciplinary approach to pain management Reinforces the team approach to pain, stressing the inclusion of the patient as part of that team Provides an opportunity for patient education about safety, interactions among medications and substances, potential negative effects, and governmental regulations Lays out what you expect of the patient and what the patient can expect of you Sample: Getting the Best Results from Opioids and Other Symptom Management Medications: A Partnership Agreement The prescribing and dispensing of controlled substances (e.g. opioids, sedatives, stimulants, etc) is closely monitored by government agencies both at the state and federal levels. To protect both you and your provider, a controlled substance agreement must be signed by patients receiving controlled substances from our healthcare team. Healthcare Provider: Amy L. Davis, DO, MS, FACP, FAAHPM Contact #: (610) 520-1677 Patient: Your Provider s Goal: To adequately treat your pain and other symptoms so that your quality of life is maximized. Your Healthcare Provider s Responsibilities: 1. To explore all aspects of your history and your experience of pain and other symptoms. 2. To accept your reports of pain and other symptoms and your responses to treatment. 3. To evaluate the causes of your symptoms and review all treatment options with you. 4. To explain the risks, benefits, and potential side effects of these treatment options to you and be available to answer any of your questions so that you are informed about your treatment options. 5. To respect your right to participate in symptom management decisions, including your freedom to accept or reject treatment options based on your beliefs, experiences, and understanding of these treatment options. 6. To facilitate your access to medical care, even when the provider is not personally available. 7. To refill your medications as agreed upon in this agreement. 8. To advocate on your behalf concerning the appropriate use of medications for symptom management. Your (Patient's) Goal: To improve my ability to function and/or work and to be able to spend time with family and friends with reduced pain and other symptoms. Your (Patient's) Responsibilities: 1. I am responsible for my controlled medications. If the medications are lost, misplaced, or stolen, or if I use them up sooner than prescribed, I understand that they will not be replaced. 2. I will take my medication in the manner and doses as prescribed by my provider. I will make no changes to the dose or timing of the medication without first discussing it with my provider listed above. 3. I will not request or accept controlled medications from any other provider without first discussing it with my above listed provider, as this may cause overdosing and be harmful to me. 4. I will not share or allow anyone else to use my medications. I will keep all medications away from children.

3 of 8 5. I will plan for when I need more medication and will request my medication refills during regular clinic visits. Refills will not be made at night, on holidays, or on weekends. This is because a provider who is on call at these times may not know me and therefore cannot safely refill my medications. 6. I understand that the use of alcohol and illegal/illicit drugs in combination with my prescribed medication may harm me and could be lethal. I agree to not use any illegal/illicit drugs or any medications not prescribed to me. 7. I agree to participate in random drug screening. I understand that a drug screen is a test that checks to see what medications or other substances I am taking. 8. I understand that controlled medications can cause drowsiness. I will not drive a motor vehicle or operate equipment or machinery that is dangerous while I am sleepy or drowsy. 9. I understand that I need to obtain my controlled medications from one pharmacy. I will inform my provider in advance if I change to a different pharmacy. My Pharmacy: Pharmacy Phone #: 10. I authorize my provider to provide a copy of this contract to my pharmacy. 11. For the purpose of optimizing my medical care, I authorize my provider to discuss all diagnoses and treatment details with pharmacists, physicians, or other health care providers when necessary. 12. I will participate in medical, psychological, or psychiatric assessments recommended by my provider. 13. I understand that if I do not comply with this agreement, my controlled medications may not be refilled due to the associated medical and safety risks, and my treatment may be discontinued. 14. I understand that if the violation of this agreement involves obtaining controlled medications from another individual, misusing or selling controlled substances, or using illegal drugs, I will no longer be able to obtain treatment from this healthcare team. This may be reported to other healthcare providers, medical facilities, and other agencies as appropriate. This agreement has been explained to me by my healthcare provider, and my questions concerning this agreement have been answered. I understand the consequences of violating this agreement. Signature of Patient: Name of Patient: Provider Signature: Date: Date: I have not executed this contract with my patient,, because he/she has not given any indication of the ability to comprehend the contents or intent of this document. I have not presented this contract to my patient,, because, in my clinical judgment, he/she would suffer immediate and severe injury from a discussion of this document. Signature of Provider Date

4 of 8 Urinary Drug Screening: Talk to the patient in advance: Communicate what it is and why Ask if any medications or substances were used since the last visit that might appear (amount, when, why) can be an opportunity for re-education about safety and/or the Agreement Assays and companies can vary in sensitivity, specificity, and exact time periods for detection Know what substances are included when using panels, and order additional screens as needed For example, fentanyl, oxycodone, hydrocodone, tramadol etc often not detected as opioids For example, MDMA ( ecstasy, E ) may not be detected as amphetamine Be aware of possible false positives and false negatives Use confirmatory tests (e.g. GC-MS) for positive results No conclusions should ever be made from a single screening tool Criteria to avoid false negatives * (Lab Report should show): At least 30mL preferred Temperature 32 C 38 C ph 4.5 8.5 Nitrates < 500 mcg/ml Specific gravity 1.002 1.020 Creatinine > 20mg/dL *Adapted from Standridge JB, Adams SM, et al. Urine drug screen: a valuable office procedure. Am Fam Physician. 2010; 81(5): 635-640. Things to remember with false negatives and false positives The cut-off for opiates was raised in 1998 by DHHS to avoid false positives from poppy seed ingestion, but some assays use the lower cut-off to avoid false negatives know the assay Hemp-containing foods can show THC on screen but GC-MS should confirm 1 Passive cocaine and marijuana smoke has never been documented to achieve detectable levels in urine in adults (but passive cocaine smoke in pediatrics can) GC-MS may detect the metabolites of heroin (morphine) or hydrocodone (hydromorphone) but not the parent compound UDS Class Potential Culprits Amphetamine/Methamphetamine Amantadine, brompheniramine, buproprion, chlorpromazine, desipramine, desoxyephedrine, ephedrine, fluoxetine, isometheptene, isoxsuprine, labetalol, phentermine, phenylephrine, phenylpropanolamine, promethazine, pseudoephedrine, ranitidine, selegiline, thioridazine, trazodone, trimethobenzamide, trimipramine, Vicks inhaler (not with new assays) Barbiturates Ibuprofen, naproxen Benzodiazepines Oxaprozin, sertraline Cannabinoids Dronabinol, efavirenz, hemp-containing foods, ibuprofen, ketoprofen, naproxen, piroxicam, promethazine, proton pump inhibitors (pentoprazole), sulindac, tolmetin Cocaine Amoxicillin, coca leaf teas, tonic water Lyseric Acid Diethylamine (LSD) Amitriptyline, dicyclomine, ergotamine, promethazine, sumatriptan Methadone Chlorpromazine, clomipramine, diphenhydramine, doxylamine, ibuprofen, quetiapine, thioridazine, verapamil Opioids Dextromethorphan, diphendyramine, fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin), poppy seeds and oil (depending on assay), rifampin, quinine Phencyclidine Dextroamphetamine, dextromethorphan, diphenhydramine, doxylamine, ibuprofen, imipramine, ketamine, meperidine, thioridazine, tramadol, venlafaxine Tricyclic Antidepressants Carbamazepine, cyclobenzaprine, cyproheptadine, diphenhydramine, hydroxyzine, quetiapine Adapted from Williams, Krista. What drugs are likely to interfere with urine drug screens? Drug Information Group. University of Illinois at Chicago, 2007. Web. 16 February 2013. <http://dig.pharm.uic.edu/faq/2011/feb/faq1.aspx>.

5 of 8 Included with permission from, and special thanks to, Dr. Wolf Additional Free Educational Resources Opioid Risk: Skills to Minimize the Risk of Prescription Opioid Misuse www.opioidrisk.com PainEdu: Improving Pain Treatment through Education www.painedu.org/course.asp Partners Against Pain (clinician and patient resources) www.partnersagainstpain.com Emerging Solutions in Pain www.emergingsolutionsinpain.com Downloadable patient education handouts www.painknowledge.org/patiented/patiented.aspx

6 of 8 References Belgrade MJ, Schamber CD, Lindgren BR. The DIRE score: predicting outcomes of opioid prescribing for chronic pain. J Pain. 2006; 7: 671-681. Brahm NC, Yeager LL, Fox MD, Farmer KC, Palmer TA. Commonly prescribed medications and potential false-positive urine drug screens. Am J Health-Syst Pharm. 2010;67(16):1344-1350. Butler SF, Fernandez K, Benoit C, et al. Validation of the Revised Screener and Opioid Assessment for Patients in Pain (SOAPP-R). J Pain. 2008; 9: 360-372. Butler SF, Katz N, Budman, et al. Cross validation of a screener to predict opioid misuse among chronic pain patients (SOAPP-R). J Addict Med. 2009; 3(3): 66-73. Dowling LS, Gatchel RJ, Adams LL, et al. An evaluation of the predictive validity of the Pain Medication Questionnaire with a heterogeneous group of patients with chronic pain. J Opioid Manag. 2007; 3(5): 257-266. Holmes CP, Gatchel RJ, Adams LL, et al. An opioid screening instrument: long-term evaluation of the utility of Pain Medication Quesionnaire. Pain Pract. 2006; 6: 74-88. Knisely JS, Wunsch MJ, Cropsey KL, et al. Prescription Opioid Misuse Index: a brief questionnaire to assess misuse. J Subst Abuse Treat. 2008; 35: 380-386. Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008; 83(1): 66-76. Opioid Risk: Skills to Minimize the Risk of Prescription Opioid Misuse. Clinical Tools, Inc. 8 February 2013. Web. 16 February 2013. <www.opioidrisk.com> Passik SD, Kirsh KL, Casper D. Addiction-related assessment tools and pain management: instruments for screening, treatment planning and monitoring compliance. Pain Med. 2008; 9(S2): S145-S166. Standridge JB, Adams SM, Zotos AP. Urine drug screen: a valuable office procedure. Am Fam Physician. 2010; 81(5): 635-640. Vincent EC, Zebelman A, Goodwin C. What common substances can cause false positives on urine drug screens for drugs of abuse? J Fam Pract. 2006;55(10):893-894, 897. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005; 6(6): 432-442. Williams, Krista. What drugs are likely to interfere with urine drug screens? Drug Information Group. University of Illinois at Chicago, 2007. Web. 16 February 2013. <http://dig.pharm.uic.edu/faq/2011/feb/faq1.aspx>. Woelfel JA. Drug abuse urine tests: false-positive results. Pharmacist's Letter/Prescriber's Letter. 2005;21(3):210314. Wolf CE. Interpretation of Urine Drug Test (UDT) based on opioid prescribed. VCU Chronic Non-malignant Pain Curriculum. Virginia Commonwealth University, 2008. Web 12 December 2012.<http://www.paineducation.vcu.edu/documents/UDTbyOpioidPrescribed.pdf>.

You cannot take care of them if you do not take care of yourself 7 of 8 Self-Care Tips n Reflection upon work: What inspired/moved me today? Why do I do this? n Attend to health: diet, exercise, rest, regular health care, plan quiet time every day n Plan activities that rejuvenate: Play! n Give important relationships priority n Debrief emotional events You re not alone n Seek professional support when needed n If you are a spiritual &/or religious person, reinforce your beliefs regularly n Development of self-awareness skills Know your baggage; Periodically re-assess how you are Mindfulness meditation Reflective writing n Promote feelings of choice & control when able n Reflective writing n Recognize & Reward yourself for work well done (e.g. early coffee break) n Set your watch or telephone alarm for midday each day. Use this as a prompt to perform some simple act of centering Take 4 deep, slow breaths Think of a loved one Recite a favorite line of poetry or a prayer n Give yourself a time out for emotional flooding after a traumatic event n Stop at a window in your workplace & notice something in nature consciously give it your full attention for a few moments n Remember to laugh! n Deliberately develop a role-shedding ritual at the end of the day Pay attention to putting away your stethoscope or hanging up your white coat Use the drive home from work deliberately Take the longer more interesting route Listen attentively to news, music, or books on tape Shower &/or change your clothes Meditate or exercise Shapiro SL. The art and science of meditation. Paper presented at: Cassidy Seminars; June 27, 2008; Skirball Cultural Center, Los Angeles, CA.

8 of 8 Burnout Sound Familiar? n I m the only one who can do this right n I don t have time to do the things I enjoy n It s hard to fall asleep I have too much on my mind n I keep thinking about Mr. X s wife n I m overwhelmed almost all the time n I can t think straight anymore Increased Risk of Burnout Younger practitioners More responsibilities at home (kids, elderly parents/grandparents, needy spouse) Being single Highly motivated professionals Diminished awareness of one s own needs (physical and emotional) or postponing attention h/o prior mental health issues (esp depression) Inadequate coping w/ one s own emotional response to dying patients The need to carry on as usual in wake of pt deaths Why is Burnout Bad? Patient Care Suffers n Suboptimal patient care practices n Medical errors by physicians increase n Associated with lower patient satisfaction n Longer post-discharge recovery n Work tardiness n Procrastination n Resentment You (and Family) Suffer Emotionally n Lower satisfaction with career choice n Anxiety n Irritability n Social withdrawal n Apathy n Chronic mental fatigue n Desire to drop out of society n Chronic sadness You Suffer Physically Physical Stress Arousal n Poorer health overall n Hypertension n Insomnia n Palpitations n Forgetfulness n Headaches. Energy Conservation n AM fatigue n Increased alcohol/caffeine consumption Exhaustion n Physical fatigue overall n Depression n Chronic heartburn n Diarrhea Constipation The heart must first pump blood to itself.