Critical Issues: Providing Relief Critical Issues: Providing Relief and Preventing Abuseand Preventing Abuse

C. Scott Anthony, D.O.C. Scott Anthony, D.O.

Tulsa Pain Consultants, Inc.Tulsa Pain Consultants, Inc.

Opioid Prescribing in Chronic PainOpioid Prescribing in Chronic Pain

Legitimate practiceLegitimate practice

Evidence of improved quality of life and Evidence of improved quality of life and functionalityfunctionality

But… issues remain:But… issues remain:Serious concerns about regulatory agenciesSerious concerns about regulatory agencies

Confusion and fearConfusion and fear

Skyrocketing abuse and diversion Skyrocketing abuse and diversion

Federal and State Federal and State Controlled Substance LawControlled Substance Law

AbuseAnalgesia

Joint Statement of 21Health Joint Statement of 21Health Organizations and the DEAOrganizations and the DEA

Undertreatment of pain is a serious problem in Undertreatment of pain is a serious problem in the United States. Effective pain management the United States. Effective pain management is an integral and important aspect of quality is an integral and important aspect of quality medical care and pain should be treated medical care and pain should be treated aggressivelyaggressively

Opioid analgesics, when used as recommended Opioid analgesics, when used as recommended may be the most effective and only treatment may be the most effective and only treatment option to manage painoption to manage pain

Joint Statement of 21Health Joint Statement of 21Health Organizations and the DEAOrganizations and the DEA

In spite of regulatory controls, drug abusers In spite of regulatory controls, drug abusers obtain these medications by diverting them obtain these medications by diverting them from legitimate channels: fraud, theft, forgery from legitimate channels: fraud, theft, forgery and dishonest physiciansand dishonest physicians

Drug abuse is a serious problem. Those who Drug abuse is a serious problem. Those who prescribe must be diligent to prevent diversionprescribe must be diligent to prevent diversion

Focusing only on the abuse potential can lead Focusing only on the abuse potential can lead to undertreatment of painto undertreatment of pain

Opioid DiversionOpioid Diversion

Public health and safety issuePublic health and safety issue

Methods:Methods:Theft, forgery of prescriptionTheft, forgery of prescription

Illegal sale of drugs and prescriptionsIllegal sale of drugs and prescriptions

Fraudulent patient contact with physiciansFraudulent patient contact with physicians

Impaired, dishonest physiciansImpaired, dishonest physicians

What about the honest physician trying to What about the honest physician trying to help? Should we worry?help? Should we worry?

National All Schedules Prescription National All Schedules Prescription Electronic Reporting (NASPER) ActElectronic Reporting (NASPER) Act2005 Federal Law that provides for the 2005 Federal Law that provides for the establishment of a state monitoring systemestablishment of a state monitoring system

Electronic monitoring for Schedule II-IV drugsElectronic monitoring for Schedule II-IV drugs

Requires dispensers to report to the stateRequires dispensers to report to the state

Each state develops an electronic database that is Each state develops an electronic database that is easily searchable by prescribers and dispenserseasily searchable by prescribers and dispensers

Prevention of diversion and abusePrevention of diversion and abuse

Physicians Should Be AwarePhysicians Should Be Aware

Pain and Policy Study GroupPain and Policy Study GroupFAQ Document in combination with the DEAFAQ Document in combination with the DEACo-sponsored document released Aug. 2004Co-sponsored document released Aug. 2004Removed from DEA website Oct. 2004Removed from DEA website Oct. 2004

PPSG with significant concernsPPSG with significant concernsAmerican College of Physicians voice concernAmerican College of Physicians voice concernNational Association of Attorneys General National Association of Attorneys General express concern in letter to DEAexpress concern in letter to DEA

DEA Concerns Outlined in the Federal DEA Concerns Outlined in the Federal Register (Nov. 2004)Register (Nov. 2004)

Multiple Schedule II prescriptionsMultiple Schedule II prescriptionsWhat constitutes a refill?What constitutes a refill?

Dealing with patients who knowingly abuse Dealing with patients who knowingly abuse their medicationstheir medications

Under no circumstances can a physician dispense Under no circumstances can a physician dispense with the knowledge…with the knowledge…

Concerns of family membersConcerns of family membersPhysicians should seriously consider any Physicians should seriously consider any expressed concern…expressed concern…

Recurring “Condemned Behavior” per Recurring “Condemned Behavior” per the DEA Federal Registerthe DEA Federal Register

Inordinately large number of prescriptionsInordinately large number of prescriptions

Inordinately large quantity prescribedInordinately large quantity prescribed

Known prescribing to drug addicts or dealersKnown prescribing to drug addicts or dealers

Prescribing inconsistent with legitimate Prescribing inconsistent with legitimate medical practicemedical practice

Physician used “street slang” when discussingPhysician used “street slang” when discussing

No logical relationship between drugs No logical relationship between drugs prescribed and treatment of the conditionprescribed and treatment of the condition

Legal PrecedenceLegal PrecedenceUnited States vs. Morton Salt Co.United States vs. Morton Salt Co.

It is a longstanding legal principle that the It is a longstanding legal principle that the Government “can investigate merely on Government “can investigate merely on suspicion that the law is being violated, or even suspicion that the law is being violated, or even that it wants assurances that it is not”that it wants assurances that it is not”

PPSG Response (Mar. 2005)PPSG Response (Mar. 2005)

DEA must reassure physicians that there are DEA must reassure physicians that there are specific indicators of diversion that are not specific indicators of diversion that are not confused with appropriate prescribingconfused with appropriate prescribing

Clarify clearly what constitutes “unlawful Clarify clearly what constitutes “unlawful conduct” regarding prescribingconduct” regarding prescribing

Avoid sending messages of fearAvoid sending messages of fear

Embrace the commitment to a “balanced Embrace the commitment to a “balanced Federal policy”Federal policy”

Drug AbuseDrug Abuse

Rapid escalation of epidemic proportionRapid escalation of epidemic proportion

7.3% of the population abuse illegal drugs7.3% of the population abuse illegal drugs

Hydrocodone, oxycodone and methadone Hydrocodone, oxycodone and methadone show >100% increase in abuse since 1994show >100% increase in abuse since 1994

Increases seen in:Increases seen in:ER visitsER visits

Health care costsHealth care costs

Loss of productivityLoss of productivity

Non-Medical Use of Prescription Non-Medical Use of Prescription DrugsDrugs

1992-2003: 94% increase1992-2003: 94% increase

3rd most abused substances3rd most abused substances

DAWN data 1992-2002:DAWN data 1992-2002:154% increase in prescription drugs prescribed 154% increase in prescription drugs prescribed

90% increase in number of people admitting to use90% increase in number of people admitting to use

There indeed is a link between increase in There indeed is a link between increase in prescribed drugs and abuse per the DAWN prescribed drugs and abuse per the DAWN and CASA dataand CASA data

Oxycodone AbuseOxycodone Abuse

166% increase in abuse 1994-2000166% increase in abuse 1994-2000

ER visits for overdose up 100% since 1996ER visits for overdose up 100% since 1996

Multiple reasonsMultiple reasonsPharmacologicalPharmacological

Easy to obtain/street cost lowerEasy to obtain/street cost lower

Abusers “knowledge”Abusers “knowledge”

Potent highPotent high

Concern about generic OxycontinConcern about generic Oxycontin

Hydrocodone AbuseHydrocodone Abuse

116% increase in abuse since 1994116% increase in abuse since 1994

Most commonly abused opioidMost commonly abused opioid

Schedule IIISchedule IIIPhone-in prescriptionsPhone-in prescriptions

Less trackingLess tracking

Acetaminophen issuesAcetaminophen issues

Methadone AbuseMethadone Abuse

140% increase since 1994140% increase since 1994

Significant problem in Oklahoma with marked Significant problem in Oklahoma with marked increase in deathsincrease in deaths

Nationwide increase in deaths due to abuseNationwide increase in deaths due to abuse

PharmacologyPharmacologyLong, variable half-lifeLong, variable half-life

Potent, difficult to convert, titratePotent, difficult to convert, titrate

Pain and AddictionPain and Addiction

Continued use despite adverse consequencesContinued use despite adverse consequencesImpaired control and compulsive useImpaired control and compulsive usePreoccupation with obtaining drugsPreoccupation with obtaining drugsCAGE QuestionaireCAGE Questionaire

Have you tried toHave you tried to CutCut down? down?Do you get Do you get AnnoyedAnnoyed with people discussing your with people discussing your use?use?Do you feel Do you feel GuiltyGuilty about using drugs? about using drugs?Do you need an Do you need an EyeEye-opener?-opener?

Pain and Drug AbusePain and Drug Abuse

Addiction and abuse are not the sameAddiction and abuse are not the same

Abuse as defined by the DSM-IVAbuse as defined by the DSM-IVOveruse in cases of celebration, stress, anxiety, Overuse in cases of celebration, stress, anxiety, despair, ignorance or self medicationdespair, ignorance or self medication

Examples: “rational abuser” or “chemical Examples: “rational abuser” or “chemical coper”coper”

Multiple studies suggest abuse rate may be Multiple studies suggest abuse rate may be 3.2-28% of those with chronic pain3.2-28% of those with chronic pain

Detecting AbuseDetecting Abuse

Using opioids for Using opioids for psychological reliefpsychological relief

Using opioids when Using opioids when mad, sad, happy or gladmad, sad, happy or glad

Using opioids with Using opioids with other illicit drugsother illicit drugs

Using illegal means to Using illegal means to obtain opioidsobtain opioids

Using opioids against Using opioids against medical advice medical advice (compulsive, overuse)(compulsive, overuse)

Using opioids with Using opioids with alcoholalcohol

““Doctor shopping”Doctor shopping”

Using deception to Using deception to obtain more opioidsobtain more opioids

Important “Red Flags” at TPCImportant “Red Flags” at TPC

Past substance abusePast substance abuseNonfunctionalNonfunctional

MedicaidMedicaidDisabilityDisabilityWork compWork comp

Excessive opioid needsExcessive opioid needsDose escalationsDose escalationsER visitsER visitsAsking for higher dosesAsking for higher dosesMultiple phone callsMultiple phone calls

Deception or lyingDeception or lyingDoctor shoppingDoctor shoppingAsking for specific Asking for specific opioids or Somaopioids or SomaCurrent or prior use of Current or prior use of illicit drugsillicit drugsPharmacy concernsPharmacy concernsIntolerance to opioidsIntolerance to opioids

Common Signs of a Drug Seeker or Common Signs of a Drug Seeker or AbuserAbuser

Physical signsPhysical signsPoor compliancePoor complianceLost prescriptionsLost prescriptionsStolen prescriptionsStolen prescriptionsFunny storiesFunny storiesNo interest in workupNo interest in workupKnowledge of opioidsKnowledge of opioidsLengthy travel to see Lengthy travel to see youyou

Appointments late in the Appointments late in the daydayNight and weekend Night and weekend phone callsphone callsManipulativeManipulativeSpeak poorly of other Speak poorly of other physiciansphysiciansHistory of many doctorsHistory of many doctorsThat “gut feeling”That “gut feeling”

A Comparative Evaluation of Illicit Drug A Comparative Evaluation of Illicit Drug Use in Patients With or Without Controlled Use in Patients With or Without Controlled

Substance Abuse in Pain ManagementSubstance Abuse in Pain Management

Pain PhysicianPain Physician, 2003;6:281-285, 2003;6:281-285

MethodsMethods

Consecutive, double blind, clinical evaluationConsecutive, double blind, clinical evaluation

150 patients150 patientsGroup I: 100 patients without signs of abuseGroup I: 100 patients without signs of abuse

Group II: 50 patients with signs of abuseGroup II: 50 patients with signs of abuse

All underwent urine drug screen to test for All underwent urine drug screen to test for marijuana, methamphetamine, amphetamine marijuana, methamphetamine, amphetamine and cocaineand cocaine

ResultsResults

Group I (without signs of drug abuse)Group I (without signs of drug abuse)10% positive for marijuana10% positive for marijuana4% positive for cocaine4% positive for cocaineNone positive for methamphetamine or None positive for methamphetamine or amphetamineamphetamine

Group II (with signs of drug abuse)Group II (with signs of drug abuse)22% positive for marijuana22% positive for marijuana12% positive for cocaine12% positive for cocaineNone for meth or amphetamineNone for meth or amphetamine

The RealityThe Reality

The national drive to eliminate under-The national drive to eliminate under-treatment of pain and relieve suffering has treatment of pain and relieve suffering has given drug abusers and addicts an added given drug abusers and addicts an added advantage and opportunity to obtain opioids advantage and opportunity to obtain opioids from physicians thus contributing to the risk of from physicians thus contributing to the risk of under treatment of those patients who would under treatment of those patients who would legitimately benefit from opioid therapylegitimately benefit from opioid therapy

Essential Components of Pain Essential Components of Pain Evaluation and AssessmentEvaluation and Assessment

Assess pain intensity and characterAssess pain intensity and character

Evaluate the psychosocial status of the patientEvaluate the psychosocial status of the patient

Perform physical and neurological Perform physical and neurological examinationexamination

Perform a diagnostic evaluation to determine Perform a diagnostic evaluation to determine pathology, recurrence or progressionpathology, recurrence or progression

Frequently reassess pain and side effects of Frequently reassess pain and side effects of treatmenttreatment

The Importance of Medical RecordsThe Importance of Medical Records

H&P, diagnostic studies and consultationsH&P, diagnostic studies and consultations

Attempted treatment modalitiesAttempted treatment modalities

Treatment objectivesTreatment objectives

Informed consentInformed consent

Periodic review of treatment planPeriodic review of treatment plan

Record of prescribed medicationsRecord of prescribed medications

Optimizing Management of Optimizing Management of Chronic PainChronic Pain

Goals to increase function and decrease painGoals to increase function and decrease pain

To achieve goals a combination of To achieve goals a combination of pharmacological and non-pharmacological pharmacological and non-pharmacological treatment is often requiredtreatment is often required

Opioid therapy alone is usually not sufficientOpioid therapy alone is usually not sufficient

Multidimensional approach works bestMultidimensional approach works best

Issues That Must Be Considered When Issues That Must Be Considered When Using OpioidsUsing Opioids

Pain is subjectivePain is subjective

Only appropriate in well selected patientsOnly appropriate in well selected patients

Some patients are focused on obtaining drugs Some patients are focused on obtaining drugs rather than pain reliefrather than pain relief

Most opioid abuse is a consequence of written Most opioid abuse is a consequence of written prescriptionsprescriptions

Detecting abuse is paramountDetecting abuse is paramount

Critical Issues When Using OpioidsCritical Issues When Using Opioids

Well-defined goalWell-defined goal

Patient selection (disease state, age etc.)Patient selection (disease state, age etc.)

Address psychological and social supportAddress psychological and social support

Case by case basisCase by case basis

Trial of therapyTrial of therapy

Documentation and follow-up careDocumentation and follow-up care

Types of Chronic Pain PatientsTypes of Chronic Pain Patients

Type I PatientsType I Patients

““chronic pain patientschronic pain patients

Poorly defined painPoorly defined pain

Multiple complaintsMultiple complaints

Using opioids poorlyUsing opioids poorly

Overlying psych issuesOverlying psych issues

Ongoing legal issuesOngoing legal issues

Unemployed or poor Unemployed or poor functionfunction

Type II PatientsType II Patients

Well defined etiologyWell defined etiology

Appropriate pain Appropriate pain mannerismsmannerisms

Few or no psych issuesFew or no psych issues

FunctionalFunctional

Compliant with Compliant with therapytherapy

Common MistakesCommon Mistakes

Continued escalation of medication with no Continued escalation of medication with no improvement in functionimprovement in function

Opioids used in pain syndromes known to be Opioids used in pain syndromes known to be poorly responsive poorly responsive

Not addressing psychological issuesNot addressing psychological issues

Lenient with abuse behaviorsLenient with abuse behaviors

Fear of converting to long acting medicationsFear of converting to long acting medications

Addressing Obvious AbuseAddressing Obvious Abuse

WEAN!WEAN!

Treat withdrawalTreat withdrawal

Contact other physicians and pharmaciesContact other physicians and pharmacies

Discharge letterDischarge letter

30 day supply of opioids?30 day supply of opioids?

Remember: An abuser will always find drugs Remember: An abuser will always find drugs but do all you can to protect yourselfbut do all you can to protect yourself

The Opioid ContractThe Opioid Contract

Mandatory for patients on Mandatory for patients on chronicchronic opioids opioidsSurprisingly the majority of our patients agree Surprisingly the majority of our patients agree and understand why we must do thisand understand why we must do thisKey points:Key points:

No function = no opioidsNo function = no opioidsLost, stolen, misplaced opioidsLost, stolen, misplaced opioidsOne pharmacyOne pharmacyUrine drug screensUrine drug screensPrivacy issuesPrivacy issues

Urine Drug ScreensUrine Drug Screens

TypesTypesDrug screen 9Drug screen 9

OPGCMSOPGCMS

Useful tool but not often used randomlyUseful tool but not often used randomly

Some studies suggest high incidence of abuseSome studies suggest high incidence of abuseNot taking prescribed drugNot taking prescribed drug

Taking opioids not prescribedTaking opioids not prescribed

Illicit drug useIllicit drug use

Informed ConsentInformed Consent

Malpractice lawsuits becoming more commonMalpractice lawsuits becoming more common““my doctor addicted me!”my doctor addicted me!”

The informed consent discusses:The informed consent discusses:Risk of addictionRisk of addiction

Risks of overuse and overdoseRisks of overuse and overdose

Risks of side effectsRisks of side effects

Key PointsKey Points

Thoroughly evaluate the pain complaintThoroughly evaluate the pain complaintConsider psychological issuesConsider psychological issuesConsider opioids as a treatment of last resortConsider opioids as a treatment of last resortUse a contract and informed consentUse a contract and informed consentPatients should demonstrate a high level of Patients should demonstrate a high level of responsibilityresponsibilityAn accountability system must be in placeAn accountability system must be in placePractice a zero-tolerance policyPractice a zero-tolerance policy