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Prescription Medication Misuse Screening and Mitigation

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Learning Objectives Recognize the risk factors and patient risk categories for medication misuse Determine which tools to use to screen for medication misuse Identify strategies for mitigating a patients risk for medication misuse Describe patient centered drug testing and how it differs from employer directed drug testing

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Prescription Medication Misuse Definition Taking medications for non-intended uses, differently than prescribed, without a prescription or with interacting substances.

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Screening for PMM Risk Assessment Risk factors for PMM Useful for risk stratifying patients Screening tools Ways to assess risk objectively Patient risk categories

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Risk Factors for Misuse Illicit drug use Previous substance use issues History of substance abuse (particularly multi-substance) Positive abnormal urine drug screen previously (unexpected positive) History of DUI/DWI Family history of drug abuse Psychiatric Dysfunction PTSD Depression Anxiety disorder Schizophrenia Younger age (less than 30, greater when less than 25) History of physical, emotional, or sexual abuse Smoking Chronic pain

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Odds Ratios for PMM History of nonopioid abuse2.34 (1.75-3.14) History of Alcohol abuse2.6 (1.12-6.26) History of Cocaine abuse4.3 (1.76-10.4) Smoking1.4 (1.1-1.8) DUI or drug conviction2.58 (1.01-6.59) Probable Depression2.4 (1.6-3.4) Mood disorder 3.5 (3.1-3.9) MDD3.2 (2.9-3.6) Bipolar disorder, type I4.7 (3.8-5.7) Anxiety disorder2.4 (2.2-2.8) PTSD2.45 (1.88-3.19) Chronic Pain1.9 (1.4-2.5) Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007;129:355-62. Ives TJ, Chelminski PR, Hammett-Stabler CA, Malone RM, Perhac JS, Potisek NM, Shilliday BB, DeWalt DA, Pignone MP. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46. Becker W, Fiellin D, Gallagher R, Barth K, Ross J, Oslin D. The association between chronic pain and prescription drug abuse in Veterans. Pain Medicine 2009; 10: 531-536. Martins S, Keyes K, Storr C, Zhu H, Chilcoat H. Pathways between nonmedical opioid use/dependence and psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions Drug and Alcohol Dependence. 2009: 1624. White AG, Birnbaum HG, Shiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Manag Care. 2009; 15: 897- 906.

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Risk Factors Limited Supporting Evidence Mostly based on studies of pain clinic patients Followed for opioid misuse Small, limited studies Not specific to Service Members Limited conclusions, but the best available to project to other patients and other medications

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Screening Tools for PMM Screening for future misuse, predicative tools SOAPP-R Opioid Risk Tool Tools for screening for current misuse PDUQ Physician administered Self report version COMM Tailored history by a clinician

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Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R) Self report survey 24 questions Each question scored 0-4 Score of 19 sensitivity 0.77 specificity 0.75 positive predictive value 0.62 negative predictive value 0.86. Butler S, Fernandez K, Benoit C, Budman S, and Jamison R. Validation of the Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R) The Journal of Pain, Vol 9, No 4 (April), 2008: pp 360-372 Available for reprint for clinical use at PAIN.edu Research use requires permission

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Opioid Risk Tool Self report tool 10 questions, maximum score of 26 (questions weighted differently based on predictive value) Score 8 is high risk Positive likelihood ratio 14.1, CI 5.35-38.4 Score 3 is low risk Positive likelihood ratio 0.08, CI 0.01-0.62 Less extensively evaluated

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Direct Comparison of Screening Tools for Future Misuse Clinical history focusing on risk factors - sensitivity of 0.77 SOAPP-R 0.72 ORT 0.45 Moore TM, Jones T, Browder J, Daffron S, and Passik SD. A Comparison of Common Screening Methods for Predicting Aberrant Drug-Related Behavior among Patients Receiving Opioids for Chronic Pain Management. Pain Medicine 2009; 10: (8) 1426-1433

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Clinician Focused History Clinical history focusing on risk factors - sensitivity of 0.77 Superior to self report screening tools Focused on risk factors and comorbid disorders When combined with SOAPP-R sensitivity was 0.90 Moore TM, Jones T, Browder J, Daffron S, and Passik SD. A Comparison of Common Screening Methods for Predicting Aberrant Drug-Related Behavior among Patients Receiving Opioids for Chronic Pain Management. Pain Medicine 2009; 10: (8) 1426-1433

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Tools to Screen for Current Misuse PDUQ COMM All tools for this purpose targeted patients already prescribed frequently misused medications no study in the general population

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Patient Drug Use Questionnaire (PDUQ) Clinician administered 42 questions 39 scored A yes is scored as a one and a no as a zero Non addicted people scored less than 10 Substance abusers scored between 11 and 25 Substance addicted patients scored 15 or higher 15 or more is indicative of problematic behavior 10 or less is a safe score Compton P, Darakjian J, Miotto K. Screening for Addiction in Patients with Chronic Pain and Problematic Substance Use: Evaluation of a Pilot Assessment Tool. Journal of Pain and Symptom Management 1998; 16: 355

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PDUQ For diagnosing CURRENT drug misuse Gold standard Certain questions more indicative Self report form less effective

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PDUQ Most Predictive Points Patient believes he/she addicted Physician believes patient is addicted Multiple prescription providers Increases analgesic dose/frequency Early prescription refills Use analgesics for other symptoms Save/hoard unused medication Supplement with alcohol/psychoactive drugs Prescription forgery Patient has a route of administration preference Emergency room visits for analgesics Obtained analgesic from street source MD/DDS limited care Family believes patient addicted Family interaction sustaining patient analgesic use All of the above had a P