Charlene M. Dewey, M.D., M.Ed., FACPCo-Director, Vanderbilt Center for Professional Health

William H. Swiggart, M.S., L.P.C./MHSPCo-Director, Vanderbilt Center for Professional Health

Martha E. Brown, M.D.Assistant Medical Director, PRN

UF Associate Professor of Psychiatry

Proper Prescribing and Substance Abuse Identification: A CME Intervention

All speakers acknowledge that they developed, teach, and operate CME courses (fee) for physicians and other health care providers on proper prescribing of CPDs.

COI

1: Discuss current information regarding controlled prescription drug abuse in the U.S., including how physicians continue to overprescribe to their patients

2: Become familiar with the components of screening, brief intervention and referral to treatment, (SBIRT)

3: Identify specific strategies to avoid risky prescribing to help physicians avoid trouble with their Boards or the DEA (including the use of the state prescription drug monitoring program and CME education)

Learning Objectives

Introduction Proper prescribing Continuing Medical Education interventions SBIRT Small group activity

Agenda

“To write a prescription is easy, but to come to an understanding with people is hard.”

~Franz Kafka A Country Doctor,1919

Introduction

“It is not what you prescribe, but rather how well you manage the patient's care, and document that care in legible form, that is important.”

~Released by the Minnesota MBE 1990, adapted by both the North Carolina and TN Boards of Medical Examiners

Introduction

The problem:Substance abuse, including controlled prescription

medication, is the nation's number one health problem affecting millions of individuals.4

Rate of controlled prescription drug (CPD) abuse has almost doubled from 7.8 million to 15.1 million in the past decade (1992 to 2003)2

New drug users of pain relievers-2.4 million. [marijuana (2.1 million) or cocaine (1.0 million)]

Controlled Prescription Drug Abuse

Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005.

Up to 43% of physicians DO NOT ask about controlled prescription drug abuse when taking a patient's health history

Only 19% received any medical school training in identifying prescription drug diversion

Only 40% received training on identifying prescription drug abuse and addiction5

many are not trained to effectively handle drug-seeking patients

due to “confrontational phobia”- a term used to describe physicians’ reluctance to say “no” to a patient, thus making physicians an “easy target for manipulation.”5

Controlled Prescription Drug Abuse

Bollinger et al, 2005

Obtained from a single doctor (19%)

Given free from a friend or rela-tive (56%)

Bought from a friend or relative (9%)

Bought from stranger/dealer (4%)

Internet (0.1%)

Sources of Misused Opioids

SAMHSA 2006

Definition: Prescribing scheduled drugs in quantities and frequency inappropriate for the patient’s complaint or illness.

Known alcoholic or drug addict Large quantities/frequent intervals Family members For trivial complaints

Misprescribing

Why Physicians Misprescribe Controlled Substances

Family of origin Core personality Patient types Pharmacological knowledge Professional practice system

Theories

DATED - fails to keep current

DISABLED - failed judgment due to impairment

DUPED - fails to detect deception

DISHONEST - personal or financial gain

DISMAYED - Rx as quick fix due to time constraints

DYSFUNCTIONAL - finds it hard to say NO

Categories of Misprescribing Physicians

ADDICTION TREATMENT WORKS

Addiction vs. Substance AbuseRelapse Rates vs. Other Chronic Diseases

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DrugDependence

Type I Diabetes Hypertension Asthma

40%

to

60

%

30%

to

50

%

50%

to

70%

50%

to

70%

% o

f P

ati

en

ts w

ho

Re

lap

se

Average Age = 51

Male = 88%

Female = 11%

N = 715

Demographics

1940's 1950's 1960's 1970's 1980's 1990's 2000's

635

74

189

227

151

16

Medical School Graduation

January 1996 – March 2010

1%

5%

10%

27%

32%

21%

2%

Practice Type

January 1996 – March 2010

Total N = 715

0

50

100

150

200

250

300

350

Solo Partnership orGroup

Hospital-Based Other

49%

34%

9% 8%

Specialty Demographics

January 1996 – March 2010

62%

7%

N = 715

FP IM Psy Surgery ER Dentist Others

441

50 6223 18

108

62%

7%9%

3% 3%

15%

Misprescribing can happen easily Many physicians are not trained to identify

substance abuse, diversion, or correct protocols for pain management

Medical Boards are becoming more punitive with physicians who misprescribe

DEA is scrutinizing prescribing practices and the flow of controlled substances

Education can be helpful and is imperative!

Challenges with Proper Prescribing

Provide fact-based education Treat pain effectively and safely Reduce contribution to diversion/misuse Use SBIRT to increase referrals and

interventions/treatments Recognize warning signs of abuse or misuse Avoid future misprescribing Assist with Medical Board requirements Avoid legal or professional sanctions by SMB or DEA

in future

CME Goals

61 of 69 physicians who completed the Prescribing Controlled Drugs Course at CPH strongly agreed that the course should be taught to all practicing physicians (3/2011-2/2012).

The overall average self score on ability to take a substance abuse history prior to the course on 69 physicians was 2.8 – compared to 4.6 after the course.

CME Course Evaluations

Additional education of physicians after residency is needed

Continuing Medical Education Courses proven helpfulPrescribing Controlled DrugsProgram for Distressed PhysiciansMaintaining Proper Boundaries (Vanderbilt)

Vanderbilt Center for Professional Health and University of Florida CME Initiatives

Small group Identify why/how physicians misprescribe Family Systems Personal reflection Role play of common patient presentations Syllabus of key lectures and readings Discuss practice organization Understand SBIRT and other tools

CME Course Elements

20 hour course to meet Board of Medicine requirements for pain management specialists in Florida scheduled for June 2012 (University of Florida)

Professional Development Series – On-line modules 2012-13 (Vanderbilt University Medical Center)

Future Initiatives

Screening, Brief Intervention and Referral to Treatment (SBIRT)

&Motivational Interviewing (MI)

SBIRTS Screening – Screening patients at risk for substance

abuse; inquiring about family history of addiction; using screening tools such as the NIAA 1-question screening tool for alcohol use, AUDIT, CAGE, CRAFT for adolescents, etc.

BI Brief Intervention - Establish rapport with pt.; ask permission; raise subject; explore pros/cons; explore discrepancies in goals; assess readiness to change; explore options for change; negotiate a plan for change-(motivational interviewing)

RT Referral to Treatment – For patients responding positively to the screening tests, refer to AA, drug addiction clinic, pain clinic, counseling, etc.

Screening, Brief Intervention and Referral to Treatment (SBIRT) is a well-studied screening and intervention procedure to improve patients’ short-term health outcomes and reduce health care costs.

The Joint Commission has proposed SBIRT as a performance measure for accreditation.

SBIRT: Introduction

SBIRT

Proposed Accreditation Standards Could Compel U.S. Hospitals to Screen Patients for Addictions (Bob Curley, 9/11/09)

Individual and family history“Have you ever used or currently use….[fill in the blank]?”

tobacco, ETOH, marijuana, street drugs, prescription drugs or other recreational drugs

Identify & quantify use

Within your family, has anyone ever used or currently use…

Use standard form/tests:5 A’sCAGE, AUDIT, DAST, MAST, CRAFT, ASSIST, etc.Combination: SMaRT

Screen for Substance Use

SMaRT

The University of Pittsburg SMaRT©: ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) Last accessed Jan 10, 2012http://www.peru.pitt.edu/projects/smart/index.php

35 year-old female with fibromyalgia and low back pain who is requesting opioids for pain management

Things to watch for: Red flags to indicate aberrancy/addiction Techniques to elicit relevant history in a patient with pain How to deal with an angry, demanding patient Technique for screening, referral, and brief intervention

(SBIRT)

SBIRT Demonstration: DVD

Adopted from: Jackson T, Dewey C, Swiggart W, Baron M and Moore D. Guidelines for Proper Opioid Prescription. Vanderbilt University School of Medicine 2009

SBIRT Demonstration

DVD SBIRT Discussion

Break into small groups Discuss question Prioritize two ideas per group Two minute report out Large group discussion

Small Group Activity

Statements: Legal issues and consequences for misprescribing are becoming more prevalent. The Joint Commission is considering requiring SBIRT as a quality indicator.

Question: How might you involve your state to require physician training in SBIRT, use of the PDMP for all patients, and training proper prescribing practices to avoid misprescribing and consequences of misprescribing?

The Future

More states are passing laws that regulate prescribing:

Regulations for pain clinics Regulations for who can prescribe CME hours required in order to prescribe long-term

narcotics Laws making diversion for own use a possible felony State Prescription Drug Monitoring Programs

Legal Issues and Consequences

Continue to push for additional education of our medical students and residents

Raise awareness of DEA rules and changes that occur http://www.deadiversion.usdoj.gov

Implement laws on regular use of State Prescription Monitoring Program http://www.pmpalliance.org

Monitor state laws and regulations that may be draconian with education of legislators

Strategies to Help Physicians

Most physicians are not bad physicians but lack: information tools to deal with patients who have substance

abuse or difficult pain issues resources

Small group education can make a difference Prevention is first priority

Lessons Learned

Reviewed guidelines and regulations Described CPD problem Discussed SBIRT Reviewed CME courses and benefits Planned for improvements in each state Reviewed consequences and future directions

Summary

The Center for Professional Health, Vanderbilt University Medical Center, Nashville, TN. www.mc.vanderbilt.edu/cph

Prescribing Controlled Drugs: Critical Issues & Common Pitfalls of Misprescribing, The University of Florida at Gainesville, FL. http://ufcme.info/Misprescribing.html

Web Pages