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Dr. Michael O’Neil Professor and Vice-Chair Dept. of Pharmacy Practice South College School of Pharmacy Knoxville, TN Drug Diversion and Substance Abuse Consultant 1
Dr. Michael O’Neil Professor and Vice-Chair Dept. of Pharmacy Practice South College School of Pharmacy Knoxville, TN Drug Diversion and Substance Abuse Consultant
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After completing this continuing education program
1) Dentists will be able recognize common scams and schemes frequently used to obtain controlled substances for inappropriate use. 2) Dentists will be able to incorporate a drug diversion prevention strategies into their practice. 3) Dentists will be able to identify overt signs of substance abuse in their patients.
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Definitions Substance Abuse Addiction Substance Use Disorders (SUD)
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Occasional Substance Disease of Use Addiction
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Statistics
In 2013, 8.8 percent of youths aged 12 to 17 were current illicit drug users In 2013, 7.1 percent of youths aged 12 to 17 were current users of marijuana,
2.2 percent were current nonmedical users of psychotherapeutic drugs (including 1.7 percent who were current nonmedical users of pain relievers)
Among young adults aged 18 to 25, the rate of current illicit drug use in 2013
(21.5 percent) The rate of current marijuana use in 2013 among young adults aged 18 to 25
(19.1 percent) Among young adults aged 18 to 25, the rate of current nonmedical use of
psychotherapeutic drugs in 2013 (4.8 percent)
Ref. http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
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The rate of current alcohol use among youths aged 12 to 17 was 11.6 percent in 2013.
In 2013, the rate of current alcohol use was 59.6 percent among young adults aged 18 to 25.
EVERY dentist is impacted by SUD regardless of the patients socioeconomic status, patient education, or ethnicity
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Substances and Medications Abused
alcohol tobacco/nicotine marijuana heroin cocaine methamphetamine opioids benzodiazepines antipsychotics muscle relaxants anticonvulsants
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Methods / Routes of Abuse oral
nasal
Inhalation
Injection
Simple physical assessment is key!
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Definitions Prescription Drug Diversion
Dr. Shopping / Pharmacy shopping
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Statistics Survey by O’Neil et al. 2010 (in publication) 94% of dentists altered their “traditional” prescribing practice
if they new a patient had a history of SUD.
75% of dentists suspected between 1-20% of their patients had a SUD.
60% of dentists believed they were the victim of prescription
drug fraud or theft. 80% of dentist suspected patients reported fake symptoms.
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Medications opioids
sedative hypnotics (benzodiazepines)
antiemetics (promethazine)
muscle relaxants (cyclobenzaprine)
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Traditional altered pill number altered refills photocopied prescriptions forged signatures stolen Rx pads Dr. shopping occasional fraudulent
phone-ins addition of medications to
a prescription false symptoms
Current
false symptoms Dr. shopping multiple fraudulent
phone-ins DEA# Theft patient ID theft
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Office assistants/staff – patient screening
/verification (caution with hearsay reports)
patient charts/intake forms / screening Controlled substance monitoring databases
(PDMP, CSMP, PMP)
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Medical assistants / administration staff 1. Validate persons ID with drivers license, medical ID card 2. Ask where pharmacy prescriptions should be called 3. Verify living address and compare distances…..greater than 50-75 miles unless a very rural area may be suspicious
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Patient Interview Disarming the patient Explaining to the patient your questions are to optimize
treatment and prevent complications NOT deny pain treatment is key.
SBIRT- Screening Brief Intervention Referral Treatment
This can be done by a dental assistant with reasonable
communication skills or it can be added to the intake paperwork.
Various tools (ASSIST, AUDIT, DAST)
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CAGE C — Have you felt that you should CUT down on your drinking or drug use? A positive response may indicate the person has lost control of drug use and feels the need to decrease use. A — Have you ever been ANNOYED by others criticizing your alcohol or drug use? Patients with addiction will often engage in behaviors that cause concern from those that observe them. The addict will often become annoyed when their behaviors are criticized by others. G — Have you ever felt bad or GUILTY about your alcohol or drug use? Guilt is a common symptom of addiction because of impairment in relationships and social functioning. E — Have you ever needed an EYE-OPENER to steady your nerves or to treat a hangover? This means that the person needs to use something the next morning to stop withdrawal from occurring or to treat symptoms of overuse of alcohol or other drugs. A positive response to any of the four questions is considered a positive screen and the patient should complete more detailed screening such as the AUDIT or DAST screening tools. 16
Physical Assessment The most common route of drug abuse is nasal
ingestion……look in the nose! -powders, plastics..
-septal destruction -persistent clear watery discharge Eyes – pupillary constriction Cutaneous lesions – track marks
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Nearly every state has this tool Lag time of reporting by pharmacies varies but
almost all “upload” to the database at least every 10 days.
Basic internet based system requiring state
registration and password assignments
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Reports may be run by appointed office staff (this regulation varies from state to state) Every patient does not need to have a report run.
Recommendations are to run a report on any new patient requiring
analgesic prescriptions and annually on repeat patients
“Timelines” to evaluate generally do not need to exceed 6 months to 1 year.
Dentists should look for unusual patterns and excessive quantities of controlled substances
Discrepancies on the report should be discussed with the patient and
confirmed through discussions with pharmacies, etc.
The report itself is NOT evidence of a crime….the patient’s intentional deception to you is the crime!
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Dentists can also run or request a report of all prescriptions filled using their DEA number This report should be reviewed annually with your office manager to identify likely fraudulent activity. Fraudulent activity should be reported to DEA, local law enforcement and pharmacies
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Common Characteristics of the Prescription Drug Seeker Unusual behavior in the waiting room
Assertive personality, often demanding immediate attention
Unusual appearance - extremes of either slovenliness or being
over-dressed, unusual chemical odors
May show unusual knowledge of controlled substances and/or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history
Reluctant or unwilling to provide reference information. Usually has no regular doctor and often no health insurance.
Will often request a specific controlled substance and is reluctant to try a different drug or claims allergies to multiple medications
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Generally has no interest in diagnosis - fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation
May exaggerate medical problems and/or simulate symptoms May exhibit mood disturbances, suicidal thoughts, lack of impulse
control, or thought disorders Cutaneous signs of drug abuse - skin tracks and related scars on the
neck, axilla, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of "pop" scars from subcutaneous injections.
Patient mat be diaphoretic, agitated, aggressive
Wants appointment at the end of office hours
Calls or comes in after regular hours
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States he/she is traveling through town, visiting friends or relatives
States nothing else works but “Drug X”
Uses water excuses
Uses direct threats to dentist or office staff
Boyfriend or parent of an adult patient is adamant about being present during the interview
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Include your office staff! Brief record review before seeing the patient Office assistant “triage” Interviewing Reporting / referring Prescribe “appropriate” 1st line therapies (NSAIDS) Avoid prescribing excessive quantities
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Evidence based medicine does not support opioids as first-
line analgesics for dental pain. Evidence based medicine supports the use of NSAIDS or the
combination of NSAIDS + acetaminophen for moderate to severe dental pain.
Do not prescribe excessive opioid doses. Most dental
procedures can be managed with less than or equal to 20 dosages 48-72 hour supply.
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Box 7. 23 Point Drug Diversion Prevention Practices
1 Request driver’s license or insurance cards of new patients. Insist on a delivery address where the patient actually lives. Patients traveling significant distances should be queried regarding why they chose your office, referral sources and known patients. Drug seekers frequently travel great distances from within and outside the state.
2 Reinforce “no sharing” of medications with family or friends. Sharing medication is quickly becoming the leading source of prescription drug abuse and misuse.
3 Use a substance abuse/ addiction questionnaire (e.g. CAGE,NIDA-Modified ASSIST) when considering chronic controlled substance treatment. Document performance of an opioid risk screening questionnaire at least quarterly.
4 Observe patient records for multiple reports of prescription drug theft or repeated prescription losses.
5 When patients present with family or friends, try to isolate the patient to assess their true needs. Frequently patients are coerced to request prescriptions by family or friends.
6 Consider tapering medications that patients have been prescribed controlled substances for greater than 6-8 weeks (e.g. opioids or benzodiazepines). Physiologic withdrawal often leads to further medication abuse, misuse, and prescription requests.
7 Set appropriate goals for pain management. Patients or practitioners with the perception that pain will be completely eliminated with treatment may lead to perceived failure of therapy and prescription misuse.
8 Maintain thorough records of prescribed medications including drug, date, dose, duration, diagnosis and refills.
9 Maintain a list of alternative medications for the management of pain, anxiety, and insomnia for patients that are addicts or alcoholics in recovery. Help minimize your patient’s risk of relapse.
10 Observe patient records for multiple requests of early refills for controlled substances, muscle relaxants, antipsychotics, gabapentin and tramadol. Frequently, medications other than controlled substances are abused.
11 Establish a single lock up site to store tamper proof prescription pads. Never leave prescription pads in patient rooms
12 Often patients that request an increase in dosage early in treatment may not be at therapeutic goal. They may be perceived as drug seekers. This is known as pseudo-addiction and may lead to under treatment of patients.
13 Always perform thorough background checks on medical and office staff
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Identifying Prescription Drug Seekers
14 You or designated office personnel should perform a prescription monitoring report on new and chronic patients receiving controlled substances. The report alone does NOT prove a crime has been committed and should be used to further questioning or an investigation of prescription drug abuse or diversion.
15 Request reports using your DEA number every six months to yearly from PDMP programs to identify unknown patients or prescription fraud.
16 Acting immediately on “hear-say” reports from office staff, patients and patient relatives may jeopardize your practice.
17 If patients report illnesses that are treated with a controlled substance AND a non-controlled substance such as an antibiotic, follow-up with the pharmacy to see if the non-controlled substance was filled. Frequently doctor shoppers only fill the controlled substances.
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Treatment Considerations and Reporting Strategies 18 Communicate with other practitioners (physicians, dentists, etc.) when mutual patients
are doctor shopping. 19 Provide at least a 30-day notice prior to discharging a patient from your practice for
contract violations or criminal activities with at least 2 notifications one being certified mail. Make certain that any termination is in accordance with all applicable laws, including those related to patient abandonment.
20 Consider referrals to medical or surgical specialists to optimize therapeutic options. 21 Maintain a list of local and regional detox centers, substance abuse treatment facilities,
and Alcoholics Anonymous and Narcotics Anonymous meetings. Refer to these organizations when substance abuse or addiction is detected.
22 Report criminal behavior occurring on your premises. Section 164.512(f)(5) of the HIPAA Privacy Rule states “A covered entity may disclose to a law enforcement official protected health information that the covered entity believes in good faith constitutes evidence of criminal conduct that occurred on the premises of the covered entity.”
23 Practitioners lenient towards doctor shoppers will inadvertently attract more doctor shoppers. Respond appropriately to suspected doctor shopping to send the message this behavior is not tolerated in your practice.
Suspected or Confirmed SUD Criminal Behavior
Referring to a local clinic Discussion with physician
Local law enforcement Regional Drug Task Force Physician, pharmacy
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Office Ready Access List for Dental Practitioners Law Enforcement / Regulatory Agencies
Local police department
State drug task force
Drug Enforcement Agency
State Board of Pharmacy
State dental board
Specialists
Addiction specialist for methadone or buprenorphine
Pain specialist
Community pharmacist
Substance abuse counselor
Local addiction treatment centers
Drug information center/Poison Center
Local hospital or Emergency department
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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine
(AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions
(IntNSA), and Southeast Consortium for Substance Abuse Training (SECSAT).
For more information visit: www.pcss-o.org
For questions email: [email protected]
Twitter: @PCSSProjects
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Funding for this initiative was made possible (in part) by Providers' Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers
and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
Each PCSS-O partner organization that provides CE credit to participants is asked to submit a post and 30 day evaluation to participants for completion.
Participants in today’s webinar will receive their evaluation by email at the completion of today’s webinar.
These questions have been developed and approved by SAMHSA.
By completing the evaluations, you are helping us improve PCSS-O resources!
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The following webinars will be provided by the ADA: February 18, 2015, 2:00 PM (Central): Interviewing
and Counseling of Patients with SUDs and Drug Seeking Patients*
March 18, 2015, 2:00 PM (Central): Management of Controlled Substances in the Practice
April 22, 2015, 2:000 PM (Central): Safe Prescribing for the addicted or non-addicted
* If interested in participating in the February 18, 2015 webinar, please send an email to [email protected] with the subject heading “Feb 18”.
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