Prescription Medication Misuse Screening and Mitigation
Transcript
Slide 1
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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