Advocacy

Measures to Counteract Prescription Drug Diversion, Misuse and Addiction

Adoption Date:
January 25, 2012

Public Policy Statement on Measures to Counteract Prescription Drug Diversion, Misuse and Addiction

PDF

Background

The diversion of prescription drugs from the person to whom they were originally prescribed, and the non-medical, sometimes lethal use of these drugs, are components of our nation's overall drug problem, and they are of special concern to physicians. The last two decades have seen dramatic increases in the use of and addiction to potentially addictive pharmaceuticals. Although the non-medical use of prescription drugs is not a new phenomenon, increases in cases of diversion, misuse, and overdose deaths have been striking and have drawn the attention of public health officials, regulatory agencies, and public policy makers on the state and national level. Notable among the proposed responses to these problems is the published strategy of the White House Office of National Drug Control Policy, addressing educational, rehabilitative and disciplinary approaches to the problem it discusses under the term “prescription drug abuse.”

Two of the most commonly misused classes of prescription medications are opioid analgesics and sedative hypnotics, both of which are considered “controlled substances” in that they appear in schedules for pharmaceuticals under the federal Controlled Substance Act. According to the Centers for Disease Control and Prevention, the number of opioid analgesic prescriptions filled at pharmacies has increased from 175 million in 2000 to 254 million in 2009. Prior to that, however, the use of these same drugs to assist patients with pain was considered too low. The medical literature described “under prescribing” as a problem, and that it was based on evidence that physicians--fearful that they would face rebuke from their peers or sanctions from licensure bodies for being “too liberal” in the prescribing patterns--were declining to offer prescriptions for controlled substances even when patients were in significant pain. Well intentioned researchers demonstrated, in short term studies, that the benefit: risk ratio was positive when terminally ill patients with painful conditions were treated with what had heretofore been considered high-dose levels of opioid analgesics. This research was embraced by policy analysts who influenced bodies such as the Federation of State Medical Boards to issue “reformed” guidelines supporting the use of opioids, even in high doses, for palliative care, for oncology care, for acute injury care, and even for the treatment of chronic non-cancer pain. These guidelines assure practitioners that, when they act in good faith, conduct thorough evaluations, document their rationale well, and monitor their patients carefully, they will not be sanctioned by their state licensing board for providing appropriate medical care. Elements of the pharmaceutical industry engaged in well-documented efforts to increase the utilization of opioid analgesics as the preferred, if not first-line treatment for chronic pain, including chronic non-cancer pain; and financial incentives from industry drove endorsements by recognized physicians and thought leaders of the use of high-dose opioids as a treatment for non-malignant pain. The recommendation that physicians and other medical personnel probe for cases of pain and intervene lest pain go undertreated, culminated in accreditation requirements, such as the often-cited “Pain Standard” of the Joint Commission, which would find health care organizations to be sub-standard if, on accreditation site visits, they could not demonstrate that they had in place a formal process to proactively extract from patients comments about their perceived level of pain at essentially every clinical encounter.

Knowing that many patients with pain also experience anxiety or sleep disturbances, clinicians have often added sedative hypnotics to a regimen of chronic opioid analgesic therapy, leading to instances of oversedation, chronic use of benzodiazepines, tolerance, withdrawal, and even addiction to benzodiazepines among some chronic pain patients. Physician comfort with prescribing benzodiazepines (some of the most frequently prescribed of all medications in the 1980s) and patient liking for these agents made the co-prescribing of opioids and benzodiazepines a not uncommon clinical scenario.

Pain management is an important component of high-quality compassionate medical care. There remains great controversy about the place of opioid medications in the treatment of pain, and little education of the non-pain specialist related to the differences in various types of pain. The fact that acute pain from a fracture or surgery is different from “failed back syndrome,” or from chronic stable pain of musculoskeletal origin, is infrequently stressed as physicians consider whether to prescribe opioids for complaints of back pain. Differences between nociceptive pain (the somatic pain commonly resultant from injury or surgery), neuropathic pain (injury to the nerve itself), and central pain (as seen in fibromyalgia, some cases of chronic headaches, or complex regional pain syndrome) and differences in recommended clinical and pharmacologic approaches for these different presentations, are not often appreciated by prescribing physicians. Furthermore, the understanding of iatrogenic injury that can arise from the prescription of scheduled medications to patients with chronic stable pain of musculoskeletal origin has been hampered by the exclusion of persons with drug misuse histories from research studies. No clear recommendation for attention to the co-occurrence of addiction in these patients has been forthcoming, and they have been routinely recommended for exclusion from services rather than referral to treatment.

Similarly, studies have shown that physicians have not received adequate education about the potential psychiatric and addiction consequences of the decision to prescribe scheduled medication. Most practicing physicians have had little if any formal training in addiction. Few physicians demonstrate understanding of the etiology of addiction. Although issues of tolerance and withdrawal are understood to exist, most physicians are not aware of the mechanisms and the behavioral consequences of these phenomena, or the relationship of these phenomena to addiction. Confusion still exists whereby some clinicians mistake physical dependence (tolerance and withdrawal) for addiction. Rarely are craving and reward seeking behaviors appreciated by prescribers as being potential consequences of their prescribing of opioid and sedative medications. And while most physicians are skilled in the initiation of prescriptions for opioid analgesic therapy (a notable exception being the safe initiation of methadone as a chronic pain treatment), most physicians are not comfortable with or skilled in discontinuation of opioid analgesic therapy or outpatient management of opioid withdrawal when opioid discontinuation results in abstinence symptoms.

The evidence that physician education about addiction would modify prescribing practices is controversial. Different medical specialties have argued that the educational needs of physicians within a given specialty must be tailored to that specialty, and broad, all-licensee educational mandates would be a waste of educational resources and practicing physicians’ time. Others have argued that basic concepts on how to recognize addiction, how to recognize physical dependence and withdrawal syndromes, and how to safely taper and discontinue opioid analgesics and sedative hypnotics are so misunderstood by physicians, dentists, and other licensed independent practitioners, that basic education for all persons granted a federal registration to prescribe controlled substances is necessary. It is possible that education that only addresses basic science aspects of pharmacology and neuroscience will not improve patient outcomes unless it is paired with clinical education that addresses strategies for the management of pain, withdrawal, and addiction, clinical drug testing and other diagnostic approaches; as well as functional assessment and basic concepts regarding occupational medicine and disability determination. But there is emerging data to suggest that when primary care physicians are targeted for focused education regarding pain, pain medication prescribing, and assessing patients for risk prior to the initiation of opioid analgesic therapy, trends in opioid overdose deaths can be reversed.

What is clear is that the current situation is untenable. Governmental agencies and the public expect the health system to be responsible, to respond to current clinical and epidemiological challenges, and to be “part of the solution” to reverse trends regarding prescription drug diversion, misuse, addiction, and overdose deaths. The “secondary use” of controlled substances in potentially lethal ways (e.g., by persons who obtain supplies of pharmaceuticals that originated from a legal prescription, but was written for someone else) must be addressed through improved education and practice. All health professionals who can prescribe scheduled medications must be included in any educational efforts to improve patient outcomes and public health. The general public needs to understand better the risks associated with controlled substances and their role in safe medication storage and disposal, and physicians have a key role they can play in patient education regarding these topics.

Recommendations:

The American Society of Addiction Medicine recommends that the following components be included in any public policy response to the growing problem of prescription drug addiction, diversion, misuse and overdose deaths.

A. Prescriber Education

1. Mandatory Prescriber Education

a. Mandatory education of physicians and all other health professionals licensed to prescribe, dispense or administer prescription drugs is a key strategy in modifying the epidemic of misuse of and addiction to scheduled medications. The Controlled Substances Act should be amended to require all DEA registrants to obtain training on the use of controlled substances. Mandatory prescriber education should be required for all classes of controlled substances and for all schedules.

b. Education should include the general principles of prescribing drugs that are commonly associated with misuse, dependence and addiction. This education should include how to recognize and appropriately intervene in the case of such findings.

c. Education should also include recognition of addiction, assessment of the risk potential for the development of addiction, and referral to appropriate addiction treatment colleagues when addiction is identified or strongly suspected to be present.

d. Education for prescribers should also address how health professionals can provide education to patients about the potential harms associated with the use of controlled substances and about the safe storage of and disposal of supplies of controlled substances.

2. Specific Drug (Class) Education

a. Specific education should be required about the controlled drugs used in the particular practice of the prescriber where prescribing scheduled drugs is an integral part of that prescriber’s practice. DEA registrants should be permitted to select educational modules that are relevant to the classes of medications they frequently prescribe in their practice.

3. Quality Indicators

a. Quality Indicators for clinical practice should be developed regarding these topics, addressing practices such as of the use of periodic and random urine drug testing, the use of pill counts, the use of treatment agreements, the use of screening tools for the development of addiction and other adverse effects when controlled substance are used, and the patient education activities of prescribers, where the prescription of controlled substances is an integral part of the services provided.

4. Guidelines for Prescriber Education

a. Content for mandatory training should be evidence-based and focused on symptom reduction, functional impairment, and careful management of the risks associated with the controlled substances being prescribed. Physician education modules and patient education materials should be developed with input from professional societies; not only those that represent primary care and medical/dental/surgical prescribers, but also those that represent addiction medicine, addiction psychiatry, pain medicine, occupational medicine and physiatry.

b. Professionals with significant pharmaceutical industry relationships (as defined by the AMA’s Council on Ethical and Judicial Affairs) should not be involved in developing educational content for mandated prescriber training.

B. Patient Education

1. Guidelines for Patient Education

a. Prescribers of controlled substances have a responsibility to educate the patient at the time of issuing a prescription, about safe drug storage and disposal practices by patients. Practitioners need to be educated on how to inform patients about locking medication supplies in the home (akin to locking firearms and ammunition, and locking toxic chemical supplies in the home) as a means of prevention of unauthorized use, theft, or accidental overdose by children. Physicians, dentists and others need to be part of the solution to the prescription drug overdose epidemic by helping patients (who may be parents or grandparents) become part of the solution to the public health crisis of prescription drug misuse and addiction.

b. Physicians should provide educational materials about chronic pain and the risks vs. benefits of long-term use of medications as part of their prescribing practices.

C. Medical School and Residency Education

1. Training for Medical Students and Residents

a. Training should include curricula topics that focus on pain medicine, addiction medicine, safe prescribing practices, safe medication storage and disposal practices, functional assessment of patients with chronic conditions, and the role of the prescriber in patient education.

D. Prescription Drug Monitoring Programs (PDMP)

1. Recommendations for full use of PDMP

a. Prescription drug monitoring programs can be effective clinical tools in medication management involving controlled substances. In 2005, President Bush authorized the federal National All Schedules Prescription Electronic Reporting (NASPER) program to issue grants to state interested in establishing or enhancing prescription drug monitoring programs (PDMP). However, funding for NASPER has been inconsistent, not all states have an operational PDMP, and few state PDMPs are interconnected. NASPER should be permanently authorized and adequately funded.

b. PDMPs developed by various states should be available for review by clinicians across state boundaries.

c. PDMP data should available in real-time by clinicians considering a decision to authorize a prescription for a controlled substance.

d. PDMP data should be considered health information, and should be protected from release outside of the health care system (e.g., to law enforcement, the courts, employers, family members or others) unless there is a specific authorization from the individual patient to release personal health information (see ASAM Public Policy Statement on Confidentiality of Patient Records and Protections Against Discrimination).

e. Medical examiners, public health authorities, quality assurance agencies, and state licensure boards, should have the same access to PDMP data that they have to other personally identifiable health information, for the purposes of assessing trends and assuring that standards of professional practice are met. But law enforcement, the judiciary, corrections professionals, employers, and others outside of the health care system should not be granted access to PDMP data except via the means available to them to secure access to other personally identifiable health information.

f. Every prescribing clinician should be familiar with the process of accessing and utilizing information from PDMP’s so that they can incorporate this information in their practices.

E. Better Data Through Research

1. Recommendations for continuing research

a. Epidemiological research conducted by the Centers for Disease Control and Prevention and others should be expanded to provide the best quality data on patterns of manufacture, distribution and sales of psychoactive drugs which have the potential for diversion and misuse. Better data is also needed on patterns of diversion and involvement of specific classes of scheduled drugs in being the direct and contributory causes of overdoses and drug-related mortality. Health services research which profiles the prescribing patterns of individuals and classes of practitioners is an appropriate approach to learning more about how to reduce the incidence of prescription drug diversion, misuse, addiction, and overdose deaths.

10 Comments

  1. 10 Alexis Geier Horan 08 Nov
    Every state has different rules around the
    PDMPs, including different reporting rules. 
    Some, like OR, do not have anything to do with reporting on patient
    abuses.  I think your best bet is to
    reach out to your local DEA office and ask them how to report a patient with
    suspicious records (as far as the diversion issue is concerned).  Do not offer names or any identifying
    information, in case that jeopardizes the PDMP rules about patient
    confidentiality.  The closest DEA office
    to you is in Seattle but, from their map, it looks like this office oversees
    the region, http://www.justice.gov/dea/divisions/sea/sea.shtml.  
  2. 9 Ochimo 02 Nov

    I am a physician in Oregon. Through the Oregon PDMP, I have identified a patient who filled 22 opiate prescriptions in October 2012 alone, from different providers. I am concerned about drug diversion, or potential for abuse and overdose.

    I tried to report this to the state PDMP, but they replied that they only provide the PDMP but do not help with this type of reporting.

    Is there something else I should do?

  3. 8 Theresa 22 Oct
    I was a pharmacy tech and became addicted to opiates.   Was arrested at my job and found another tech position and was able to relapse with no problem, which resulted in another arrest from another job.   Why the heck was I able to get hired into a 2nd pharmacy?  
  4. 7 Susan Awad 24 Sep

    Ms. Sauerbier,

    The National Institute on Drug Abuse provides an excellent screening and brief intervention tool for clinicians.  It’s both an online, interactive guide and a repository for other useful SBIRT resources.  http://www.drugabuse.gov/nidamed/nm-assist-screening-tobacco-alcohol-other-drug-use

     

    Hope this helps!


  5. 6 Cheryl Sauerbier 02 Sep
    For the  purpose of nursing education, what do you feel is the best way to assess for pain in the ED to identify the drug seekers from the true chronic pain patient? Nursing is frustrated with the fragmented assessments and releasing of patients some with prescriptions and others without.
  6. 5 James Reinglass, M. D. 11 Feb

    Must be both State ,

    and National computer record of dates, drugs,name, and address of prescribing physician- all of which should originate from the pharmacy.  This data should interconnect with the state and national computers.


    James Reinglass, M.D., Diplomat American Board of Addiction Medicine.

  7. 4 Dan Vinson 31 Jan

    I appreciate ASAM's leadership on this complex issue. We physicians need to do better.

    What do you all think about "bundling" training in buprenorphine with training in managing all chronic opioids? Those of us who've been prescribing buprenorphine, as I have for the past 3 years all by myself in this big academic healthcare center, have because of interest and necessity learned a lot about other opioids. It might make it easier to recruit other physicians to get certified to prescribe buprenorphine if the training required for that medication could be integrated with the required training in other opioids. Then not only would physicians be better trained in managing chronic opioids, but also a lot better prepared to recognize and treat opioid addiction when we see it developing. As a colleague said, "buprenorphine makes a wonderful exit strategy."

    We need to actively promote integrating buprenorphine into routine medical practice. It's a safer opioid than most, not that hard to learn, and delightful to manage. It is truly wonderful to see many patients who are doing very well on it for 2 years or longer. (I heartily agree with your comments, Dr. Chavez!)

    Thanks

    Dan Vinson, MD

    University of Missouri - Columbia

  8. 3 Sab 30 Jan
    What is often overlooked in all these discussions is  that patients with chronic pain also have psychiatric problems. Where are the psychiatrists to help with this growing problem? Why are their services being cut by insurance companies? Pain management, it must be understood is a multidisciplinary affair and not to be dumped, as often is, at the door of primary care providers.
  9. 2 Rick Chavez, M.D. 30 Jan

    I am so happy that ASAM is finally doing something about this problem.  I am a consultant to the DEA and the Medical Board of California.  Last year my review of physician practices for the DEA resulted in 4 doctors going to prison for gross negligence and contributing to drug abuse, misuse, and diversion in their communities.  One physician was sentence to 25 years in prison believe it or not.  This year I have already reviewed 4 physicians and January isn't yet done!  Practicing physicians, residents, and medical students need ongoing education and training in monitoring and prescribing controlled drugs.  Not only that, but workers comp carriers and insurance companies need to understand the gravity of the situation and remunerate doctors who take the inordinate amount of time that this care requires.  If physicians are not encouraged to spend time with their patients they may stop treating pain patients altogether.  Chronic pain is also at epidemic levels and as the baby boomer generation becomes the majority, they will want to stay active, youthful, and "pain free."

    Monitoring patients on controlled drugs also means understanding the mechanisms and disorders that cause pain and how to treat pain problems as well.  75 to 100 million people or 20 to 25% of all AMERICANS suffer from chronic pain.  Currently, 80% of all pain doctors are anesthesia based (about 7000 boarded by the ABA) and 20% or 2900 are certified by the American Board of Pain Medicine, not nearly enough to handle the huge number of people who will be 55 yrs old or older.  Most of the anesthesiologists are trained mainly in interventional therpies and aren't really interested in medical management and opiate therapy.  In my community, I am already booked for the next 4 months.  New patients call daily because their doctor doesnt prescribe pain medications.  I just don't know how to help my colleagues become more proficient in this area, so that I can send them back their patients for long-term care.

    I believe that ASAM, and perhaps the ABPM (American Board of Pain Medicine) as spearheading a national debate on these problems.  Mandating education is the beginning, but Mandating better pain management is equally important.  We may have to firmly address other issues as well.  In Oregon, arrests related to methamphetamine abuse and addiction dropped from 27% to 4.5% in some communities after Oregon passed a law to make pseudo-ephedrine type drugs prescription only.  Meth is destroying our country and soon the East Coast will feel what we in California have been dealing with for years.  The Mexican Cartels see the East Coast as a prime target!  Big Pharma should not be our concern when our communities are dying.  Medical Marijuana in California is a joke.  Anyone with a hang nail can get a card.  Our kids are the ones who are abusing this drug.  Young brains need to be protected, and ASAM should be fighting the fight.  It is time for our orgaization to step up and become the leader that it should be.  As physicians we can circumvent the politics and make decisions based on science, the art of medicine, and common sense.  Thankyou ASAM for making a stand and insisting that we tackle this epidemic which saw for the first time more chronic pain patients overdose and die from prescription drugs than individuals who died in automobile accidents last year.  This statistic does not include the patients who are treated for drug addiction.  What does this statistic tell us?  It says that many physicians who treat pain are not monitoring their patients closely enough or are prescribing excessive amounts and types of controlled drugs irrationally.  I have reviewed many cases for the DEA and the California Medical Board and what I see time and time again is irrational "Poly-pharmacy."  The other problem is that many doctors who prescribe SUBOXONE for opioid addction treatment don't understand that buprenorphine is a "maintenance" drug.  It is not meant to be used sparingly and stopped after 2 to 3 weeks.  Training in SUBOXONE use has to be more intensive.  We are seeing people go through rehab 3, 4, or 5 times simply because the rehab doctors aren't treating opioid addiction as a "chronic" disease.  ASAM can be the driving force in educating physicians on the importance of long-term treatment.  30 days in rehab is just the start, but because of a mentality that says "any medication usage is not natural" our addiction treatment success is no better than it was in 1960 despite all the new and wonderful medications that we now have.

    Thankyou for the opportunity to start the debate.

    RICK CHAVEZ, M.D.

    MEDICAL DIRECTOR

    THE P.A.I.N. INSTITUTE

    The Pain & Addiction Integrated Network, Inc.

    Board Certified, American Board of Family Medicine

    Board Certified, American Board of Addiction Medicine

    Board Certified, American Board of Pain Medicine

    Assistant Clinical Professor of Family Medicine, UCLA David Geffen School of Medicine (thru 7/1/11)

  10. 1 April Rovero 27 Jan

    It is obvious to those of us who are working at a grassroots level and who have been personally impacted by poor physician prescribing that the recommendations you've offered in this document are essential to combating our nation's prescription drug epidemic.  What is often ignored in discussion and debate about the contributors to the epidemic are the addiction and deaths that result from a legitimate health condition that was inappropriately managed by a physician who doesn't have the training or understanding necessary to properly manage their patient's condition. In so many cases, a patient becomes hopelessly addicted to medications they agreed to take in good faith, expecting that their doctor "knew best", and had their best interests in mind as they prescribed. So often, due to either a lack of education/knowledge or out of financially motivated reasons, doctors don't do right by their patients and the toll can be disastrous on the individual, their family and the community at large. 

     

    Thank you so much for your well-developed recommendations.  We hope that they are taken to heart and implemented as soon as possible.  We lose a person every 19 minutes these days to a prescription drug related death.  The minutes are ticking by and the sooner we turn this train wreck around, the better. We lost our 21-year our son to this epidemic and simply want this devastation to stop as soon as possible so others don't have to suffer the same horrible loss we have had to endure. 

     

    Thanks,

     

    April Rovero

    Founder/President

    National Coalition Against Prescription Drug Abuse

    www.ncapda.org

     

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