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Kati Kroll, PharmD

PGY1 Pharmacy Resident

Saint Alphonsus Regional Medical Center

• The presenter has no vested interest nor anything to disclose

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1. Briefly summarize the societal and medical concerns surround prescription drug abuse, misuse and diversion.

2. List basic strategies to identify and prevent prescription drug abuse, misuse and diversion.

3. Recognize warning signs that indicate a patient should be triaged to the emergency room instead of calling poison control upon ingestion or exposure to medications or other substances.

4. Recite and/or be able to locate the phone number for poison control.

Is prescription abuse and misuse a problem?

What problems are associated with prescription drug abuse?

Is it our problem? (Pharmacies)

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Intentional

Medication Abuse/Intentional

overdose

“pharming”Generation Rx

Unintentional/Accidental

Misunderstandings/ Errors

Poisoning

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• Directed or intentional effort to obtain and utilize pharmacologic agents to induce or produce a psychological or physiological effect

• Terminology: • Non-medical use • “pharming”• Generation Rx

• Incidence growing in recent decades:• Abuse of pharmaceuticals has now surpassed rates of abuse of all illicit drugs in the US except marijuana1

• 2010: an estimated 2.4 million Americans used prescription medications non-medically for the first time within the past year2

• Averages to over 6,000 initiations per DAY

• Who:• Majority: adolescents (18-25 years old)

• Males vs Females: similar rates

• Concomitant depression

• 2x rate of non-medical and illicit drug use

• Small metropolitan and rural America

• Why:• Perception that abusing prescription medications is “safer” than illicit drugs

• Lesser legal repercussions than illicit drugs

• Ease of access- majority of adolescents describe as “fairly or very easy” to obtain

• Stimulation of dopamine reward pathway in the brain

• Coping mechanism

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Choose a health condition associated with pain… can you find the signs and

symptoms online?

Example: neuropathy

Could you tell a doctor what the

symptoms are, even though you may not

have it?

• More common amongst middle-aged women

• Multiple prescriptions from multiple prescribers

Doctor Shopping

• Employees and/or public

• In 3 year period: 28 million dosage units of controlled substances stolen

Theft (homes or pharmacies)

• Two-thirds of teens reported this mode of obtaining meds (stolen or given)

• “Pharming” parties

Friends or Relatives

• Buying from patients• Internet prescriptions without medical visits

Internet/Drug dealers/patients

• Self-diagnosis • Drug seeking • Internet searches provide the “right words to say” in appointments

Feigning Illness

• Stolen prescription pads

• Altered quantities• Non-local prescribers

Forged or Alerted Prescriptions

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Methods of Abuse

• Medications used without an indication

• Higher doses or frequencies

• Alternative routes of administration

• Crushing

• Snorting

• Injecting

• Combination with other medications or drugs

Opioids

OpioidsEffects: pain relief, euphoria, drowsiness, sedation, weakness, impaired coordination,

confusion, constipation, itching, dry mouth, dizziness, nausea and vomiting

Dangers: slowed or arrested breathing, anoxic brain damage,

unconsciousness/coma, and death

Codeine Robitussin A-C, Tylenol

#3

CII, CIII and

CV

Injected

Swallowed

Morphine Roxanol, duramorph, MS

contin

CII, CIII Injected

Swallowed

Smoked

Methadone Methadose CII Swallowed

Injected

Fentanyl &

analogs

Actiq, duragesic,

sublimaze

CII Injected

Smoked

Snorted

Oxycodone Oxycontin, Percocet CII and CIII Chewed/Swallowed

Snorted

Injected

Suppositories

Hydrocodone Vicodin, norco, dilaudid CII and CIII

Meperidine or

Ketamine

Demerol, Darvocet CII, CIII and

CIV

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Stimulants

Stimulants

Effects: exhilarated feelings, increased energy, mental alertness,

"buzzed", insomnia and decreased appetite

Dangers: increased heart rate, tremor, weight loss, nervousness/anxiety,

seizures, heart attacks and strokes

Amphetamines Adderall and

Dexedrine

CII Injected

Swallowed

Smoked/snorted

Methylphenida

tes

Concerta, Ritalin CII Injected

Swallowed

Snorted

Sedatives/Depressants

Depressants

Effects: sedation/drowsiness, decreased anxiety, feelings of well-being, lowered

inhibitions, slurred speech, poor concentrations, confusion, dizziness, impaired

coordination and memory

Dangers: hypotension, slowed breathing, tolerance, withdrawal, addiction,

increased risk of respiratory distress and death when combined with alcohol

Barbiturates Phenobarbital,

Nembutal, seconal,

amytal

CII, CIII

and CV

Injected

Swallowed

Benzodiazepines Ativan, halcion, Librium,

valium, xanax

CIV Swallowed

Sleep

Medications

Ambien (zolpidem),

sonata (zaleplon),

lunesta (eszopiclone)

CIV Swallowed

Snorted

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Inconveniences

• Nausea/Vomiting • Constipation • Cardiovascular dysfunction• Drowsiness/ Sedation • Incoordination/ Numbness

Serious Events

• Physical dependence/ Addiction • Seizures • Neurological damage (hypoxia)• Suppressed or cessation of

breathing • Coma and Death

• Controlled substance scheduling:

• Actual or potential risk for abuse

• Current patterns of abuse

• Dependence liability

• Known or possible risks to public health

• Scope, duration and significance of the drug’s abuse

• Precursor of another controlled substance

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Reasons for abuse/misuse:• Ease of access

• Available at many retail stores (not just pharmacies)

• Perception that they are safe/harmless

• Relatively low cost

• Substitute for a prescription medication

• Intensify or lessen effects of other drugs

Top 10 OTC Products of Abuse6

• Dextromethorphan• Pain medications• Caffeine and energy drinks• Diet Pills• Laxatives and herbal diuretics • Motion sickness medications• Sexual performance enhancers• Pseudoephedrine• Herbal ecstasy• Herbal hallucinogens/stimulants

Over-the-Counter (OTC) medications are most commonly abused by adolescents aged

13-16 years old6

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Pseudoephedrine

• Used to produce methamphetamine

• Combating Methamphetamine Epidemic Act (CMEA) 2006

• Restricted access & sales limits

• Locked or behind the counter

• Daily: 3.6 grams

• Monthly: 9 grams

• Identification and log book

Role of Pharmacy Technicians:

1. Comply with policy on sale and record keeping

2. Explain to patients the purpose of limits 3. Know what to do when abuse is suspected

(reporting)4. Recognize other supplies to make Meth:

• Iodine, anhydrous ammonia, propane, rubbing alcohol, Epsom salts, lithium, etc

5. Recognize physical signs of Meth abuse:• Formication (crawling skin), punding

(non-goal-directed repetitive activity), dyskinesia, poor teeth (meth mouth), depression, anxiety or psychosis

Schedule 5 Medications

• Small amounts of prescription medications that are CVs can be sold OTC

• Limits on quantities sold within 48 hours

• Special record-keeping and restrictions

Role of Pharmacy Technicians:

1. ONLY a pharmacist can complete the sale

2. Customer must have valid ID or be personally known to the pharmacist and be >18 years old

3. Know your pharmacy’s policy on these medications

Medications:

Guaifenesin plus codeine (Cheratussin AC)

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??Behind The Counter

??

Prescription

Non-Prescription

(OTC)

Behind-the-Counter (BTC)

• Has been proposed and considered by the Food and Drug Administration (FDA)• Four times in past few decades

• Proposed:• Only available in healthcare settings

• Require an intervention by a pharmacist

• No prescription required

• Keep an eye on this issue in the future

What characteristics or behaviors would make you suspicious that someone is abusing medications?

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Drug Abuse

?

Depression/Low Self Esteem

Attempted Early Refills

Declining hygiene/ Lack of Interest

Aggression/ Rebellion/ Defensive

Inattention/ Social

Withdrawal

Family history

Sluggish/ Flat Affect

Sleep disturbances

Frequent borrowing of

money/ unexpected

cash

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• Unintentional or accidental use of medications which results in overdose, adverse effects, inadequate therapy or poisoning

• Use of medications is increasing in the United States

• More complicated indications

• Confusing for patients (especially elderly)

• Multiple changes to therapy

• Medication misuse contributes to ~50% of emergency room visits (2011)1

• Second leading cause of accidental death in the US (second to car accidents)

• Elderly especially at risk• Higher or lower doses, wrong route, etc

Misunderstanding Instructions

• Medications without indications• Antibiotics or antipsychotics

Inappropriate Prescribing

• Dispensing errors: wrong medication, wrong patient or incorrect instructions

Medication Errors

• Toxicities• Failure to adjust doses (renal function) and/or appropriate monitoring

Adverse Drug Events

• Medications that look like candy

Poisoning

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Elderly

• Account for over 1/3 of all prescriptions dispensed3

• Cognitive decline

• Dementia

• Poor hearing and vision

• Changes in metabolism= greater risk for toxicity

• Retention of discontinued medications

Children

• Unfamiliar dosing by healthcare workers

• Off-label indications

• Dependence on caretakers

• Difficult/unclear diagnosis

• Inadequate therapy

• Visits to physicians, urgent care or emergency department

• Poisioning/Death

• “Opioid analgesic poisoning” listed on death certificates increased 91% from 1999 to 2002

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• Often medications can look like candy to a child • Colorful

• Similar shapes

• Gummy/Chewy Texture

• Flavored Medications

• Medications should never be referred to as “candy”

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Clues of Possible Poisoning

• Breath that smells like chemicals

• Stains or odors on person

• Clothing or surroundings

• Burns

• Empty containers

Signs and Symptoms

1. Burning/Redness of skin or lips

2. Nausea or vomiting3. Difficulty breathing 4. Sleepiness/

Incoordination5. Confusion6. Seizures

• Who to call for help:• Poison control: 800-222-1222

• Appears stable

• Collect:

• Symptoms

• Age and weight

• Any information on poison

• Timeline of exposure

• 911/Emergency services

• Unconsciousness/unresponsive

• Difficulty or lack of breathing

• Uncontrollable restlessness

• Having seizures

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1. Store medications where kids cannot reach them

2. Put medications away after each use

• Don’t store in bathrooms or public areas

3. Utilize safety caps on bottles

4. Double-check medication instructions

5. Educate guests and children

6. Emergency preparedness

• Program poison control number into cell phones

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• Available or under construction in 48 states

• Facilitate investigation of controlled substance refill history

• Data collected:• Patient data: Name, DOB and address

• Prescription: medication, quantity, date filled and date written

• Prescriber

• Pharmacy-specific policies differ concerning pharmacist’s responsibilities: • Report to prescriber

• Refusal to fill

• Confidential information: HIPPA

• Screen for drug abuse

• Only 40% of physicians report receiving training to identify prescription drug abuse or addiction1

• Investigate patient requests for early refills

• Be mindful and aware of “doctor shopping”

• Limit punishment of those legitimately in pain

• Must be seen right away• Unable to provide medical details• Unsure of names of previous

prescribers• Use of specific medication

names/doses

• Claimed allergies to non-opioids• Unusual knowledge of controlled

substances • Use of surrogate (child, elderly) • Pressure prescriber: guilt/threats• Scripted symptoms (internet diagnosis)

Deceptive Patient Practices:

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• Follow prescription instructions

• Ask for instruction or clarification if needed

• Be aware of drug interactions

• Consult with prescriber/pharmacist before changing or starting therapy

• Tell each prescriber all current medications (medication list)

• Discard un-used/expired prescriptions

• Practice safe storage of medications- educate children

• Recognize signs of toxicity, number for poison control and when to call 911 vs poison control

Potential for drug abuse or addiction

• ≥2= Probable Addiction

Screening/Self-Assessment Questionnaire: CAGE

CUT

Have you ever felt the need to CUT down on your use of prescription drugs?

ANNOYED

Have you ever felt ANNOYED by remarks your friends or loved ones made about your use of prescription drugs?

GUILTY

Have you ever felt GUILTY or remorseful about your use of prescription drugs?

EVER

Have you EVER used prescription drugs as a way to “get going” or to “calm down”?

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• Screen for medication over or under use

• Attempt to verify “legitimate medical purpose”

• Be skeptical of out of town prescribers

• Communicate with prescribers

• Screen for prescription alteration

• Changed quantities or evidence of photocopies

• Unusual legibility, lack of abbreviations, etc

• Be suspicious of unusual prescribing patterns

• Prescribing numerous similar medications

• Prescribing of antagonist medications (stimulants+sedatives)

• Utilize prescription monitoring databases for controlled substances

• Learn or create policies for information obtained

Education

• Medication use

• Removing old patches before applying new ones

• Scheduling of twice daily (12 hours), three times daily (8 hours) and prn medications

• Signs of toxicity

• Proper/safe storage

• Disposal of expired/un-used medications

Patients Characteristics:

1. Patient’s lack of familiarity with prescriber

2. Prescription irregularities/ abnormalities• Call alternate number for prescriber (Google it)

3. Specific requests concerning brand or dosage forms

4. Out of town- patient or prescriber 5. Overly friendly, nervous, paranoid,

aggressive, etc6. Paying cash 7. Pharmacists gut instinct

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• We are directly related in the dispensing of medications • Last stop in the chain of healthcare providers

• Screen for abuse

• Educate to prevent misuse

• Taxes are higher because of abuse and misuse • Non-medical use of controlled substances is estimated to cost the healthcare system $72 billion annually5

• Lives are being lost unnecessarily • Medication misuse: Second leading cause of accidental death in the US

• Deaths from overdose: 15,000 people2

Once an opioid medication pain medication is prescribed and dispensed, it is estimated that 75% of these drugs are used without a prescription by someone else1

Group effort:

• Education (schools, public service announcements, parents, etc)

• Prescriptions and OTCs can be dangerous if used inappropriately

•Cooperation of medical professions

• Sharing of information/concerns

•Discourage internet medical advice/questionnaires

• Referrals to counseling/abuse therapy

• Involvement of friends and loved ones (HIPPA)

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1. Gianutsos G PhD. Prescription Drug Abuse: Strategies to Reduce Diversion. US Pharmacist. December 2009. Accessed Janurary 28, 2015. Available at: http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/106448/

2. Dart RC, Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, Green JL. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015 Jan 15;372(3):241-8. doi: 10.1056/NEJMsa1406143. PubMed PMID:25587948

3. Nau D.P., Kirking D.M. Nau, David P., and Duane M. Kirking.(2010). Chapter 2. Understanding Problems in the Use of Medications. In Warholak TL, Nau DP. Warholak T.L., Nau D.P. Eds. Terri L. Warholak, and David P. Nau. (Eds), Quality and Safety in Pharmacy Practice. Retrieved January 23, 2015 from http://0-accesspharmacy.mhmedical.com.libcat.ferris.edu/content.aspx?bookid=452&Sectionid=40698438.

4. Buxton I.O. Buxton, Iain L. O.(2011). Appendix I. Principles of Prescription Order Writing and Patient Compliance. In Brunton LL, Chabner BA, Knollmann BC. Brunton L.L., Chabner B.A., KnollmannB.C. Eds. Laurence L. Brunton, et al. (Eds), Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e. Retrieved January 23, 2015 from http://0-accesspharmacy.mhmedical.com.libcat.ferris.edu/content.aspx?bookid=374&Sectionid=41266282.

5. United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 2003 National Survey on Drug Use and Health. http://oas.samhsa.gov/nhsda.htm. Accessed August 17, 2009.

6. Understanding Sales Restrictions for Non-Prescription Drug Products. PowerPAK Continuing Education for Pharmacists and Pharmacy Technicians. http://www.powerpak.com/course/content/110880