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Managing Risk - Identifying Issues in the WorkplaceNational Rx Drug Abuse Summit 4-10-12

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  • 1. Managing Risk -Identifying Issues in the Workplace April 10-12, 2012Walt Disney World Swan Resort
  • 2. Accepted Learning Objectives:1. Identify the signs and symptoms of drug addiction.2. Describe the proper procedure for employers to take when they suspect substance abuse in their employees.3. Explain the potential liabilities faced by employers who do not address substance abuse issues within the workplace.
  • 3. Disclosure Statement Det. Ryan Buzzini hasdisclosed no relevant, real or apparent personal or professional financial relationships. Phil Walls has disclosed that he will discuss the off-label use of drugs such as Actiq and Fentora that create a high risk environment for developing addiction.
  • 4. Doctors pour drugs, of which they knowlittle, for diseases, of which we know less, Into patientsof which we know nothing. Voltaire
  • 5. From 1991 to 2009, prescriptions for opioid analgesics increased almost threefold, to over 200 million. Overdoses attributed to prescription painkillers killed nearly 15,000 people in the U.S. in 2008, more than three times as many as in 1999.
  • 6. Prescription opioid overdose is now the secondleading cause of accidental death in the U.S., killingmore people than heroin and cocaine combined.
  • 7. In Workers CompensationThe abuse of prescription opioids hasbecome a grave personal risk to injuredworkers, a disruptive force in the lives ofthose close to claimants harmed by abuse,and a cost concern to other stakeholders inthe United States workers compensationsystem. Joint statement of ACOEM and IAIABC
  • 8. Temporary disability payments are 3.5 times higher when opioids are prescribed A study of 17 states found that many physicians who prescribed narcotics to injured workers were not using recommended tools to monitor use, abuse and diversion
  • 9. Drug Use Statistics 80% of the worlds supply of opioids is consumed in the US 99% of the worlds supply of hydrocodone is consumed in the US 2/3 of the worlds supply of illicit substances are consumed in the USManchikanti, L. National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician. 10:399-424, 2007.
  • 10. Search Results: undertreatment of painApril 15, 2011 Despite Awareness, Undertreated Cancer Pain PersistsJuly 5, 2011 Pain Common but Undertreated, www.medscape.comJuly 11, 2011 Case Report: Undertreatment of Pain in a 40-Year- Old Woman, Psychiatry WeeklyETC.
  • 11. Commonly Prescribed Drugs (from all payer types) Atorvastatin AmoxicillinHydrocodone Comb. Oxycodone Comb.Propoxyphene Comb.Tramadol and Comb. Codeine Comb. Oxycodone Other Opioids Fentanyl Morphine Number of Prescriptions (in millions) IMS 2005
  • 12. Drug Enforcement Administration Bureau of Prohibition 1927-1930 Bureau of Narcotics 1930-1968 Bureau of Narcotics and Dangerous Drugs (BNDD) 1968-1973 Drug Enforcement Administration 1973
  • 13. Role of the DEA Controlled Substances Narcotics vs. Opioids Illicit drugs Diversion of prescription drugs Schedules level based on potential for abuse and addiction Addiction vs. Tolerance
  • 14. Controlled Substances Schedule II Rx cannot be phoned or faxed to pharmacy Rx cannot be refilled Schedule III, IV and V Rx may be phoned or faxed to pharmacy. Fax must originate from doctors office. Rx may be refilled if authorized by MD up to 5 times within 6 months of the date Rx was written (all other prescriptions expire after 12 months).
  • 15. Schedule IIExamples Actiq (oral transmucosal fentanyl citrate, OTFC) Avinza (morphine sulfate) Dolophine, Methadose (methadone) Duragesic (fentanyl patches) Embeda (morphine sulfate and naltrexone) Fentora (OTFC) Kadian (morphine sulfate) OxyContin (oxycodone)
  • 16. Schedule III and IV Darvocet N 100 (propoxyphene napsylate and APAP) Tylenol #3 (codeine with acetaminophen) Vicodin/Lortab/Lorcet (hydrocodone with APAP) Talwin (pentazocine with naloxone) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Xanax (alprazolam)
  • 17. Schedule V Codeine containing cough syrups Certain paregoric formulations
  • 18. Tolerance Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effects over time Tolerance develops at different rates, in different people, to different effects
  • 19. Physical Dependence A state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
  • 20. Addiction Concensus Medical Definition A primary, chronic neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestationFrom AAPM, APS, ASAM Definitions Related to the Use of Opioids forthe Treatment of Pain. Available at: http://www.ampainsoc.org/advocacy/opioids2.htm.
  • 21. Addictive Behaviors Addictive behaviors include one or more of the following: Impaired control over drug use Compulsive use Continued use despite harm (physical, mental, and/or social) CravingSavageSR, et al. J Pain Symptom Manage. 2003;26(1):655667.[Evidence Level C]
  • 22. Opioid Effects: Analgesia and Reward General Reinforcing effects Analgesia -Reduce anxiety Altered mood Decreased anxiety -Decrease boredom Respiratory depression (-) GI motility -Decrease aggression Cough suppression - Increase self-esteem Miosis Pruritus, nausea, vomitingClinical Manual Addiction Psychopharmacology, 2005.
  • 23. Pseudoaddiction Behaviors that may occur when pain is inadequately treated Patients may become focused on obtaining medications May seem to be drug-seeking Behaviors resolve when pain is appropriately treated
  • 24. Diversion The use of a legitimately prescribed medication for illicit or illegitimate purposesperhaps with the intent to sell or distribute Examples Stolen, altered, or forged prescriptions Trading for profit on medication from others Scams
  • 25. Aberrant Behavior vs Abuse Aberrant Behavior: 40% Abuse: 20% Addiction: 2%5% Total Pain Population Webster LR, et al. Pain Med. 2005;6:432442.Webster LR, Webster RM. Pain Med. 2005;6:432442;
  • 26. What about Schedule I? Highest potential for abuse and addiction No approved medical use Cocaine (CS II) Heroin Marijuana Methamphetamine
  • 27. FDA Panel Votes Against Requiring Prescriptions For Medicines Containing Dextromethorphan.NBC Nightly News (9/14) reported that in "a decision that surprised some people late this afternoon," and "despite an alarming number of teenagers who are using common over-the-counter medicines to get high," a FDA panel "considering whether or not to recommend a prescription to buy them has decided that it is not a good idea for now."
  • 28. Red Flags In Screening/Early Therapy Little or no re

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