RED FLAGS FOR OPIOID

ABUSEKIM HEINEMAN, PMAC

NATIONAL STATISTICS

• OPIOIDS KILL AROUND 142 AMERICANS ON A DAILY BASIS

• IN 2015, 2 MILLION PEOPLE IN THE UNITED STATES WERE ADDICTED TO OPIOID PAINKILLERS.

• 3 OUT OF 4 HEROINE USERS BEGAN MISUSING PRESCRIPTION PAIN MEDICATIONS.

• THE NUMBER OF OPIOID PRESCRIPTIONS DISPENSED BY DOCTORS STEADILY INCREASED FROM

1992 AT 112 MILLION TO 282 MILLION IN 2012. CURRENTLY THE NUMBERS ARE ON THE

DECLINE, FALLING TO 236 MILLION IN 2016.

NATIONAL STATISTICS

• FROM 2007 TO 2016, HYDROCODONE WAS THE MOST WIDELY PRESCRIBED OPIOID.

• IN 2016, 6.2 BILLION HYDROCODONE PILLS WERE DISTRIBUTED IN THE UNITED STATES.

• IN 2015, THE INTERNATIONAL NARCOTICS CONTROL BOARD REPORTED AMERICANS

REPRESENTED 99.7% OF THE WORLDS HYDROCODONE CONSUMPTION.

ANY GOOD NEWS?

• MULTIPLE CHANGES IN STATE POLICY HAVE CONTRIBUTED TO DECLINES IN THE NUMBER OF

CONTROLLED SUBSTANCE PRESCRIPTIONS.

• IN 2017 HHS DECLARED A PUBLIC HEALTH EMERGENCY AND ANNOUNCED A 5-POINT

STRATEGY TO COMBAT THE OPIOID CRISIS

• AS OF NOVEMBER 2017, 28 STATES HAD RESPONDED TO THE OPIOID EPIDEMIC BY

IMPLEMENTING POLICIES OR GUIDELINES SETTING LIMITS ON THE SUPPLY OF OPIOIDS THAT CAN

BE PRESCRIBED BY DOCTORS. THE OPIOID LIMITS IN FIVE OF THOSE STATES ONLY APPLY TO

MEDICAID RECIPIENTS. TWO OF THOSE STATES HAVE NO SET PILL OR DAY LIMIT FOR OPIOID

PRESCRIPTIONS BUT REQUIRE DOCTORS TO PRESCRIBE THE LOWEST EFFECTIVE DOSE.

PRESCRIPTION DRUG MONITORING PROGRAMS

WHAT IS PRESCRIPTION DRUG

MONITORING?

• A PDMP IS A STATEWIDE ELECTRONIC DATABASE THAT

TRACKS ALL CONTROLLED SUBSTANCE PRESCRIPTIONS.

AUTHORIZED USERS CAN ACCESS PRESCRIPTION DATA

SUCH AS MEDICATIONS DISPENSED AND DOSES.

BENEFITS OF PDMP

• PDMPS IMPROVE PATIENT SAFETY BY ALLOWING CLINICIANS TO:

1. IDENTIFY PATIENTS WHO ARE OBTAINING OPIOIDS FROM MULTIPLE

PROVIDERS.

2. CALCULATE THE TOTAL AMOUNT OF OPIOIDS PRESCRIBED PER DAY (IN

MME/DAY).

3. IDENTIFY PATIENTS WHO ARE BEING PRESCRIBED OTHER SUBSTANCES THAT

MAY INCREASE RISK OF OPIOIDS—SUCH AS BENZODIAZEPINES.

HOW CAN I REGISTER AND USE MY STATE’S PDMP?

PROCESSES FOR REGISTERING AND USING PDMPS VARY FROM STATE TO STATE.

FOR INFORMATION ON YOUR STATE’S REQUIREMENTS, CHECK THE NATIONAL ALLIANCE FOR

MODEL STATE DRUG LAWS ONLINE:

WWW.NAMSDL.ORG/PRESCRIPTION-MONITORING-PROGRAMS.CFM

OR

CHECK WITH YOUR STATE DEPARTMENT OF HEALTH AND HUMAN SERVICES

OPIOID ABUSE AND PODIATRY

• THE OPIOID EPIDEMIC IS A CONCERN IN EVERY STATE. IT MAKES NO DIFFERENCE WITH RACE,

PROFESSION, AGE OR SOCIOECONOMIC STATUS.

• OUR PODIATRY OFFICES MUST HAVE POLICIES AND PROCEDURES FOR THE USE OF AND THE

MONITORING OF OPIOID PRESCRIPTIONS.

• AS ASSISTANTS, THERE ARE RED FLAGS WE CAN WATCH FOR TO PROTECT OURSELVES, OUR

DOCTORS AND OUR PRACTICES

1. YOU FIND THE PATIENT LYING OR THEIR

STORY JUST DOES NOT MAKE SENSE.

YOU CAN COMBAT THIS BY TAKING A DETAILED HISTORY. USE OPEN ENDED QUESTIONS

WHEN TALKING AND GATHERING HISTORY. YOU WILL OFTEN FIND INCONSISTENCIES IN A

MADE UP STORY.

2. EXAGGERATED SYMPTOMS

• MANY SEEKERS ARE GREAT ACTORS! YOU MAY FIND THEY EXAGGERATE SYMPTOMS. SOME

PATIENTS WALK IN JUST FINE BUT WHEN CALLED BY AN ASSISTANT TO BE SEEN BY THE DOCTOR

THEIR PRESENTATION CHANGES. THEY MAY BEGIN LIMPING, HAVING TROUBLE WALKING OR

EVEN BEGIN CRYING.

3. YOU FIND THE PATIENT IS ALREADY TAKING

MULTIPLE CONTROLLED SUBSTANCES.

• BY UTILIZING DRUG MONITORING DATABASES YOU CAN FIND OUT IF A PATIENT IS ALREADY

TAKING OPIOIDS AND/OR BENZODIAZEPINES (EX: XANAX, VALIUM, ATIVAN).

4. PATIENTS REFER TO CERTAIN MEDICATIONS

USING SLANG TERMS SUCH AS “HYDROS” OR

“OXIES”

• THIS DEMONSTRATES A CERTAIN LEVEL OF KNOWLEDGE AND COMFORT WITH ASKING FOR

THESE SPECIFIC DRUGS. TRY TALKING TO THE PATIENT ABOUT ALTERNATIVE TREATMENTS TO SEE

IF THEY ARE OPEN.

5. THE PATIENT TRAVELED FROM A TOWN OR CITY

THAT IS NOT CLOSE BY.

• IF YOU HAVE A PATIENT THAT TRAVELS FROM A TOWN OR CITY YOU USUALLY DO NOT HAVE

PATIENTS FROM, THIS COULD BE A SIGN THEY HAVE TRIED MULTIPLE PROVIDERS IN THEIR LOCAL

AREA AND ARE WIDENING THEIR RADIUS TO FIND DOCTORS THEY HAVE NOT ALREADY SEEN.

6. DOCTOR SHOPPING

• WHEN PATIENTS HAVE SEEN MULTIPLE PROVIDERS IN A SHORT PERIOD OF TIME, THIS INDICATES

“DOCTOR SHOPPING”. SOMETIMES THEY WILL SEE MULTIPLE PROVIDERS OF THE SAME

SPECIALTY OR IT CAN BE MULTIPLE PROVIDERS AND MULTIPLE SPECIALTIES.

7. PATIENTS USE MULTIPLE PHARMACIES

• WHEN PATIENTS DO NOT LIST A SPECIFIC PHARMACY THIS MAY INDICATE THEY ARE USING

MULTIPLE PHARMACIES. THIS IS A SIGN THEY MAY NOT WANT YOU TO BE ABLE TO GET A

HISTORY OF THEIR CURRENT MEDICATIONS.

8. ALLERGIES TO PAIN MEDICATIONS

• WHEN PATIENTS CLAIM TO HAVE ALLERGIES TO ALL PAIN MEDICATIONS EXCEPT THE SPECIFIC

DRUG THEY ARE REQUESTING.

9. KNOWLEDGE OF SPECIFIC DRUG

• PATIENT PRESENTS TO THEIR APPOINTMENT REQUESTING A SPECIFIC DRUG, DOSE AND

QUANTITY.

10. AGGRESSIVE OR ANGRY BEHAVIOR

• PATIENTS BECOME ANGRY OR AGGRESSIVE IF AN ALTERNATE DRUG OR TREATMENT IS

SUGGESTED.

WHAT CAN YOU DO?

• HAVE A WRITTEN CLINIC POLICY FOR OPIOID MEDICATIONS. THIS CAN HELP TAKE THE

PRESSURE OF YOU AS A STAFF MEMBER BY SAYING “OUR CLINIC POLICY IS …..”.

• HAVE A PATIENT-PROVIDER AGREEMENT FOR OPIOID TREATMENT. YOU CAN REVIEW CLINIC

POLICY AND DISCUSS ANY CONCERNS PRIOR TO TREATMENT. IF A PATIENT IS A SHOPPER OR

ABUSER THEY WILL NOT BE OPEN TO SIGNING THE AGREEMENT.

SAMPLE AGREEMENT

Patient-Provider Agreement for Opioid/Narcotic Treatment

The use of opioids is only one part of treatment. Opioids can be very useful, but can also cause serious

problems. The purpose of this agreement is to outline the risks and benefits and to outline the safest manner

to prescribe opioids/narcotics.

Goals for using this medication:

To decrease the intensity of pain

Provider Responsibilities:

To explain the risks and benefits of using opioids for pain.

To actively discuss with me (patient) the creation, review and treatment plan for care.

To explain alternative or complementary treatments or therapies. This may include physical therapy, non-

narcotic analgesics or other treatments or therapies that may be deemed medically necessary.

To check the Prescription Monitoring Program to see what medications I am being prescribed by other

providers.

To communicate any concerns regarding the use of opioid medications.

If necessary, and in collaboration with me, to work with other physicians and specialists to ensure I am

receiving effective treatment.

To protect the confidentiality of my health care and prescription information to the extent authorized by

law.

Patient Responsibilities:

I, ___________________________, understand and commit to the following for the best treatment of my pain and the

safest use of opioids:

Follow my treatment plan

Tell my provider all the medications I take (including herbal remedies and over-the-counter medications)

Communicate to my provider how I am doing, such as, daily functioning, pain level and side effects.

Obtain opioids from one provider only. Obtain opioid medications from one pharmacy only.

Only take medication at the dose and frequency prescribed.

Will not use medication not prescribed to me or use illicit drugs.

Not use alcohol with this medication unless provider has said it is safe to do so.

Securely store my medication at all times. Safely dispose of unused medication. I will not share, sell or trade my

medication.

Opioid medication will not be replaced if it is lost, stolen, damaged or used up sooner that prescribed.

Additional medication requests will be discussed at next clinic appointment and generally will not be available on an

emergency basis.

Bring medications in original bottle to every visit.

I have been told the possible risks and benefits of this medication

Opioid medications may help my pain but may cause other problems like addiction, overdose and death.

Common side effects of opioid medications include nausea, constipation, sweating and itchiness of skin.

Drowsiness may occur when starting opioid medications or when increasing the dose. I agree to refrain

from driving a motor vehicle or operating dangerous machinery until such drowsiness disappears.

I understand there is a risk of becoming addicted to the medication I am being prescribed. If physical

dependence occurs, a sudden decrease or discontinuation of the medication will lead to opioid

withdrawal. I understand opioid withdrawal is uncomfortable but is not life threatening.

I understand the use of mood modifying substances (tranquilizers, sleeping pills, alcohol or illicit drugs)

can cause adverse effects or interfere with the opioid therapy.

If I have had a history of drug or alcohol problems, I will have an increased chance of addiction to this

medication.

I have discussed this agreement with my provider and have had an opportunity to ask questions. I understand the

benefits, risks and potential complications associated with opioid medications. I understand if I break this

agreement, my physician reserves the right to stop prescribing opioid medications for me.

________________________________________ ____________________

Patient Signature Date

________________________________________ ____________________

Provider Signature Date

WE ARE IMPORTANT!

• BY WATCHING FOR THESE RED FLAGS AND UTILIZING AVAILABLE INFORMATION, WE CAN HELP

OUR DOCTORS DO THEIR PART IN CONTROLLING THIS EPIDEMIC. AS ASSISTANTS, WE ARE

USUALLY THE FIRST AND LAST PEOPLE OUR PATIENTS SEE AND TALK TO IN OUR OFFICES. THIS

MAKES US A VERY IMPORTANT LINK IN THE CHAIN OF TREATMENT!

JUST A LITTLE FUNNY…….

THE DOCTOR

• LEAPS TALL BUILDINGS IN A SINGLE BOUND

• IS MORE POWERFUL THAN A LOCOMOTIVE

• IS FASTER THAN A SPEEDING BULLET

• WALKS ON WATER

THE ASSISTANT

• LIFTS BUILDINGS AND WALKS UNDER THEM

• KICKS LOCOMOTIVES OFF THE TRACKS

• CATCHES SPEEDING BULLETS IN HER TEETH

AND EATS THEM

• FREEZES WATER WITH A SINGLE GLANCE

THANK YOU!KIM HEINEMAN, PMAC

SECRETARY, ASPMA

KHEINEMAN@MFS.OMHCOXMAIL.COM