II. Epidemiology

  1. Prescription Drug Diversion is common
    1. Prescription Drug Abusers get their medications from family or friends in over 70% of cases
  2. For every 1 death from prescription abuse
    1. Treatment admissions for Opioid Abuse: 10
    2. Emergency department visits for misuse or abuse: 32
    3. Abuse or dependence on prescriptions: 130
    4. Non-medical users of prescription Opioids: 825
  3. Opioid prescriptions are the leading entry point to Heroin abuse in U.S.
    1. Current Heroin abusers started with Opioid prescriptions in 75% of cases
    2. While prescription Opioids are expensive, Heroin remains relatively inexpensive
    3. Cicero (2014) JAMA Psychiatry 71(7): 821-6 [PubMed]

III. Signs: Drug Seeking or Narcotic Addiction

  1. See Substance Abuse Evaluation
  2. Selling prescription drugs
  3. Prescription forgery
  4. Steeling or borrowing drugs from others
  5. Injecting oral Narcotics
  6. Obtaining Narcotics from multiple physicians
  7. Making appointments at the end of the day, weekends and evenings
  8. Concurrent use of psychoactive substances
    1. Illicit Drugs
    2. Alcohol
  9. Multiple dose increases
    1. Increase despite warnings
    2. Increase despite adverse effects
  10. Resistance to change therapy despite low efficacy
  11. Diminished work and home functioning
  12. Multiple episodes of prescription loss
  13. Excessive flattery of providers
  14. Refusing to grant permission to obtain old records from prior facilities
  15. New patients presenting for refill of long-standing use of controlled substances

IV. Signs: Pseudo-addiction (seeking adequate pain relief)

  1. See Chronic Pain
  2. Aggressive pursuit of more Opioid
  3. Opioid hoarding when symptoms are reduced
  4. Requesting specific Opioids
  5. Dose escalation without physician consent once or twice
  6. Unapproved Narcotic use to treat other symptoms

V. Management

  1. See Opioid Abuse
  2. Address suspected Opioid misuse or abuse directly and offer medical help and CD treatment referral
    1. I am concerned
    2. Patients treated for pain with prescription Opioids may become dependent on those medications
    3. Dependence may lead to addiction, and I suspect that may be the case for you
    4. I have Chemical Dependency counseling available
  3. References
    1. Mason and Papp in Herbert (2015) EM:Rap 15(3): 13

VI. Prevention: General

  1. Check Prescription Drug Monitoring Program (see link below under resources)
  2. Patient should sign a Controlled Substance Contract
  3. Random Urine Drug Screens every 3 to 6 months
    1. Drug screens should be positive for the medication prescribed
    2. Drug screens should be negative for other non-prescribed substances
  4. Discuss with patient the risks of sharing their controlled substances
    1. Risks include Overdose in a patient not tolerant to adverse effects (e.g. respiratory depression)
    2. Children are at particular risk of Overdose
  5. Patient's should properly dispose of unused controlled substances

VII. Prevention: Prescription Drug Monitoring Program

  1. As of 2015, monitoring programs are available in all U.S. states except Missouri
    1. Many states share data regionally
  2. Monitoring programs list nearly all controlled substances prescribed
    1. Typically displays last year of controlled substance pharmacy fills
    2. Displays prescribing provider, preparation and quantity given
    3. Methadone clinics and military pharmacies may not report controlled substance prescriptions
  3. Prescription Drug Monitoring Programs (alliance of states sites)
    1. http://www.pmpalliance.org/content/pmp-access
  4. References
    1. (2015) Prescriber's Letter 22(11):64

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