Avoiding Diversion

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Contents 1 Course 4: Avoiding Diversion 1.1 Practice Gap/Need 1.2 Goal 1.3 Core Competencies & Clinical Skills 1.3.1 A. Identify Diversion 1.3.2 B. Follow a Clinical Protocol 1.3.3 C. Use Practice Management Guidelines 1.4 Case Studies/Standardized Patients

Course 4: Avoiding Diversion

Protecting Your Medical Practice from Diversion Problems

Practice Gap/Need

Deaths from opioid overdose have increased over the past decade: Overdose deaths involving prescription opioids were largely responsible for a doubling of deaths by poisoning in the U.S. between 1999 and 2006 (Warner, et al, 2009). This corresponds to an increase in opioid prescribing over the same period. Diverted prescription drugs are often responsible for overdose: approximately half of overdose deaths in a West Virginia study were in persons who were not prescribed an opioid (Hall et al, 2008). Patients who obtain prescriptions from multiple doctors are also a significant group among overdose deaths: approximately a fifth of overdose deaths in the West Virginia study were in persons who had prescriptions from 5 or more doctors (Hall et al, 2008). One study found a correlation of overdose deaths with concurrent depression, substance abuse, or benzodiazepine prescription and suggested that overdose could have been avoided with closer oversight (Dunn et al, 2010).

Some overdose is due to opioid abuse and other non-medical use of opioids. Co-morbid substance abuse affects 20 to 40% of patients on opioid therapy for chronic pain (Katz, et al., 2003; Manchikanti et al., 2001). Non-medical use of opioids is high: an estimated 4.7 million people over age 12 have used opiate pain medication in the past month, according to the 2008 National Survey on Drug Use and Health, which represents a slight increase over the past 5 years (SAMHSA, 2009).

The importance of preventing, identifying and treating substance abuse when managing chronic pain with opioids is well documented (Compton, 2008). However, a 2004 national survey of 979 physicians for a report on diversion by the National Center on Addiction and Substance Abuse at Columbia University (CASA) identified a number of deficiencies in both competency and practice in substance abuse practices that are important in pain management. For instance, nearly half of physicians do not ask about prescription drug abuse when taking an initial health history at a patient's first visit and physicians with more training in pain and addiction are more likely to ask for this information (CASA, July 2005, p. 53). The same survey found that nearly 25% of physicians do not discuss the possibility of addiction when prescribing a controlled substance (CASA, July 2005, p. 54). In CASA's national survey of 648 primary care physicians in 1999, only 30.2% felt "very prepared" to diagnose prescription drug abuse and rates were even lower for alcoholism (19.9%) and illegal drug use (16.9%) (CASA, April 2000, p. ii. The same survey found that very few physician (2.1%) feel that treatment is very effective for illegal drug abuse (CASA, April, 2000, p. iii).

In CASA's report on the problem of diversion, they recommended that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance abuse and addiction (CASA, July 2005, p. 100). In addition, the National Institute on Drug Abuse (NIH) has identified a need for increased education and training for physicians in the identification and treatment of comorbid pain and substance abuse (NIDA RFP 093, 2008). However, The majority of 979 physicians surveyed in 2004 by the National Center on Addiction and Substance Abuse at Columbia University (CASA) did not receive training, either in medical school or in CME, in identifying prescription drug abuse and addiction (CASA, JULY 2005, pp. 90-91). Only a minority of medical schools (19.1%) and residencies (39.2%) provided training in identifying prescription drug diversion, according to the 2004 CASA survey and only around a third of physicians surveyed received such training in continuing education (CASA, JULY 2005, p. 6).

A multidisciplinary panel, after a review of the evidence chronic opioid therapy in chronic non-cancer pain, recommended that physicians follow certain guidelines when prescribing opioids; many of the recommendations were designed to reduce the risk of addiction and other substance abuse (Chou, et al. 2009). According to these guidelines, ideally, physicians should screen every pain patient for substance abuse or risk of substance abuse (Chou, et al. 2009). Physicians should use first line pain therapies first, and only use opioids when they are indicated (Chou, 2009). Physicians should structure treatment so that the risk of developing addiction is minimized and modify treatment structure when risk is identified (Chou et al, 2009). Physicians should follow certain baseline precautions with every chronic pain patient requiring chronic opioic therapy (Gourlay et al, 2005).

CASA's report on diversion outlines a number of steps that physicians should take to minimize diversion, but their survey revealed many physicians are not taking these steps; for example, fewer than a third require a urine drug test or conducting random pill counts (CASA, JULY 2005, p. 7).

Physicians need to follow steps that could minimize drug diversion (CASA, JULY 2005, p. 7). Education in risks for overdose and the importance of corresponding increased oversight and education could contribute to a decrease in overdose incidents.

Goal

The learner will be able to educate patients about proper use and storage of pain medications, assess for signs of diversion of pain medications, and take steps to limit diversion from the practice.

Core Competencies & Clinical Skills

Each learner should be more proficient in the following core competencies and clinical skills after completing this course:

A. Identify Diversion

Identify patients who are diverting medication or whose medication is being diverted

1. Conduct thorough patient interviews to determine history and course of treatment
2. Contact patient's prior treatment providers to determine dosing and duration of past treatment
3. Use sensitive interviewing techniques to inquire about patient's use of medications
4. Identify red flags that suggest illicit drug-seeking behavior
5. Review records of chronic pain patients for patterns suggestive of diversion before prescribing refills
6. Use urine drug testing where indicated
7. Continue to check prescription monitoring programs
8. Bring special attention to patients taking extended release drugs due to their greater risk for abuse

B. Follow a Clinical Protocol

Follow a clinical protocol that reduces diversion of medications by patients or their family members

1. Provide refill prescriptions only with verification of continuation of pain diagnosis
2. Decrease the size of prescriptions and increase the frequency of follow-up visits according to severity of addiction, suspected diversion, or risk for diversion
3. Explain to patients the proper medication storage and monitoring that should occur in their homes

C. Use Practice Management Guidelines

Follow practice management guidelines that reduce risk of diversion

1. Keep careful prescribing records for all pain medicine prescribed
2. Follow an office protocol that safeguards prescription pads and sample medications
3. Verify identities of patients receiving a prescription for pain medication
4. Utilize state-based reporting systems for pain medication prescriptions
5. Work with pharmacists and law enforcement to detect and prevent diversion
6. Comply with DEA regulations
7. Understand responsibilities with respect to law enforcement vs patient confidentiality

Case Studies/Standardized Patients

Case 1: Sam Seller - 29 YOBM

• Chief Complaint: Requests prescription for phantom limb pain
• Narrative: Sam claims his phantom limb pain is severe and the only thing that helps is hydrocodone. Sam lost his right lower leg during friendly fire combat in Iraq. He is new to the area and is a new patient in your practice, and is vague about where he has obtained his prior medication.
• Opioid Issue: Requests a specific opioid; vague history
• Relevant Past Medical, Psychosocial, Family History: No significant findings
• Competencies Covered: A, B

Case 2: Ozzie Oblivious - 55 YOWM

• Chief Complaint: Regular evaluation for refill on pain medication
• Narrative: Ozzie comes in for a regular visit to refill his oxycodone, which he takes for chronic pain related to neck pain. His treatment agreement includes pill counts due to past addiction. This is the second time that his pill count has been too low - last time he was 2 pills short, and this time he is 5 pills short. Ozzie insists that he has not been taking more than his usual dose. Ozzie is divorced but his 17-year-old son stays with him on weekends.
• Opioid Issue: Teenage son may be diverting his medication
• Relevant Past Medical, Psychosocial, Family History: Has been a model patient for many years since his pain started 8 years ago after an injury
• Competencies Covered: A, C