Prescribing Controlled Substances Responsibly

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Prescribing Controlled Substances Responsibly

• Lianne Beck, MD
• Assistant Professor
• Emory Family Medicine

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Scope of the Problem

• In 2005, more than 10 million Americans were
  abusing prescription drugs more than the
  combined number of people abusing cocaine,
  heroin, hallucinogens and inhalents.
• The CDC report that prescription opioids are now
  associated with more drug overdose deaths than
  cocaine and heroin combined between 1999 and
  2002 there was a 91 increase in the reporting of
  opioid analgesics on death certificates.

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Scope of the Problem

• In 2005, more new drug users began abusing pain
  relievers (2.2 million) than marijuana (2.1
  million) or cocaine (872,000). By comparison, in
  1990 only an estimated 628,000 people initiated
  illicit use of pain killers.
• Data from a set of selected states show that
  almost 13,000 incidents of prescription
  controlled substances were diverted by theft from
  2000 to 2003. In 2003 alone, 2 million dosages of
  six opioid analgesics were reported stolen from
  the supply chain, mainly from retail pharmacies.

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Scope of the Problem

• http//www.ajc.com/news/gwinnett/prescription-drug
  s-popular-among-372523.html
• http//www.gcpstv.org/

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Drug Schedules

• http//www.mspta.com/dre/pdf/Drug20schedules.pdf

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Drug Seeking Behaviors

• Unusual behavior in the waiting room.
• Assertive personality, often demanding immediate
  action.
• Unusual appearance - extremes of either
  slovenliness or being over-dressed.
• May show unusual knowledge of controlled
  substances and/or gives medical history with
  textbook symptoms OR gives evasive or vague
  answers to questions regarding medical history.
• Reluctant or unwilling to provide reference
  information. Usually has no regular doctor and
  often no health insurance.

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Drug Seeking Behaviors

• Will often request a specific controlled drug and
  is reluctant to try a different drug.
• Generally has no interest in diagnosis - fails to
  keep appointments for further diagnostic tests or
  refuses to see another practitioner for
  consultation.
• May exaggerate medical problems and/or simulate
  symptoms.
• May exhibit mood disturbances, suicidal thoughts,
  lack of impulse control, thought disorders,
  and/or sexual dysfunction.
• Cutaneous signs of drug abuse - skin tracks and
  related scars on the neck, axilla, forearm,
  wrist, foot and ankle. Such marks are usually
  multiple, hyper-pigmented and linear. New lesions
  may be inflamed. Shows signs of "pop" scars from
  subcutaneous injections.

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Drug Seeking Behaviors

• Must be seen right away.
• Wants an appointment toward end of office hours.
• Calls or comes in after regular hours.
• States he/she's traveling through town, visiting
  friends or relatives (not a permanent resident).
• Feigns physical problems, such as abdominal or
  back pain, kidney stone, or migraine headache in
  an effort to obtain narcotic drugs.
• Feigns psychological problems, such as anxiety,
  insomnia, fatigue or depression in an effort to
  obtain stimulants or depressants.

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Drug Seeking Behaviors

• States that specific non-narcotic analgesics do
  not work or that he/she is allergic to them.
• Contends to be a patient of a practitioner who is
  currently unavailable or will not give the name
  of a primary or reference physician.
• States that a prescription has been lost or
  stolen and needs replacing.
• Deceives the practitioner, such as by requesting
  refills more often than originally prescribed.
• Pressures the practitioner by eliciting sympathy
  or guilt or by direct threats.
• Utilizes a child or an elderly person when
  seeking methylphenidate or pain medication.

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Federation of State Medical BoardsModel Policy

• Patient evaluation, including risk assessment
• Treatment plans that incorporate functional goals
• Informed consent and prescribing agreements
• Periodic review and monitoring of patients
• Referral and patient management
• Documentation
• Compliance with state and federal law

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Functional Goals Evidence

• Letter from physical therapist
• Report by family member or friend
• Letter from group leader
• Report by family member or friend
• Pedometer recordings or written log of activity
• Report by family member/friend
• Report by partner
• Pay stubs or letter from employer
• Gym attendance records or report from family
  member/friend

• Begin physical therapy
• Sleep in a bed as opposed to a lounge chair
• Participation in a pain support group
• Increase activities of daily living
• Walk around the block
• Increased social activities
• Resumed sexual relations
• Returned to work
• Daily exercise

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Helpful Resources

• Tips for Georgia Physicians
• http//gdna.georgia.gov/00/channel_modifieddate/0,
  2096,132319894_145437852,00.html
• Guidelines for Use of Controlled Substances for
  the Treatment of Pain Ten Steps
• http//dps.georgia.gov/vgn/images/portal/cit_1210/
  45/23/36282207PAIN_MANAGEMENT_041008.pdf
• http//www.fsmb.org/pain/
• http//www.painmed.org/pdf/noncancer_opioid_guidel
  ines.pdf