II. Epidemiology
- Prescription Drug Diversion is common
- Prescription Drug Abusers get their medications from family or friends in over 70% of cases
- For every 1 death from prescription abuse
- Treatment admissions for Opioid Abuse: 10
- Emergency department visits for misuse or abuse: 32
- Abuse or dependence on prescriptions: 130
- Non-medical users of prescription Opioids: 825
-
Opioid prescriptions are the leading entry point to Heroin abuse in U.S.
- Current Heroin abusers started with Opioid prescriptions in 75% of cases
- While prescription Opioids are expensive, Heroin remains relatively inexpensive
- Cicero (2014) JAMA Psychiatry 71(7): 821-6 [PubMed]
III. Signs: Drug Seeking, Misuse or Narcotic Addiction
- See Substance Abuse Evaluation
- Selling prescription drugs
- Prescription forgery
- Stealing or borrowing drugs from others
- Veterinary prescriptions (e.g. Opioids for pain or Cough Suppression) are being taken by pet owners
- Injecting oral Opioids
- Obtaining Opioids from multiple physicians
- Making appointments at the end of the day, weekends and evenings
- Concurrent use of psychoactive substances
- Multiple dose increases
- Increase despite warnings
- Increase despite adverse effects
- Resistance to change therapy despite low efficacy
- Diminished work and home functioning
- Multiple episodes of prescription loss
- Excessive flattery of providers
- Refusing to grant permission to obtain old records from prior facilities
- New patients presenting for refill of long-standing use of controlled substances
- Out of town patient with unavailable primary provider and bypassed closer facilities
- No picture identification
- Patient is not interested in a diagnosis, tests or non-Opioid treatments
- Magnified symptoms with inconsistencies, but otherwise rehearsed textbook history of a painful condition
IV. Signs: Pseudo-addiction (seeking adequate pain relief)
- See Chronic Pain
- Aggressive pursuit of more Opioid
- Opioid hoarding when symptoms are reduced
- Requesting specific Opioids, especially via Parenteral Route (and refusing non-Opioid alternatives)
- Dose escalation without physician consent once or twice
- Unapproved Narcotic use to treat other symptoms
V. Management
- See Opioid Abuse
- Address suspected Opioid misuse or abuse directly and offer medical help and CD treatment referral
- I am concerned
- Patients treated for pain with prescription Opioids may become dependent on those medications
- Dependence may lead to addiction, and I suspect that may be the case for you
- I have Chemical Dependency counseling available
- References
- Mason and Papp in Herbert (2015) EM:Rap 15(3): 13
VI. Prevention: General
- Check Prescription Drug Monitoring Program (see link below under resources)
- Patient should sign a Controlled Substance Contract
- Random Urine Drug Screens every 3 to 6 months
- Drug screens should be positive for the medication prescribed
- Drug screens should be negative for other non-prescribed substances
- Discuss with patient the risks of sharing their controlled substances
- Patient's should properly dispose of unused controlled substances
VII. Prevention: Prescription Drug Monitoring Program (PDMP)
- As of 2015, monitoring programs are available in all U.S. states except Missouri
- Many states share data regionally
- Monitoring programs list nearly all controlled substances prescribed
- Typically displays last year of controlled substance pharmacy fills
- Displays prescribing provider, preparation and quantity given
- Methadone clinics and military pharmacies may not report controlled substance prescriptions
- Red flags for Opioid misuse on PDMP
- Early refills (except for limited quantities as part of taper)
- Similar prescriptions from multiple medical providers at different groups and facilities
- Combined controlled substance use (e.g. Opioids with Benzodiazepines)
- Total Morphine Equivalents >120 mg/day
- Prescription Drug Monitoring Programs (alliance of states sites)
- References
- (2015) Prescriber's Letter 22(11):64