`

Prescribers’ Clinical Support System for Opioid Therapies- PCSS-O

Bringing Education to New Heights Prevention of Prescription Drug Abuse and Misuse Proper Prescription Protocol/Methodologies Dr. Peter Blauzvern Chairman of the NCDS and NYSDA Council on Dental Practice Nassau County Task Force on the Prevention of Prescription Drug Abuse and Misuse

1

• Arrests of 33yr. old David Laffer and wife Melinda Brady, 29, for the murders of Pharmacist Raymond Ferguson, 45, clerk Jennifer Mejia, 17, and two customers, Byron Sheffield, 71, and Jamie Tacetta, 33, at the Haven Drugs Pharmacy in Medford, NY, June 2011. 2

The shooting of ATF Agent John Capano, who selflessly came to the aid of Charlie’s Family Pharmacy in Seaford, NY, on New Years’ Eve 2011.

3

It’s Happening all across the U.S. • Nassau County, N.Y., issued a health alert in 2011 when the first signs of an alarming spike in

Opana use. Medicaid data for the county showed prescriptions for extended-release Opana had increased 45% in six months.

• DEA intelligence briefing noted increases in Opana uses in Pennsylvania, including Philadelphia, and Delaware. In New Castle, Del., the DEA said, drug users had switched from uncrushable OxyContin to the crushable oxymorphone "for ease of use," pushing the price for a 40 mg tablet to $65. A tablet costs $4 to $8 when purchased legitimately at a pharmacy.

• In Ohio, authorities in Akron, Cincinnati and Athens noted surges in Opana as a replacement for OxyContin, the state's Substance Abuse Monitoring Network reported earlier this year.

• The spike is particularly pronounced in Kentucky. In 2010, toxicology tests identified oxymorphone, the key ingredient in Opana, in 2% of the state's overdose cases, said Van Ingram, executive director of the Kentucky Office of Drug Control Policy. By 2011, oxymorphone was present in the blood of 23% of overdose victims.

FLORENCE, Ky. - Realtors in Northern Kentucky are being warned about a suspicious person showing up at open houses and raiding the medicine cabinets.. • San Diego-based Zogenix Inc.’s bid for FDA approval to begin marketing Zohydro – a new

version of pure, extended-release hydrocodone that is said to be 10 times more powerful than Vicodin – has prompted some activists to appeal to the FDA not to rubber-stamp more opioid drugs in the midst of an out-of-control epidemic.

4

5

• In May 2011, U.S. Senator Sherrod Brown of Ohio introduced the Stop Trafficking of Pills (STOP) Act, S. 882, which would mandate lock-in programs to ensure that high-risk prescription drug users receiving Medicaid or Medicare benefits access their medications only through one prescriber and one pharmacy.

• In March 2011, U.S. Rep. Vern Buchanan (FL-13) proposed a bill, H.R. 1065, which would reclassify hydrocodone combination medications, such as Vicodin and Lortab, from Schedule III to the more restrictive Schedule II, in an effort to prevent diversion and abuse of the drugs. Buchanan’s Pill Mill Crackdown Act of 2011 would also toughen federal penalties for people who operate pill mills by doubling the prison sentence from 10 to 20 years, and tripling the fine from $1 million to $3 million.61

• Beginning January 1, 2012, all dispensers in Oklahoma must report the dispensing of scheduled narcotics within 5 minutes of being delivered to the customer. Oklahoma will be the first state in the nation to implement a truly real-time electronic prescription database.

• As of July 2011, legislators in California (S.B. 632), Florida (S.B. 818), New Jersey (A. 4041), New York (A. 7634), Pennsylvania (H.B. 1635), and Texas (S.B. 1756) have proposed legislation that would require dispensers to check with a patient’s health care professional before filling a prescription with a non-tamper-resistant formulation if the practitioner had prescribed a tamper-resistant formula.

The start of the Prescription Drug Abuse-Misuse Prevention Task Force

by County Executive Ed Mangano. • The Task Force was formed after the Pharmacy

tragedies and arrests in 2011, to make recommendations to The Nassau County Executive to combat this problem.

• Members appointed to the Task Force include law enforcement officials from the Police Dept., DEA, FBI, DA’s office, Legislators, Dept. of Social Services, Medicaid Fraud Dept., Probation Dept., hospital administrators, chemical dependency experts, dental, medical, and pharmacy professionals, and concerned parents. 6

Task Force Mission Statement

To develop practical recommendations to address the problem of prescription drug abuse that can be executed at the County level and/or to advocate at the State level of government.

7

8

First six weeks of 2011, 4 arrests for prescription forgery. (A Felony)

First six weeks of 2012, the total was 17.

NCPD Narcotics Sq.

Nassau County Arrests:

• In Nassau County opiate arrests have now doubled.

• Heroin arrests have declined significantly as opiates have become more abused.

• 129 arrests in 2009.

• 175 arrests in 2010.

• 432 opiate related arrests in 2011, 48 directly related to prescription fraud.

• Most offenders from age 18 to 35/males. 9 NCPDNS 2012

Legal Actions:

• 7-2010- Dr. Saji Francis- Practice near Massapequa High School, pleads guilty for selling oxycodone to undercover police.

• 11-2011-Dr. Eric Jacobson’s office, in Great Neck, NY,

raided in connection with Haven Drugs shootings

and alleged illegal drug actions.

• 12-2011-Dr. Frank Telang of Bethpage/Port Jefferson, arrested by DEA and SCPD.

• 12-2011-DEA agents arrest Physician, Leonard Stambler in Baldwin, NY.

• 2-2012 – NY State Senate Hearings in Albany.

10

• 2-2012- DEA diversion squad arrest Pharmacist Lutful Chowdhury, in Baldwin.

• 6-2012-DEA agents raid Dr. William Conway’s Baldwin office- arrested as a suspect of diversion of prescription drugs (780,000 oxycodone pills).

• 6-2012- Sting operation conducted in NYC and L.I., by agents from the DEA, NYPD, Federal Prosecutors, and District Attorneys Office nets over 98 arrests, including 2 L.I. physicians, 1 nurse practitioner, for alleged illegal distribution of prescription drugs.

• 6-2012- Governor Cuomo and N.Y. State Legislature released the new I-Stop Act. To be finalized by 1-2013. Signed 8-27-2012 by Gov. Cuomo.

Further Actions:

11

In Nassau County

• Opiate overdose deaths are 3x that of heroin overdose deaths.

• One person every week dies in Nassau County from prescription drug abuse.

• Nassau County deaths by prescription oxycodone overdose have tripled since 2005.

• 82 deaths from oxycodone alone from 2008 to 2011.

• 2008 to 2011: 322 deaths from all opiate derivatives.

12

NCMEOffice

Recommendations of the Task Force: Some we agree with, some we have other answers…..

• Senator Kemp Hanon, rather than create a new system, revamp the current Health Dept. Database.

• Create ISTOP- Internet System for Tracking Over-Prescribing- all new program/database. Considers penalties and fines for not utilizing.

• Mandated CE on issue…5hrs. annually.

• Limits on opioid prescriptions.

• Public awareness campaigns.

13

Recommendations of the Task Force:

• Teach proper protocol for prescription use.

• Enhance addiction treatment facilities.

• Enact new legislation to control abuse, strengthen existing laws. As in Fla., make doctor shopping a felony, not a misdemeanor.

• Drug screening prior to prescribing.

• Support and advance E-Prescribing.

• Increase monitored drug drop boxes.

• Additional help/addiction hotlines.

14

I-STOP Legislation: Internet System for Tracking Over Prescribing.

• Proposed by NY Attorney General Eric Schneiderman in 2011. • To modernize the NYS Prescription Drug Monitoring Program. • Establish online database that is streamlined. • Data in real time. Updated information at time of script

issuance and drug dispensing. • Accessible to pharmacists (previously excluded), prescribers,

and law enforcement. • Finalize E-Prescribing. • Medical/Dental education courses as well as public awareness

measures regarding pain management and prescription drugs.

• The Department of Health will establish a safe disposal program for unused medications along w/ local law enforce.

• Initially contained penalties and fines for pharmacists and prescribers that don’t utilize program. 15

Other Reasons for Action:

• In NY State, number of prescription narcotics increased from 16.6 million in 2007 to 22.5 million in 2010.

• Hydrocodone prescriptions increased 16.7%.

• Oxycodone prescriptions increased 82%.

• These drugs are diverted from their lawful purpose into illicit drug trafficking in epidemic proportions (NYS AG office).

• Affects on healthcare facilities- staggering costs, increased ED visits.

16

17

Continued:

• Increased healthcare costs.

• Non-medical use of opioid prescription drug cost insurance companies up to 72.5 to 100 Billion dollars annually in healthcare costs. (Report by Coalition

Against Insurance Fraud Org. Sept. 2011, a national alliance of consumer groups, ins. Co., and Govt. agencies fighting ins. fraud, founded in 1993.)

• Increased criminal justice expenses, i.e.: courts, prisons, and govt. resources.

• Affects on younger generation’s addiction rate.

• DEA reports about 2,500 teenagers, every day, get high for the first time on prescription drugs.

*1 in 12 High School Seniors- admit to non-medical use of Vicodin. *1 in 20 HS Seniors- non med use of Oxycontin. Higher dropout rates, increase risk of HIV, Infectious disease, STD’s, and overdose. NIDA/NIH 2011

18

* *

www.youtube.com/embed/2ToprUxRFF4?rel=0

CBS with Katie Couric : Dr. Herbert Kleber,

Professor of Psychiatry Pioneer in the research and treatment of substance abuse:

Columbia University Medical Center.

19

The CDCP reports: • In the US, most prescription painkillers (immediate release

opioids) are prescribed by primary care, internal medicine physicians, and dentists, not specialists.

• Medical Family Practice is responsible for over 15% of the prescriptions written.

• Dentistry and Internal Medicine follow closely with 12%.

• Over 12 billion doses of opioids are prescribed a year in the US.

• 12% for DDS’s = over 1.4 Billion doses annually.

• 1 billion seconds = 31 years,

• 1 billion hours ago man wasn’t walking on earth.

• Finally, for perspective, 12 billion dollars has been spent since yesterday afternoon by US Gov’t. 12,000,000,000!

20

Third Molar Extraction Study • Third molar extraction surgery is responsible for 85% of

oral surgeons “almost always” prescribing opioid analgesics, according to a nationwide dental survey of 850 random OS.

• Oral surgeons, after third molar extraction, preferred the peripherally acting postoperative analgesic - ibuprofen (73.5%), however, 85% of oral surgeons also “almost always” prescribed a centrally acting opioid analgesic. The drug of choice- Hydrocodone bitartrate and APAP (acetaminophen) - 64%.

• 8 to 40 tablets of hydrocodone/APAP are prescribed, with instructions in 96% of cases to "take as needed for pain.“

• 36% of prescribers polled believed “most of the time”, there would be leftover medication.

THCIP/NIDA 2010 21

Basic Review of Schedules for Controlled Substances.(DEA)

Schedule I

• High abuse potential, lack of accepted safety, and no accepted medical use in the US: heroin, LSD, peyote, cannabis, and ecstasy(a methamphetamine).

-Medical marijuana laws enacted(legalized) in Wash.D.C., and16 states including;

CA (1996), Alaska (1998), Wash St.(1998), ), Oregon(1998), Maine(1999), Hawaii(2000), Nevada(2000), Vermont(2004), Montana(2004), RI(2006), N.Mexico(2007), Mich.(2008), Wash.D.C.(2010), NJ (2010), Ariz.(2010), Colorado(2010), and ), Delaware(2011).

22

18 States with Pending Legislation of Medical Marijuana as of March 2012

23

1. Alabama 2. Connecticut(2012) 3. Idaho 4. Illinois 5. Indiana 6. Iowa 7. Kansas 8. Maryland

9. Massachusetts 10. Mississippi 11. Missouri 12. New Hampshire 13. New York 14.Ohio 15. Oklahoma 16. Pennsylvania 17. West Virginia 18. Wisconsin

Schedule II • Schedule II- High abuse potential, potential for

severe psychological and/or physical dependence: Narcotics such as morphine and opium; hydromorphone (dilaudid), methadone (dolophine), meperidine (demerol), oxycontin (oxycodone), duragesic (fentanyl). (Brand name)

Schedule II stimulants include: amphetamine (adderall), methylphenidate (ritalin, concerta), and methamphetamine (desoxyn).

Other schedule II substances are: cocaine, amobarbital, glutethimide, and pentobarbital.

24 usdoj.gov

Schedule III • Schedule III- potential for abuse less than substances in

schedules I or II, abuse may lead to moderate or low physical dependence, or high psychological dependence.

• Schedule III narcotics include: combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin®) and products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with codeine®). Also included are buprenorphine products (Suboxone® and Subutex®) used to treat opioid addiction. Schedule III non-narcotics include: benzphetamine (Didrex®), phendimetrazine, ketamine, and anabolic steroids such as oxandrolone (Oxandrin®).

25

usdoj.gov

Schedule IV

• Schedule IV- substances in this schedule have a low potential for abuse relative to substances in schedule III.

• An example of a schedule IV narcotic is propoxyphene (Darvon® and Darvocet-N 100®).

• Other schedule IV substances include: alprazolam (Xanax®), clonazepam (Klonopin®), clorazepate (Tranxene®), diazepam (Valium®), lorazepam (Ativan®), midazolam (Versed®), temazepam (Restoril®), and triazolam (Halcion®).

26 USdoj.gov

Schedule V

• Schedule V- substances in this schedule have a low potential for abuse relative to substances listed in schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. These are generally used for antitussive, antidiarrheal, and analgesic purposes.

• Examples include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC® and Phenergan with Codeine®).

27 USdoj.gov

Abuse Statistics in USA!

• CDC – Prescription drug abuse is the fastest growing drug problem in the USA.

• 7,000+ Pharmacy robberies in the US since 2004. • Prescription drug abuse accounts for 1 death every 19

minutes in the US. • 2010- HHS (NSDUH) report- over 2.4 million Americans

(12 or older) reported non-medical use of prescription drugs for the first time in the past year. Over 6,500 new people/day!*

• In 2010 -the number of new nonmedical users of OxyContin® aged 12 or older was 598,000, with an average age at first use of 22.8 years among those aged 12 to 49. These estimates are similar to those for 2009 -584,000 and 22.3 years.

28 cdc..gov and USDHSS 2011 *1/2 are female, 1/3 age 12 to 17!

Additional CDCP Stats!

• In 2007, 27,000 unintentional drug overdose deaths occurred in the US.

• In 2008 it went to 36,450 deaths. Car accident deaths were 39,973.

• In 2010, the CDC reported enough opioid prescriptions were filled to provide every adult in the U.S. a 5mg dose, q4h, for 30 days.

• 2011, the CDC reported prescription drug deaths in the U.S. surpassed traffic accident fatalities.

29

Opioids

Cocaine

Heroin

CDC/NVSS 2009

OD Deaths 1999 to 2009 about a 5 fold increase

30

Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined. Source: National Vital Statistics System. Multiple cause of death dataset. Available at http://www.cdc.gov/nchs/nvss.htm.

What is causing the high incidence of PDAM?

• Increased availability- 1991 =72.5 mil. to 2010= 209.5 million prescriptions. Stimulants went from 5 mil. to 45 mil. in same period.

• Increase use/abuse for pain, sleep disturbances, stimulants for focus, anxiety, and just to get high.

• Aggressive industry marketing of various meds. • Safety misperceptions. • Greater social acceptability. • Pill mills. • Theft from pharmacies, manufacturers, & distributors. • Friends and family. • Illegal internet activity.

31 NIDA/NIH

The figure above shows rates of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold in the United States during 1999-2010. During 1999-2010, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially in a similar pattern. CDCP.gov

32

The 1st figure shows drug overdose death rates in 2008 by State. The 2nd figure shows the rates of kilograms (kg) of opioid pain relievers (OPR) sold in 2010 in the United States. The States with lower death rates had lower rates of nonmedical use of OPR and OPR sales. CDC.gov

33

DEATHS!

SALES!

www.youtube.com/embed/7S65-isBqcM?rel=0

Oxycotin Express-Broward County, Fla. “Pill Mill”

34

CDCP Stats continued:

• The U.S. Dept. of Health reports prescription painkillers are now the second most-abused drugs after marijuana.

• The number of patients treated in emergency rooms for prescription drug overdoses more than doubled between 2004 and 2008.

• Visits went from 144,644 in 2004 to 305,885 in 2008 for opioid analgesics.

• In 2009 it was over 475,000 ER visits.

35 Cdcp/samhsa/dawn

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

7.1% 4.4% 4.8% 11.4% 17.3% 55%

Prescribed by 1 doctor

Bought from friend or family*

*Obtained free from friend or relative-

Took from friend or family w/o asking*

Got drugs from dealer or stranger

Other sources, and Internet

cdcp.gov2011

People who abused Prescription Painkillers get them from a variety of sources:

36 * combined over 70% involve friends or family!

37

April 2011- The ONDCP-released the Fed. Govt’s. plan for addressing prescription drug abuse in U.S.; Epidemic: Responding to America's Prescription Drug Abuse Crisis:- includes four components: education, tracking/monitoring, proper medication disposal, and law enforcement.

• Education -improve medical/dental prescribing methods for opioids and derivatives. -discuss drug interactions(doctor and patient/parent/guardian). -doctor shopping behavior. -(Sen. Charles Schumer co-sponsor legislation- mandating special education/training for opioid prescribers.)

• Tracking and Monitoring Programs -36 States have drug monitoring programs in place as of 12-2011. -13 additional states have enacted legislation but not operational yet.

38

• Proper Drug Disposal -DEA sponsored National Prescription Drug Take-Back Events in 2010 and 2011 in over 5,000 sites across USA. -309 Tons of drugs collected in first 2 events! -4-28-2012, 5,659 sites in 50 States= 276 tons of unwanted medications. (4 events net over 774 tons). Next Sept.29,2012. -Local Police Departments. 9 NEW NYST. HDQTRS. -To Flush or Not to Flush???>>>EPA vs. FDA. • Enhance Law Enforcement and Legislation -Strengthen existing laws. -Improve legislation in some states. -Implement Insurance Restrictions to prevent “doctor shopping”: -the plan outlines specific actions the federal government can take to help law enforcement agencies effectively address pill mills and doctor shopping. Remember vast majority of prescribers and pharmacists are honest and responsible.

CDC.gov

Where to begin: Your medicine cabinet

The CDCP in 2010 reported nationally 60% of the abused substances used by high school seniors were prescription drugs!

39

Remember 7 out of 10 people who abuse prescription drugs state they got them from a friend or family member with or without their knowledge!

40

Proper Drug Disposal

• Do not keep unused or “extra” painkillers. -no dresser drawer, nightstand, refrigerator, kitchen cabinet, nor medicine cabinet- easy access to be diverted by others. • Dispose of unused medicine properly including

disposal of original container and label. • Check the manufacturers recommendation on the

label for proper disposal. • Place unwanted medication in a plastic bag with

soapy water, coffee grinds, salt, dirt, or cat litter. • Throw out in the garbage on pickup day. • Look for Police/DEA Sponsored Take-Back Events.

OR

41

The question is: To flush or not to flush?

EPA vs. FDA

FDA:MEDICINES RECOMMENDED FOR DISPOSAL BY FLUSHING • This list from FDA tells you what expired, unwanted,

or unused medicines you should flush down the sink or toilet to help prevent danger to people and pets in the home. Flushing these medicines will get rid of them right away and help keep your family and pets safe.

• FDA continually evaluates medicines for safety risks and will update the list as needed.

• List revised: January 2012 • Consumers are advised to check their local laws and

ordinances to make sure medicines can legally be disposed of with their household trash.

• For specific drug product labeling information, go to DailyMed or Drugs@FDA.

42

43

Medicine Active Ingredient

Abstral, tablets (sublingual) Fentanyl

Actiq, oral transmucosal lozenge * Fentanyl Citrate

Avinza, capsules (extended release) Morphine Sulfate

Daytrana, transdermal patch system Methylphenidate

Demerol, tablets * Meperidine Hydrochloride

Demerol, oral solution * Meperidine Hydrochloride

Diastat/Diastat AcuDial, rectal gel Diazepam

Dilaudid, tablets * Hydromorphone Hydrochloride

Dilaudid, oral liquid * Hydromorphone Hydrochloride

Dolophine Hydrochloride, tablets * Methadone Hydrochloride

Duragesic, patch (extended release) * Fentanyl

Embeda, capsules (extended release) Morphine Sulfate; Naltrexone Hydrochloride

Exalgo, tablets (extended release) Hydromorphone Hydrochloride

Fentora, tablets (buccal) Fentanyl Citrate

Kadian, capsules (extended release) Morphine Sulfate

Methadone Hydrochloride, oral solution * Methadone Hydrochloride

Methadose, tablets * Methadone Hydrochloride

Morphine Sulfate, tablets (immediate release) * Morphine Sulfate

Morphine Sulfate, oral solution * Morphine Sulfate

MS Contin, tablets (extended release) * Morphine Sulfate

Nucynta ER, tablets (extended release) Tapentadol

Onsolis, soluble film (buccal) Fentanyl Citrate

Opana, tablets (immediate release) Oxymorphone Hydrochloride

Opana ER, tablets (extended release) Oxymorphone Hydrochloride

Oramorph SR, tablets (sustained release) Morphine Sulfate

Oxecta, tablets (immediate release) Oxycodone Hydrochloride

Oxycodone Hydrochloride, capsules Oxycodone Hydrochloride

Oxycodone Hydrochloride, oral solution Oxycodone Hydrochloride

Oxycontin, tablets (extended release) * Oxycodone Hydrochloride

Percocet, tablets * Acetaminophen; Oxycodone Hydrochloride

Percodan, tablets * Aspirin; Oxycodone Hydrochloride

Xyrem, oral solution Sodium Oxybate

Senator Carl L. Marcellino partnered with the Glen Cove Police Department and the Glen Cove Fire Department to help residents safely dispose of their expired or unused medications.

44

OR THIS!

Be aware that there exists a 10% incidence of substance abuse in the general population according to the CDCP. • Take Detailed Med/Dent History. • Review Drug History thoroughly, any past abuse. • Consult with patient’s physicians. • Review prior treatment and adverse reactions. • Collaborate with family members/support network,

IF consent given. • “Drug seekers” exploit a Docs sensitivity to their

patients’ pain to get the drugs they want. They are very good at it! Be aware!

Office Protocol

45

46

Your Responsibilities (DOJ/DEA):

• As a healthcare professional, you share responsibility for solving the prescription drug abuse and diversion problem.

• You have a legal and ethical responsibility to uphold the law and to help protect society from drug abuse.

• You have a professional responsibility to prescribe controlled substances appropriately, while guarding against abuse.

• You have a personal responsibility to protect your practice from becoming an easy target for drug diversion.

• You must become aware of the potential situations where drug diversion can occur and the safe- guards that can be enacted to prevent this diversion.

Doctor Shopping: Be Aware Of The Signs

According to the Drug Enforcement Administration (DEA), "doctor shopping" is one of the primary ways that addicts obtain prescription drugs for non-medical use. "Doctor shopping" refers to when an individual visits several different doctors to obtain prescriptions for drugs, and then has the prescriptions filled at different pharmacies. This allows the individual to obtain more of the prescribed substance than any one doctor or pharmacist would allow. Legally, doctor shopping is not a minor matter; it is prosecuted on the federal level as a felony and is punishable by up to five years in prison in some states.

47

48

Recognizing the Drug Seeker:

Telling the difference between a legitimate patient in pain and a drug abuser isn't easy.

• A drug-seeking individual may be unfamiliar to you.

• A person who claims to be from out-of-town.

• A person who claims to have lost or forgotten a prescription.

• Or the drug seeker may actually be familiar to you such as a friend, neighbor, relative, or colleague.

• Drug abusers and "doctor-shoppers" often possess similar traits and modus operandi.

DOJ/DEA

49

Common Characteristics of the Drug Seeker:

• Unusual behavior in the waiting room.

• Assertive personality, often demanding immediate action.

• Unusual appearance.

• May show unusual knowledge of controlled substances.

• Gives evasive or vague answers to questions regarding medical history.

• Unwilling to provide reference information.

• Usually has no regular doctor and often no health insurance( pays cash).

USDOJ.GOV

Common Characteristics of the Drug Seeker continued:

• Will often request a specific controlled drug and is reluctant to try a different drug.

• Generally has no interest in diagnosis - fails to keep/make appointment for further diagnostic tests or refuses to see another practitioner for consultation.

• May exaggerate pain or problems and/or simulate symptoms to get stronger meds.

• May exhibit mood disturbances, lack of impulse control.

• Cutaneous signs of drug abuse - skin tracks and related scars on the neck, axilla, forearm, wrist, foot and ankle. (Be observant). USDOJ.GOV

50

51

Other Methods Often Used by the Drug-Seeking Patient Include:

• 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).

• States strongly, only specific narcotic prescription drugs work on them.

DOJ/DEA

Modus Operandi continued:

• Person claims that specific non-narcotic analgesics do not work for them or that he/she is allergic to them.

• Contends to be a patient of a dentist/physician who is currently unavailable or will not give the name of their regular dentist/physician.

• States that a prescription has been lost or stolen-needs immediate replacement.

• Frequently requesting refills more often than originally prescribed and planned.

• Pressures you by eliciting sympathy or guilt or by direct threat.

DOJ/DEA.GOV 52

53

What to do when confronted by a suspected Drug Abuser: DO: • perform a thorough examination appropriate to the

condition. • document examination results and questions you asked

the patient. • request picture I.D., or other I.D. and Social Security

number. Photocopy these documents and include in the patient's record.

• call a previous practitioner, pharmacist, or hospital to confirm patient's story.

• confirm a telephone number, if provided by the patient. • confirm the current address/phone # at each visit. • write prescriptions for limited quantities and duration.

DOJ/DEA

What Not To Do When Confronted by a Suspected Drug Abuser:

DON'T:

• Don’t "take their word for it" when you are suspicious. Stand by your diagnosis, ask questions.

• Don’t dispense drugs just to get rid of a “drug-seeking” patient. Your office can become a target.

• Don’t prescribe, dispense, or administer controlled substances outside the scope of your professional practice or in the absence of a formal practitioner-patient relationship.

• Don’t put anyone or yourself in harms way, call 911 if you feel threatened.

54 DOJ/DEA.gov

Methods for reducing abuse. • Educate parents and patients of dangers of prescription

“painkillers” (opioids) ie: abuse potential, side effects, respiratory depression, dependence, addiction, if family history of abuse. Remember REMS!

• “Gatekeeper” theory- the parent is responsible for monitoring pain needs for their child. Keep out of teens hands.

• Limit prescriptions, doses, and duration. • No refills without seeing patient for reassessment. • Describe procedures for unused drug disposal one on

one. • Utilize NSAIDS (i.e.: dolobid, naprosyn, toradol, lodine,

mobic, motrin, and alleve). • Long acting local anesthetics- Marcaine.

55

Methods continued/review.

• Treat your prescription pad like “cash”, leave it lying around and it will disappear.

• Better yet, treat it like a dangerous weapon!(Because that is what it can turn into.)

• Numerical and written form. (10 and Ten).

• Check with pharmacist for script renewals and patient reported “lost” prescription.

• Pharmacists-do not dispense with incomplete, improper, or questionable script, check DEA #, call prescriber for verification.

56

57

Do not preprint DEA #

If copied VOID shows up!

Thermal test Blue to White!

Keep track of #’s

Where NOT to Keep Prescription Pads

58

Treatment Rooms!

Where NOT to Keep Prescription Pads

59

FRONT DESK

NOT SECURE!

Unattended Prescription Pad in Hospital Conference Room!

This just invites trouble.

60

Other security measures!

• Keep prescription pads in a safe location.

• Lock box or locked drawer. • Keep record of script #. 61

Proper prescription protocol.

Write out dosage, “ten” not “10”.(Numerical and written form).

62

Keep your scripts from

becoming this!

63

64

Have a closer professional relationship with your local

pharmacist.

E-Prescribing- will significantly reduce prescription fraud!

• E-Prescribing - a prescriber's ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care - is an important element in improving the quality of patient care.

• The inclusion of electronic prescribing in the Medicare Modernization Act (MMA) took place in 2003.

• The July 2006 Institute of Medicine report.

• Adopting the standards to facilitate e-prescribing is one of the key action items in the government’s plan.

• Curtail altered, forged, lost, and or stolen prescriptions.

• Reduce medication errors due to misinterpretation of handwriting.

65

E-Prescribing continued: Attention New York State Prescribers • Chapter 178 of the Laws of 2010 enacted a bill to allow

electronic prescriptions for controlled substances in New York. The Department of Health (DOH) is currently working on the corresponding regulations. Until such notice, regulations as written in Title 10 Part 80 Rules and Regulations on Controlled Substances in New York State apply. Electronic prescribing of controlled substances is not yet permissible in New York State.

• Electronic prescriptions for non-controlled substances are permitted in New York State under the authority of the New York State Education Department.

Attention New York State Prescribers • Public Health Law requires that all prescriptions written in

New York State be issued on an official New York State prescription form. The law was enacted to combat prescription fraud and went into effect on April 19, 2006.

66

Organizations to be aware of for support/information.

• Be familiar with drug abuse treatment organizations and centers for patient referral.

• Check with your local hospitals for programs. • NAFAS, National Alliance for Addiction Services.

www.nassaualliance.org/ The L.I. 24 Hour Crisis Hotline is 516-679-1111. Also, NAFAS deals with other addictions, i.e.; alcohol, marijuana, cocaine, benzodiazepines, etc.

-NAFAS is a non for profit coalition of community service providers committed to comprehensive prevention and treatment for people and families faced with the consequences from drug, alcohol, and gambling abuses.

• SAMHSA, Substance Abuse and Mental Health Services Administration. www.samhsa.gov /1-877-SAMHSA-7(726-4727)

-SAMHSA works to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services.

• CDC.gov., Drufree.org, hazelden.org, Drugabuse.gov., Health.ny.gov, whitehouse.gov/ondcp, www.pharmacist.com, Report Medicaid Fraud-www.nassaucountyny.gov, Takeback events- www.takebacknetwork.com, www.fda.gov., OASAS-Office of Alcoholism and Substance Abuse Services.

67

68

Leaders In Dentistry

• American Dental Association(ADA)- further awareness of this prescription drug problem through The Dentist Health and Wellness Conference held annually in Chicago, ADA- HDQ. www.ada.org

• New York State Dental Association(NYSDA)- support through State Council on Chemical Dependency. www.nysdental.org

• Nassau County Dental Society(NCDS)- support through Local Component Council on Chemical Dependency. www.nassaudental.org

In Summary

Conveying further awareness of prescription drug abuse and misuse to our colleagues, and ultimately the communities we serve, will once again improve our patients’ lives and help prevent the tragedies associated with prescription drug abuse.

69

Dr. Peter Blauzvern

70

Thank you!

That was very Interesting!!!