After seeing a patient on a Diversion Alert installment.. Recommendations from Dr. James Berry of Mercy Recovery Center OVERVIEW OF DIVERSION
OPPORTUNITIES FOR DIVERSION Manufacture Distribution Pharmacy Patient End -user Impactors: drug design, third-party coverage, law enforcement, drug smugglers, pre-existing level of addiction, social factors, prescribers MYTHS REGARDING DIVERSION • The root cause of Maine’s opiate addiction epidemic is the diversion of prescribed opioids. • If we eliminate diversion, we will drive addicts into treatment and reduce the personal and social ills associated with addiction. • The reformulation of Oxycontin in 2009 was a major breakthrough in combating diversion and illicit use. • By adhering to the “universal precautions” recommended by the MMA and the Medical Board, we can significantly impact diversion. • Eliminating diversion of Suboxone is a desirable goal.
ONE FINAL MYTH • MYTH : Opiates are a RIGHT. For many chronic pain patients they are necessary for them to have a reasonable life. • FACT : Opiates are a TREATMENT MODALITY: Opiates are one of several treatment modalities for chronic pain; available evidence does not support their chronic use. USE OF THE PMP • Use both periodically and when a question of outside prescribing needs investigation • Look at quantities, dates, prescribers, payers. Was there doctor or pharmacy-shopping? Were prescriptions paid for in cash if the patient had coverage? Prescriptions refilled at odd intervals? • Get the patient’s story. • An opportunity for education. • May reveal polypharmacy issues • Keep in mind limitations of the PMP.
USEFULL INFORMATION FROM DIVERSION ALERT • Patient diverting YOUR prescription • Patient diverting someone else’s medication or an illicit substance. • Patient arrested for possession of a scheduled drug unrelated to what you prescribed. • Patient arrested for alcohol-related incident • The subject is a patient but you have never prescribed controlled substances to him/her • The subject is a relevant person but not a patient: a relative, partner, potential patient. Follow up with the arresting agency • The nature of the charges and circumstances may provide useful information as you consider what to do. • For Diversion Alert data, your primary source for additional information should be law enforcement— HIPAA applies when talking to them. • Per professional and HIPAA regulations, consider talking to prescribers and pharmacists who share the patient’s treatment with you
Talk to the patient • Raise the issue with the patient. • What is the issue behind the arrest— addiction, profit, coming to the aid of a friend? • Keep in mind that the patient’s story is usually not the whole story. • They may experience shame—if so approach the issue gently and nonjudgmentally. Don’t discount peripheral players in a crime If a patient appears to be only a peripheral player in the alleged crime reported on a Diversion Alert installment (i.e. a girlfriend of the person arrested), you still have to exercise caution in prescribing controlled substances to them: the principle of "guilt by association" applies here.
HOW TO STAY OUT OF TROUBLE • Document that you received the information, investigated the allegations, and had a discussion with your patient • Come up with a tentative plan before you talk to the patient. • Document your final plan and the reasoning behind it. • Follow through on your plan and document that you did. (it is okay to modify your plan but explain why you did so.) LAY THE GROUNDWORK- THE CONTOLLED SUBSTANCE AGREEMENT • Your medication is part of a treatment plan for the condition, and the patient will follow other elements of the plan. • If there is no longer a net benefit form the medication, it will be discontinued. • Make clear your BOTTOM LINE: what infractions will result in immediate termination of the contract, what ones reflect expectations and will trigger a warning. • There should be an item requiring adherence to laws regarding drugs and alcohol. • Review and have the patient initial the agreement yearly.
PROVIDER RESPONSES • If the patient is diverting what you prescribed you should stop prescribing controlled substances to that patient • If the patient is diverting or using a drug from a different category, you can consider continued prescribing with precautions. • Is addiction or alcohol playing a role? • Offer indicated referrals: counseling, addiction screening or treatment, inpatient detox • Do not discharge a patient just because they show up on Diversion Alert If you stop prescribing controlled substances to patient: • Provide a short taper of a month's duration - avoid giving a taper longer than a month if diversion of the prescribed drug is strongly suspected. • if the patient is coming off a high dose of opiates, consider referral to a detox center, Suboxone program, or methadone clinic. • Offer other appropriate referrals, alternative treatments.
If you do discontinue medications, offer alternatives for pain, anxiety or ADHD treatment. Controlled substances are ONE MODALITY for treating these conditions—there are other treatment modalities, both drug and non-drug . You are discontinuing a medication, not terminating the relationship or ceasing to treat the patient's condition, unless the patient so chooses. ROADBLOCKS TO ALTERNATIVE THERAPIES • Lack of availability or affordability of resources • Patient “wedded to their medication” • Active addiction • Unresolved mental health or social issues • Post-acute withdrawal
ALTERNATIVES TO OPIATES—BACK PAIN • Drugs: anticonvulsants, SNRIs, muscle relaxants, amitriptyline, Lidoderm • Procedural: nerve blocks, steroids • Manipulative: PT, OMT, chiropractic, massage therapy • Self-directed: Medical yoga, mindfulness, behavioral therapies(CBT, DBT, ACT) ALTERNATIVES TO BENZOS--ANXIETY • Medications: SSRIs, buspirone, clonidine, gabapentin • Life-style modification, yoga • Counseling-based: CBT, relaxation therapy, etc.
ALTERNATIVES TO STIMULANTS: ADHD • Medications--stimulants in order of addictive potential : Adderall>Vyvanse>short-acting Ritalin>sustained-release Ritalin (Concerta)>Welbutrin>Strattera or Intuniv • Medications or stressors exacerbating ADHD (cannabis, benzodiazepines). • Non-medical approaches—lists, reminders, schedules. • Life style congruent with ADHD: ambulance driver>accountant WHAT CAN PRESCRIBERS DO TO COMBAT DIVERSION AND MISUSE? • Follow Universal Precautions • Prescribe for accepted indications to low-risk patients • Pay attention to the patient’s social context • Keep an eye out for addiction • Do not ignore “red flags” • Keep doses low • Keep quantities dispensed low • Favor less addictive/less desirable opioid formulations • Favor less harmful opioids • Diversion that has already happened is more serious than a risk for diversion
AVOID HARMFUL POLYPHARMACY • Do not prescribe long-term opiates with other sedative drugs—benzos, cannabis, antipsychotics, hypnotics, sedating antidepressants. . • Ditto for benzos • Concurrent benzos, hypnotics, cannabis, and alcohol will negate the benefits of stimulants for ADHD. • Screen for problem alcohol use. DOSING Opioids: Daily dose of 120 mg morphine equivalent or less. This translates to: 80 mg oxycodone 60 mg methadone
OPIOID RISK • Riskiest: methadone, duragesic patch • Safest: buprenorphine • Most abused: oxycodone 30 mg • Least abused: sustained-release morphine, reformulated Oxycontin, oxycodone 5 mg and hydrocodone 5 mg with acetaminophen. • Sleeper: Ultram—causes seizures Note: nothing is safe when combined with other sedative classes Addiction is a disease, patients need empathy, support in addition to consequences. • Finding a patient on Diversion Alert may cause you discomfort - you may feel angry at having been duped. • As you enforce the rules and protect your patient’s health and safety, try to be somewhat sympathetic to the patient's plight, criminal charges often result in shame, stress, and family turmoil.
Disclosure and Contact information I have no conflicts of interest to disclose. James Berry, MD Interim Medical Director Mercy Recovery Center Westbrook, Maine berryj@mercyme.com 207-857-8383
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