This course meets the 1-unit requirement for coursework in drug diversion mandated by West Virginia Senate Bill 437. It is for any licensee who participates in prescribing, dispensing, or administering controlled substances.
Evidence-based information about the problem of drug diversion and the safeguards to prevent diversion, misuse, abuse, addiction, and overdose deaths.
The following information applies to occupational therapy professionals:
Criteria for Successful Completion
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.
Objectives: When you finish this course you will be able to:
The misuse and abuse of drugs is a crisis, in our country and around the world. By 2020 mental health and substance abuse disorders will surpass all physical diseases as a major cause of disability worldwide. Abuse of prescription drugs / drug diversion is the largest drug problem in the United States, and one that is growing. According to the United States Centers for Disease Control and Prevention (CDC), people from all age groups, ethnic backgrounds, and genders are affected by this disease.
Accidental overdose and misuse of prescription drugs leads to the severe consequences of death and addiction. The 2013 National Survey on Drug Use and Health (NSDUH) indicates that 15.2 million people aged 12 or older used prescription drugs nonmedically in the past year, and 6.5 million did so in the past month. Prescription drugs are abused and misused more often than any other drugs except marijuana and alcohol (SAMHSA/NSDUH, 2014a).
Health professionals face a dilemma because their patients often need prescription drugs but there is also a need to prevent the diversion and misuse of drugs. Among the prescription drugs diverted and misused are pain relievers, tranquilizers, stimulants, and sedatives. Opioid analgesics are powerful painkillers medically indicated in the treatment of chronic pain; however, when the patient takes the wrong dose, or the wrong person takes the opioid pain medication, consequences can be deadly.
While the sales of opioid analgesics increased four-fold between 1999 and 2010, the United States concurrently experienced an almost four-fold increase in opioid overdose deaths (SAMHSA/NSDUH, 2014a). Other consequences of the abundance of opioids include emergency department visits and admissions, falls and fractures in older adults, and initiating injection drug use, which increases risk for infections such as hepatitis C and HIV.
West Virginia’s SB437 is a response to the state’s need for additional education about drug diversion and abuse mitigation. The following are some statistics for the State of West Virginia:
What is the role of clinicians in the problem of prescription drug diversion, misuse, and abuse? Clinicians are in a unique position to educate, identify, and intervene with patients and colleagues who are at risk for prescription drug misuse and abuse. Recognizing the signs of misuse and risk factors of drug abuse and diversion by patients and fellow healthcare professionals is an important responsibility of all clinicians. Educated health professionals can be instrumental in changing patterns of misuse and abuse of prescription drugs for individuals, colleagues, and communities, and thereby reducing the public health epidemic.
Aberrant drug-related behaviors: any medication-related behaviors that depart from strict adherence to the physician-prescribed plan of care, ranging from mildly problematic behavior (such as hoarding medications) to illegal acts (such as selling medications).
Addiction: a primary, chronic, neurobiologic disease whose development and manifestation is influenced by genetic, psychosocial, and environmental factors. Addiction behaviors often include impaired control over use, compulsive use, continued use despite resulting harm, and craving (Corsini & Zacharoff, 2014).
Abuse/nonmedical use: Abuse is the use of an illicit drug or the intentional self-administration of a prescription (or over-the counter) medication for any nonmedical purpose, such as altering one’s state of consciousness, eg, “getting high.” However, some critics dislike the term abuse being applied to substance use disorders and claim it is inaccurate and reflects morality-based language to depict what may actually be a medical condition (Corsini & Zacharoff, 2014).
Chronic pain: any pain that last more than 12 weeks, but may last for months or years. Whereas acute pain is a normal sensation that alerts the body to injury or damage, chronic pain persists. Chronic pain may result from an injury or an ongoing cause such as illness, or there may be no clear cause (NIH, 2011).
Diversion: the intentional removal of a medication from legitimate distribution and dispensing channels. Diversion also involves the sharing or purchasing of prescription medication between family members and friends or individual theft from family and friends (Corsini & Zacharoff, 2014). Diversion can also occur in healthcare settings if health professionals divert medication from the intended recipient.
Misuse: any therapeutic use of a medication other than as directed or indicated, whether intentional or unintentional, and regardless of whether it results in harm. Increasing a medication dose without prescriber approval is misuse, whether the reason is dependence, tolerance, desire to achieve greater therapeutic effect, or forgetfulness (Corsini & Zacharoff, 2014).
Physical dependence: a state in which the body has adapted to a drug or class of drugs to the degree that withdrawal syndrome occurs upon abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist (Corsini & Zacharoff, 2014).
Drug abuse is not a new problem. The United States Congress passed the first Controlled Substances Act in 1970, but addictive drugs were first outlawed in America in the early 1900s. The 2012 Controlled Substances Act (current) presents schedules numbered I, II, II, IV, and V.
Controlled Substances, 2012
Medical use/abuse potential
On August 22, 2014, the U.S. Drug Enforcement Agency (DEA) formally rescheduled hydrocodone combination products (HCPs), moving them from Schedule III to Schedule II of the Controlled Substances Act.
Acute Pain is a normal physiologic sensation that signals injury or disease. It serves a vital function, warning of the need for medical treatment.
Chronic pain is pain that persists, often for weeks, months, or years. The presence of chronic pain is a disease state in itself. When the pain’s warning function is completed, continued pain is an abnormal state. Its distinct pathology causes changes in the nervous system that often worsen. Its effects on a patient’s psychology and cognitive ability are significant, and include anxiety, depression, and anger.
Chronic pain affects approximately 100 million Americans, according to a 2011 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education.
In past decades, concern about undertreatment of pain led to increases in prescribing of analgesics. In 1998 the Federation of State Medical Boards (FSMB) released guidelines that supported the use of opioids for chronic, noncancer pain. This contributed to the increase in opioid prescriptions that followed. The Joint Commission, an accrediting body, then issued the Pain Standard, which evaluated healthcare organizations (including hospitals, ambulatory care centers, behavioral health, and home care) on the basis of their consistent, documented assessment of patients’ pain (ASAM, 2012).
Balance is the goal in treating patients’ pain and preventing drug diversion, according to a Joint Statement from twenty-one health organizations and the Drug Enforcement Agency (DEA):
Preventing drug abuse is an important societal goal, but there is consensus, by law enforcement agencies, health care practitioners, and patient advocates alike, that it should not hinder patients’ ability to receive the care they need and deserve. . . . Undertreatment of pain is a serious problem in the United States, including pain among patients with chronic conditions and those who are critically ill or near death. Effective pain management is an integral and important aspect of quality medical care, and pain should be treated aggressively. (Joint Statement, 2002)
Because of changes in pain treatment, prescriptions of opioid analgesics have increased dramatically from the 1990s—from 76 million prescriptions in 1991 to 210 million subscriptions in 2010. This increase resulted in their increased availability for nonmedical users (NIDA, 2014).
The U.S. culture of drug use, faith in pharmaceutical solutions, and desire for rapid relief from pain has contributed to the increase in opioid prescriptions. Alcohol use plays a role in drug abuse. Manufacturers of pharmaceuticals market directly to consumers in all types of media. This, combined with information about medications that is widely available on the Internet, leads to patients’ asking doctors for drugs by name.
The increase of prescription opioids has exacted a severe toll. Unintentional overdose deaths have quadrupled since 1999, and now far outnumber those from heroin and cocaine combined (about 16,000 for opioids vs. about 2,000 for heroin and 3,000 for cocaine). The CDC considers prescription drug abuse to be epidemic. According to the CDC, approximately one hundred Americans died from overdose every day in 2010. Prescription drugs were involved in more than half of the 38,300 overdose deaths that year, and opioid pain relievers were involved in over 16,600 of these deaths (ONDCP, 2014).
Drug use affects not only the drug abuser but also the family unit and the community at large. Overdose and accidental death impacts family members and caregivers as well as our healthcare system. Drug abuse impacts on-the-job performance and missed work. The overall cost of prescription opioid abuse in the United States has been estimated at $9.5 billion (in 2005 U.S. dollars), including healthcare, criminal justice, and workplace costs (Passik, 2009).
The 2013 West Virginia Behavioral Health Epidemiological Profile reveals some societal costs of drug abuse in the state. In addition to high mortality rates related to opioid overdose, rates of drug-related hospital admissions are four times higher than the national average (34% compared to 8.7%). Other health consequences include increases in cases of acute hepatitis C (rates per 100,000 population have more than tripled from 2007 to 2012) and HIV/AIDS (in 2012, 7% of reported cases in West Virginia were intravenous drug users).
After marijuana, prescription drugs are the second-most abused category of drugs in the United States (ONDCP, 2011). The three classes of the most commonly abused prescription drugs are:
One way to understand the scope of the problem of prescription drug misuse and abuse is to look at data on drug-related emergency department (ED) visits. The Drug Abuse Warning Network (DAWN) is a tracking system managed by the Substance Abuse and Mental Health Services Administration (SAMHSA). DAWN monitors trends in drug misuse and abuse and estimates the impact of drug misuse and abuse on the nation’s healthcare system.
“In 2009, there were nearly 4.6 million drug-related ED visits nationwide, including drug abuse, adverse reactions to drugs, and other drug-related consequences. Of these, almost 50% were for adverse reactions to medications taken as prescribed, and 45% involved drug abuse. DAWN estimates that of the 2.1 million drug abuse visits, 27.1% involved nonmedical use of pharmaceuticals (ie, prescription or OTC medications, dietary supplements)” (NIDA, 2011)
Furthermore, the emergency department (ED) visits involving prescription drugs (alone or in combination) increased 98.4% between 2004 and 2009, from 627,291 visits in 2004 to 1,244,679 visits in 2009 (NIDA, 2011).
For patients aged 20 or younger, ED visits resulting from nonmedical use of prescription drugs increased 45.4% between 2004 (116,644 visits) and 2009 (169,589 visits). Among patients aged 21 or older, there was an increase of 111% (NIDA, 2011).
In 2009, 1.2 million ED visits involved the nonmedical use of pharmaceuticals or dietary supplements. The most frequently reported drugs in such visits were opiate/opioid analgesics (50%) and psychotherapeutic agents commonly used to treat anxiety and sleep disorders (33%) (NIDA, 2011).
People of all ages, genders, and backgrounds use illicit or prescription drugs nonmedically.
Drug diversion is any intentional removal of a prescription medication from the legitimate channels of distribution and dispensing.
Although we might assume that drug users acquire their prescription drugs from street dealers, this is not usually the case. Because prescription medications are fairly commonly prescribed, often nonmedical users merely have to look in the medicine cabinet of a family member or friend. Among people aged 12 and older who used prescription pain relievers for nonmedical reasons in the past 12 months, 55.9% obtained them from a friend or relative (SAMSHA/NSDUH, 2013).
Another source for prescription drugs is legitimate prescriptions obtained illicitly. Patients may request prescriptions from more than one physician, and thereby receive more than one prescription for pharmaceuticals. This is known as “doctor shopping.” The patient does not inform the physicians of the multiple prescribers, and fills multiple prescriptions for the same or similar medication at different pharmacies.
Patients seeking to feed a habit of drug misuse or abuse may attempt to pass fraudulent prescriptions at the pharmacy. Fraudulent prescriptions come in the following forms:
Drug diversion isn’t only a problem in patients, however. Pharmacists, physicians, nurses, and other health professionals often have access to prescription drugs. These individuals are subject to the same propensities, temptations, genetic and medical histories, and physical and mental health problems as patients.
Prescribers may be involved in drug diversion by providing drugs to patients engaging in the practices of fraud or doctor shopping, who may be selling or sharing drugs.
Health professionals may also divert drugs for their own use. According to research by Storr and colleagues conducted in 2000, the prevalence of substance abuse and addiction in nurses and other healthcare professionals is no higher than that of the general population. Estimates range from 8% to 20% for use and abuse combined (NCSBN, 2011). Shaw and colleagues determined that because nurses comprise the largest group of healthcare professionals, those with substance use and abuse disorders are more visible, more stigmatized among health professionals, and receive more severe sanctions than physicians with similar abuse and addiction (NCSBN, 2011).
Clinicians must be trained to recognizing substance misuse and abuse among fellow health professionals because substance abuse on the job and untreated addiction disorder jeopardizes patient safety.
Dunn (2005) found that general symptoms of substance use problems among nurses include the following:
Signs and symptoms of a prescription drug substance use disorder among nurses can include the following:
Negative impacts on patient safety may result from any of the following:
Addiction and substance abuse have been called an occupational hazard for all health professionals. In addition to general risk factors that all members of the population are subject to (eg, depression, anxiety, stress, low self-esteem, use of other substances, early age of first misuse, alcohol and drug use by peers, family use, genetic predisposition to alcohol or drug dependence), nurses face specific risk factors in their workplace environments:
Of these risk factors, the top four are access to drugs, attitude, stress, and lack of education about addiction (NCSBN, 2011).
The use of prescription drugs including opioid analgesics for other than legitimate medical purposes poses a significant health risk to individual patients and to society. Inappropriate prescribing can lead to drug diversion and abuse by individuals seeking to use opioids nonmedically. It falls to clinicians to use systematic precautions to minimize the possibility for abuse and diversion of controlled substances (WVBM, 2010).
Research shows that there are three main categories of risk factors for opioid abuse and addiction:
The factor that is the most strongly predictive of opioid abuse, misuse, or other aberrant drug-related behavior is a personal or family history of alcohol or drug abuse (Chou, 2009). However, clinicians should recognize that “a history of substance abuse does not prohibit treatment with extended release/long-acting opioid analgesics but may require additional monitoring and expert consultation” (FDA, 2014).
SAMHSA’s Opioid Overdose Prevention Toolkit recommends that a thorough patient assessment and health history include specific questions. For example:
Further, a patient history should include questions about the patient’s use of alcohol and over-the-counter medicines (SAMHSA, 2014d).
During a physical examination, clinicians should also be on the lookout for the following signs in patients being seen for chronic pain:
Any treatment for pain should periodically be reviewed and evaluated by the clinician. New information about the patient’s state of health, condition or cause of pain, psychosocial and mental health, and nature of pain is noted. The clinician should look at the patient’s dosage, the medication schedule (to determine if the patient is indeed taking the prescription as directed) and whether the current treatment should be continued or modified. This decision depends on evaluation of the progress toward the treatment objectives previously outlined in the plan of care. At such a review, it is critical to reinforce correct medication usage.
Regular monitoring and ongoing assessment to determine if the treatment plan is on track and the patient is achieving results is essential. Clinicians should incorporate the following practices in their patient monitoring:
The purpose of risk assessment is to determine the likelihood that a patient will develop or display aberrant drug-related behaviors. Healthcare providers must be observant at all times for signs of nonadherance to treatment plans and dosage instructions. Aberrant drug-related behaviors include the following:
Spectrum of Aberrant Drug-Taking Behaviors
More suggestive of addiction*
*Documented in patient’s medical chart.
Less suggestive of addiction
As is evident above, not all aberrant drug-related behaviors by patients signify addiction. They may instead signify that the patient:
Clinicians should look closely to determine the reason for the unexpected or aberrant behaviors. Such behaviors are important clinical signs.
It is important to consider all behaviors, and the multitude of reasons that patients may not take their medications as they are prescribed. Understanding the specific reason for each unexpected behavior can help the clinician to take the correct next step, and make decisions that help minimize risk, improve safety, and most of all benefit the patient (Corsini & Zacharoff, 2014).
Healthcare professionals must be on the lookout for the following signs and symptoms of opioid abuse:
Prescribers have a number of tools at their disposal to help with ongoing assessment of chronic pain patients who are receiving opioid analgesic therapy. Here are a few of those tools.
Developed by Bruce D. Naliboff with support from VA Health Services Research and Development, this is a 20-item, yes/no assessment tool that can increase a provider’s confidence in determinations of appropriate vs. inappropriate opioid use (Wu et al., 2006).
This is a five-point questionnaire that assesses the risk of opioid abuse through evaluation of behaviors that are consistent with opioid abuse rather than answers to specific questions (Chabal et al., 1997).
This is a 26-item self-report assessment tool for ongoing monitoring of aberrant behaviors. It helps clinicians to identify whether a long-term chronic pain patient is exhibiting aberrant behaviors associated with opioid medication misuse (Dowling et al., 2007).
The PDUQ assesses problematic opioid misuse, abuse, and dependence in chronic pain patients. Evidence suggests the PDUQ’s key screening indicators are excellent predictors for the presence of addiction (Compton et al., 2008).
A self-administered questionnaire consisting of 28 items with binary (yes/no) answers created by Harvey A. Skinner in 1982. Scores of 6 or more indicate the presence of substance dependence or abuse with satisfactory measures of reliability and high levels of validity, sensitivity, and specificity (Yudko et al., 1997).
A 17-item patient self-assessment that helps clinicians identify whether a patient, currently on long-term opioid therapy, may be exhibiting aberrant behaviors associated with misuse of opioid medications. Since the COMM examines concurrent misuse, it is ideal for helping clinicians monitor patients’ aberrant medication-related behaviors over the course of treatment (Butler et al., 2007).
Regular urine drug screening (UDS) is appropriate for patients who are at higher risk for opioid abuse or addiction, and for any patient who is exhibiting signs of misuse or aberrant drug behavior. Urine screening can indicate drug diversion, misuse, or abuse, and the presence of an illegal drug might indicate addiction. Any nonprescribed opioid may signal drug abuse or doctor shopping.
Pill counting is one method of ensuring medication adherence and helps to prevent drug diversion. Counting pills is done to compare the number of doses remaining in a prescription container with the number of doses that should remain, if the patient adhered to the medication schedule perfectly. However, a clinician cannot be sure that absent pills were consumed; they may have been diverted instead. Healthcare professionals must keep careful records about the amount of medication dispensed, prescription date, date the prescription was filled, and how many doses remain before the refill.
Clinicians should request a report of a patient’s medication history from the state’s PDMP before prescribing controlled substances. PDMPs track controlled substances prescribed by authorized practitioners and dispensed by pharmacies. PDMPs assist in patient care, provide early-warning signs of drug epidemics, and help to detecting drug diversion and insurance fraud.
West Virginia’s Prescription Drug Monitoring Program, the Controlled Substance Automated Prescription Program (CSAPP), was established in 1995 by the State Board of Pharmacy for the monitoring of Schedule II–IV Controlled Substances. Data collection occurs once per week and collects an average of 3.3 prescriptions annually (ONDCP, 2013). The goal of CSAPP is to provide prescribers and dispensers with access to information that will help them make better prescribing decisions and positively impact West Virginia’s drug problem. Furthermore, CSAPP can help to identify patients who may benefit from a substance abuse referral (CSAPP, 2013).
If a healthcare professional suspects that drug diversion has occurred, he or she must document the suspicion and make a report to the following agencies:
Local law enforcement and local fraud alert networks
More information can be found here (HSS CMS, 2014).
Combating prescription drug abuse necessitates the proper disposal of unused, unneeded, or expired medications. Patients must have a secure and convenient way to dispose of controlled substances. The Drug Enforcement Agency has strict regulations for drug take-back programs, including National Prescription Drug Take Back Days (ONDCP, 2013). Healthcare providers should encourage patients to use such take-back disposal services when available.
The previous eight National Prescription Drug Take-Back events have removed over 14 tons of prescription drugs from homes throughout West Virginia and more than 2,100 tons of pills nationwide (U.S. Attorney’s Office, 2014).
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