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.
The problem of drug diversion: evidence-based information about 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.
The 2016 National Survey on Drug Use and Health (NSDUH) indicates 28.6 million people aged 12 or older used an illicit drug in the past 30 days, which corresponds to about 1 in 10 Americans overall (10.6%) and an estimated 11.8 million people misused opioids in the past year, including 11.5 million pain relief misusers and 948,000 heroin users.
Additional information was gathered in NSDUH for the misuse of pain relievers in 2017. Among people aged 12 or older who misused pain relievers in the past year, about 6 out of 10 people indicated that the main reason they misused the last time was to relieve physical pain (62.3%), and about half (53.0%) indicated that they obtained the last pain relievers they misused from a friend or relative (SAMHSA, 2017b).
Accidental overdose and misuse of prescription drugs leads to the severe consequences of death and addiction. In 2016, there were more than 63,600 drug overdose deaths in the United States. The age-adjusted rate of drug overdose deaths in 2016 (19.8 per 100,000) was 21% higher than the rate in 2015 (16.3) (Hedegaard et al., 2017). The New York Times recently reported that opioids are now the leading cause of death of Americans under the age of 50 (Katz, 2017).
Health professionals face a dilemma because their patients often need prescription drugs but they also face 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, the consequences can be deadly.
While the sales of opioid analgesics increased 4-fold between 1999 and 2010, the United States concurrently experienced an almost 4-fold increase in opioid overdose deaths (SAMHSA/NSDUH, 2014). 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 West Virginia:
* Neonatal Abstinence Syndrome (NAS) is a withdrawal syndrome that occurs after prenatal exposure to drugs is discontinued suddenly at birth.
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). Like other chronic diseases, addiction often involves cycles of relapse and remission. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DMS-5) does not use the term addiction for diagnosis (SAMHSA, 2018).
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 lasts several months (variously defined as 3 to 6 months), 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, 2018).
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.
Opioid use disorder (OUD): per the DSM-5, a disorder characterized by loss of control of opioid use, risky opioid use, impaired social functioning, tolerance, and withdrawal. Tolerance and withdrawal do not count toward the diagnosis in people experiencing these symptoms when using opioids under appropriate medical supervision. OUD covers a range of severity and replaces what DSM-IV termed “opioid abuse” and “opioid dependence.” An OUD diagnosis is applicable to a person who uses opioids and experiences at least 2 of the 11 symptoms in a 12-month period (SAMHSA, 2018).
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 Controlled Substances Act presents schedules numbered I, II, II, IV, and V.
Controlled Substances, 2018
Medical use/abuse potential
No accepted therapeutic use. Lack of safety even under medical supervision. High potential for abuse; abuse may lead to severe psychological or physical dependence
Accepted therapeutic use. Highly restricted. High potential for abuse; abuse may lead to severe psychological or physical dependence
Accepted therapeutic use. Highly restricted. Less high potential for abuse; abuse may lead to moderate or low physical dependence or high psychological dependence.
Accepted therapeutic use. Low potential for abuse relative to Schedule I, II, and III drugs; abuse may lead to limited physical dependence or psychological dependence.
Accepted therapeutic use. Low potential for abuse relative to Schedule I, II, III, and IV drugs; abuse may lead to limited physical dependence or psychological dependence.
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.
The National Institutes of Health, National Center for Complementary and Integrative Health (NCCIH), reports the following statistics about chronic pain in the United States:
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 (Zimmerman, 2017).
Balance is the goal in treating patients’ pain and preventing drug diversion. On January 1, 2018, the Joint Commission implemented a new and revised pain assessment and management standards. The new standards, which revise the original standards established in 2001, state that hospitals must:
NCCIH is part of the National Institutes of Health Pain Consortium, which coordinates pain research across NIH. NCCIH-supported studies are helping to build an evidence base on the effectiveness and safety of complementary modalities for treating chronic pain. The scientific evidence suggests that some of the complementary health approaches that may help people manage chronic pain include mindfulness-based interventions, hypnosis, and cannabinoids (NIH, 2018).
. . . The amount of opioids being prescribed by our nation’s doctors, dentists and nurses is excessive. While opioids offer relief to many patients with pain and should remain an available and acceptable option for pain management when medically indicated, it is clear from prescribing data and related addiction treatment admission and overdose death data that the medical community has over-relied on opioids to treat pain. (ASAM, 2017)
Because of changes in pain treatment, prescriptions of opioid analgesics have increased dramatically from the 1990s. This increase resulted in their increased availability for nonmedical users (NIDA, 2018).
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. The CDC considers prescription drug abuse to be epidemic. According to the CDC, approximately 116 Americans died from opioid-related causes every day in 2016.
The drugs involved in overdose deaths in the United States have changed in recent years. The rate of drug overdose deaths involving synthetic opioids other than methadone (drugs such as fentanyl, fentanyl analogs, and tramadol) doubled in a single year from 3.1 per 100,000 in 2015 to 6.2 in 2016. Overdose deaths involving heroin increased from 4.1 in 2015 to 4.9 in 2016. Overdose deaths involving natural and semisynthetic opioids (morphine, codeine, hydrocodone, and oxycodone) increased from 3.9 in 2015 to 4.4 in 2016 (Hedegaard et al., 2017).
In response to this crisis, the federal government has taken steps to inform more judicious opioid prescribing through the development of the CDC’s Guideline for Prescribing Opioids for Chronic Pain. Current data shows that the rates of prescribing are decreasing. Between 2006 and 2016, the annual prescribing rate per 100 persons decreased from 72.4 to 66.5 for all opioids, which is an overall 8.1% reduction (CDC, 2017a).
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. A study published in 2016 found the total economic burden of the opioid crisis in the United States is estimated to be $78.5 billion. More than one-third of this amount is due to increased healthcare and substance abuse treatment costs ($28.9 billion) (Florence et al., 2016).
A U.S. Council of Economic Advisers (CEA) report estimates that in 2015 the economic cost of the national opioid crisis was $504.0 billion, or 2.8% of GDP that year. This is more than 6 times larger than the most recently estimated economic cost of the epidemic (CEA, 2017).
The 2018 National Institute on Drug Abuse (NIDA) report on opioids in West Virginia reveals some societal costs of drug abuse in the state. Other health consequences include increases in cases of hepatitis C (HCV) and HIV. In 2015 West Virginia reported 6,347 cases of chronic HCV and 63 cases of acute HCV, or rates of 344.2 cases of chronic HCV per 100,000 population and 3.4 cases of acute HCV per 100,000. Among acute cases, nearly 40% were attributed to intravenous drug use. Of the 39,513 new cases of HIV in 2015 in the United States, 74 occurred in West Virginia (NIDA, 2018).
After marijuana, prescription drugs are the second-most abused category of drugs in the United States (SAMHSA, 2017b). The three classes of the most commonly abused prescription drugs are:
One way to understand the scope of the problem of illegal and prescription drug misuse and abuse is to look at data on drug-related emergency department (ED) visits. The 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes reports an estimated 259,665 hospitalizations for nonfatal, unintentional drug poisoning occurred in 2014. Opioid poisoning accounted for 20.4% (53,000) of these hospitalizations. Heroin was specified as the involved opioid for 21.7% (11,475) of opioid hospitalizations (CDC, 2017a).
An estimated 418,313 ED visits for nonfatal, unintentional drug poisoning occurred in 2014. Opioids accounted for 22.1% (92,262) of these ED visits. Heroin was specified as the involved opioid for 58.5% (53,930) of opioid ED visits. Cocaine accounted for 6,424 and methamphetamines for 11,012 visits (CDC, 2017a).
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.
In 2015, among persons aged 12 and older who had misused prescription pain relievers in the past 12 months, the following sources were reported for the most recent misuse:
Strikingly, these data suggest that drug dealers are a relatively small source of illicitly used prescription opioids. Diversion through family and friends is now the greatest source of illicit opioids (Dixon, 2018).
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. Recent data shows, however, the majority of opioids are obtained by prescription from one physician, not from "doctor shopping” (Dixon, 2018).
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:
[Material in this section is from NCSBN, 2011 and 2014, unless otherwise identified.]
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. Nurses and other healthcare professionals have about the same prevalence of substance abuse and addiction as the general public. But, there are unique workplace factors that actually increase a nurse’s opportunity and risk for addiction. The behavior that results from addiction has far-reaching negative effects, mot only on clinicians themselves but also upon the patients who depend on the nurse for safe, competent care.
Substance use disorder can affect nurses regardless of age, occupation, economic circumstances, ethnic background, or gender. The earlier substance use disorder in a nurse is identified and treatment is started, the sooner patients are protected and the better the chances are of the nurse returning to work.
Clinicians must be trained to recognizing substance misuse and abuse among fellow health professionals because substance abuse on the job and untreated substance use disorder jeopardizes patient safety and creates significant legal and ethical responsibilities for colleagues who work with these individuals.
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:
Nurse managers and colleagues should also watch for subtle changes in appearance over time as well as behavioral changes, such as wearing long sleeves in warm weather, increasing isolation from colleagues, inappropriate verbal or emotional response, or diminished alertness, confusion, or memory lapses.
Many nurses with substance use disorder are unidentified, unreported, untreated, and may continue to practice where their impairment may endanger the lives of their patients.
Addiction and substance abuse have been called an occupational hazard for all health professionals. In addition to general risk factors to which all members of the population are subject (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. The National Council of State Boards of Nursing (NCSBN) had made the NCSBN courses “Understanding Substance Use Disorder in Nursing” and “Nurse Manager Guidelines for Substance Use Disorder” free of charge for all nurses and nursing students (https://www.ncsbn.org/).
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.
Research shows that there are several categories of risk factors for opioid abuse and addiction:
One factor that is strongly predictive of opioid abuse, misuse, or other aberrant drug-related behavior is a personal or family history of alcohol or drug abuse. However, the FDA (2014) wants clinicians to 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, 2016a).
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.
“Because organized medicine basically caused this problem, it’s really going to take organized medicine to reverse it,” said Gary Franklin, University of Washington (Solis, 2014).
Regular monitoring and ongoing assessment is essential to determine if the treatment plan is on track and the patient is achieving results. 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
Steven Passick created this list in 2009 but it remains useful today.
More suggestive of addiction*
*Documented in patient’s medical chart.
Less suggestive of addiction
Source: Passik, 2009.
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 use disorder:
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 shorter 10-question DAST (DAST-10) also is used.
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 misus2007). e, 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. 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, 2018).
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
Other resources for information and assistance are listed at the end of this course.
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. Healthcare providers should encourage patients to use such take-back disposal services when available.
The 14th National Take Back Day, which took place October 28, 2017, collected 912,305 pounds (456 tons) of prescription drugs nationwide. In West Virginia 5,473 pounds of prescription drugs were collected (DEA, 2018).
Addiction is a chronic, treatable illness. Treating patients with opioid use disorder (OUD) requires continuing care rather than an episodic, acute-care approach. Patients should have access to medical treatment, mental health services, addiction counseling, and other recovery support services. Treatment should be tailored to each patient’s needs and preferences (ASAM, 2015). In fact, there is no single best approach that works for all patients. A comprehensive approach to treatment is part of addressing the problem of drug diversion. Research shows that many people in need of treatment for substance use disorder do not receive treatment.
The FDA has approved medications to treat OUD and improve patients’ health and wellness. These medications are methadone, naltrexone, and buprenorphine. These medications can reduce or eliminate withdrawal symptoms (methadone, buprenorphine), blunt or block the effects of illicit opioids (methadone, naltrexone, buprenorphine), and reduce or eliminate craving to use opioids (methadone, naltrexone, buprenorphine). People with OUD can benefit from medications for varying lengths of time, including lifetime treatment. Further, studies show that medication as part of treatment of OUD is cost-effective.
Did You Know . . .
Treatment with OUD medication is linked to better outcomes and retention than treatment without medications.
Healthcare providers need special training and certification to prescribe medications to treat OUD. A patient taking FDA-approved medication for OUD can be considered to be in recovery. Clinicians should also be aware that diversion of medications for treating OUD do occur (ASAM, 2015).
Opioid overdose–related deaths can be prevented when naloxone is administered in a timely manner. As a narcotic antagonist, naloxone displaces opiates from receptor sites in the brain and reverses respiratory depression that usually is the cause of overdose deaths.
Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline:
1-800-662-HELP (4357) or
1-800-487-4889 (TDD—for hearing impaired)
Behavioral Health Treatment Locator
(search by address, city, or zip code)
Buprenorphine Treatment Physician Locator
State Substance Abuse Agencies
Center for Behavioral Health Statistics and Quality (CBHSQ)
http://store.samhsa.gov1; 877-SAMHSA (1-877-726-4727)
Centers for Disease Control and Prevention (CDC)
American Society of Addiction Medicine (ASAM). (2015). National Practice Guideline in the Use of Medications for the Treatment of Addiction Involving Opioid Use. Retrieved April 8,2018 from https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf.
American Society of Addiction Medicine (ASAM). (2012). Public policy statement on measures to counteract prescription drug diversion, misuse, and addiction. Retrieved April 20, 2018 from http://www.asam.org.
American Society of Addiction Medicine (ASAM). (2017). June 16, 2017 Letter to Chris Christie, Chair, President’s Commission on Combating Drug Addiction and the Opioid Crisis. Retrieved 4/20/18 from https://www.asam.org/docs/default-source/advocacy/letters-and-comments/asam-recommendations-6-16-17.pdf?sfvrsn=2#search=%22trends%20in%20pain%20management%22.
Butler SF, Budman SH, Fanciullo GJ, et al. (2007). Cross Validation of the Current Opioid Misuse Measure (COMM) to Monitor Chronic Pain Patients on Opioid Therapy. Retrieved July 5, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955853/.
Centers for Disease Control and Prevention (CDC). (2017a). Annual Surveillance Report of Drug-Related Risks and Outcomes—United States, 2017. Surveillance Special Report 1. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2017. Retrieved April 14, 2018 from https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf.
Centers for Disease Control and Prevention (CDC). (2017b). Guideline for Prescribing Opioids for Chronic Pain. Fact Sheet. Retrieved 4/15/2018 from https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf.
Chabal C, Erjavec MK, Jacobson L, et al. (1997). Prescription Opiate Abuse in Chronic Pain Patients: Clinical Criteria, Incidence, and Predictors. Retrieved July 5 2018 from https://journals.lww.com/clinicalpain/Abstract/1997/06000/Prescription_Opiate_Abuse_in_Chronic_Pain.9.aspx.
Compton P, Darakjian J, Miotto K. (2008, October). Introduction of a Self-report Version of the Prescription Drug Use Questionnaire and Relationship to Medication Agreement Non-Compliance. J Pain Symptom Manage. 36(4): 383–95.
Controlled Substance Automated Prescription Program (CSAPP). (2018). West Virginia Board of Pharmacy. Retrieved April 8, 2018 from https://www.csappwv.com/Account/Login.aspx?ReturnUrl=%2f.
Corsini E, Zacharoff KL. (2014, 2011). Definitions related to aberrant drug-related behavior: Is there correct terminology? Retrieved 4/20/2018 from https://www.painedu.org/definitions-aberrant-drug-related-behavior/.
Council on Economic Advisers (CEA). (2017). The Underestimated Cost of the Opioid Crisis. Retrieved 4/15/2018 from https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf.
Dixon DW. (2018). Opioid Abuse: Practice Essentials, Background, Pathophysiology Retrieved 4/15/2018 from https://emedicine.medscape.com/article/287790-overview#showall.
Dowling LS, Gatchel RJ, Adams LL. (2007). An evaluation of the predictive validity of the Pain Medication Questionnaire with a heterogeneous group of patients with chronic pain. Retrieved July 5, 2018 from https://www.ncbi.nlm.nih.gov/pubmed/18181380.
Drug Enforcement Administration (DEA), Diversion and Control Division. (2018). Controlled substances. Retrieved July 5, 2018 from https://www.deadiversion.usdoj.gov/schedules/.
Food and Drug Administration (FDA). (2014). Opioid Patient-Prescriber Agreement. Retrieved 4/20/2018 from https://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/ucm188762.htm#opioidppa.
Florence CS, Zhou C, Luo, F, Xu L. (2016, October). The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care 10:901–906. Retrieved 4/14/2018 from https://journals.lww.com/lww-medicalcare/Abstract/2016/10000/The_Economic_Burden_of_Prescription_Opioid.2.aspx.
Hedegaard H, Warner M, Miniño AM. (2017). Drug Overdose Deaths in the United States 1999–2016. NCHS Data Brief, No. 294. Hyattsville, MD: National Center for Health Statistics. Retrieved 4/14/2018 from https://www.cdc.gov/nchs/products/databriefs/db294.htm.
Joint Commission, The. (2018). Facts about Joint Commission Accreditation Standards for Health Care Organizations: Pain Assessment and Management. Retrieved 4/7/2018 from https://www.jointcommission.org/facts_about_joint_commission_accreditation_standards_for_health_care_organizations_pain_assessment_and_management/.
Katz J. (2017, January 5). Drug Deaths in America Are Rising Faster than Ever. The New York Times. Retrieved 4/14/2018 from https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html.
National Center on Addiction and Substance Abuse (CASA). 2017. Who Develops Addiction? Retrieved 4/8/2018 from https://www.centeronaddiction.org/addiction/addiction-risk-factors.
National Council of State Boards of Nursing (NCSBN). (2011). Substance Use Disorder in Nursing: A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs. Retrieved April 18, 2018 from https://www.ncsbn.org/SUDN_11.pdf. [Still a valid source. No update made yet.]
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