ATrain Education

 

Continuing Education for Health Professionals

DE: Substance Abuse, Chemical Dependency, and Drug Diversion

Module 3

Prescription Drug Abuse and Misuse

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).

The State of Delaware is facing a significant drug abuse problem. Delaware has a higher rate of sales of opioid pain relievers (10.2 kilograms sold per 10,000 population) compared to the national rate (7.1) in 2010 (TAH, 2013). There is wide variation among states in prescribing practices. Delaware ranks 17th among all fifty states, with 90.8 prescriptions for opioid pain relievers per 100 persons, compared to the mean of 87.3 (CDC MMWR, 2014). According to the 2014 Delaware School Survey, 3 percent of eighth graders and 7 percent of eleventh graders report past year use of pain killers (UDCDAS, 2015). The Delaware Health and Social Services, Division of Substance Abuse and Mental Health reports 1,793 admissions to DSAMH Funded Treatment Programs for “other opiates and synthetics” drug abuse (UDCDAS, 2015).

Societal and Economic Impacts of Drug Abuse

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).

What Drugs Are Most Diverted or Abused?

After marijuana, prescription drugs are the second-most abused category of drugs in the United States (ONDCP, 2011a). The three classes of the most commonly abused prescription drugs are:

  • Opioids that include oxycodone (Percocet, Tylox, OxyContin), hydrocodone (Vicodin, Lortab), and methadone (Dolophine);
  • Central nervous system depressants that include butalbital (Fiorinal/Fioricet), diazepam (Valium), and alprazolam (Xanax);
  • Stimulants that include methylphenidate (Ritalin) and amphetamine/dextroamphetamine (Adderall).

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’s purpose is to monitor trends in drug misuse and abuse, identify the emergence of new substances and drug combinations, assess health hazards associated with drug abuse, and estimate 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)
  • 21.2% involved illicit drugs
  • 14.3% involved alcohol, in combination with other drugs. (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).

Who Are the Drug Abusers?

People of all ages, genders, and backgrounds use illicit or prescription drugs nonmedically. Data from the 2013 National Survey on Drug Use and Health (NSDUH) shows that nonmedical use of prescription pharmaceuticals was 2.6% in men and 2.3% in women.

  • In 2013 about 15 million people aged 12 or older used prescription drugs nonmedically in the past year, and 6.5 million did so in the past month.
  • In 2013 youths aged 12 to 17, or young adults age 18 to 25, were more likely to misuse prescription drugs in the past year than adults aged 26 or older.
  • On an average day during the past year, about 2,500 adolescents used prescription pain relievers nonmedically for the first time (SAMHSA, 2014a).
  • According to the National Institute on Drug Abuse, as of 2014 prescription drug misuse or abuse is increasing among people in their fifties (SAMHSA, 2014b; NCHS, 2014).

How Drug Abusers Get Drugs

Drug diversion is the intentional removal of a prescription medication from the legitimate channels of distribution and dispensing. Diversion also occurs when family or friends share or purchase prescription medication, or when medication is stolen from its intended recipient or is otherwise illegally acquired (Corsini & Zacharoff, 2014). Diversion can also occur in healthcare settings if health professionals divert medication from the intended recipient for personal use or financial gain.

Friends and Family

Although we might assume that drug users acquire their prescription drugs from street dealers, this is not usually the case. Because prescription pain 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). If the prescription drug is not freely given, a drug user may steal it from an unsuspecting family member or acquaintance who has a legitimate need for the medication (ONDCP, 2014).

Doctor Shopping

Another source for prescription opioids 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.

A 2009 study found that elders in Wilmington, Delaware, were diverting their medications for economic reasons. “It was clear from the focus groups with prescription drug abusers that the elderly generally were not drug dealers, but filled their prescriptions and sold part or all to a few abusers known to them, as well as to dealers or pill brokers for much less than the street value of the drugs” (Incardi et al., 2009). Furthermore,

Focus group participants indicated that even in a small state like Delaware, doctor shopping appeared to be fairly easy. The vast majority of abusers reported obtaining medications through doctor shopping, and most reported frequenting at least four physicians in order to obtain sufficient amounts of their desired medications. Occasionally clinics and hospital emergency rooms were reported as locations for doctor shopping as well. Regardless of location, the most common scenario reported by abusers was to present to a physician with complaints about pain. (Incardi et al., 2009)

A recent study by McDonald and Carlson (2013) found that 1 out of every 143 U.S. patients who received a prescription for an opioid pain medicine in 2008 obtained prescriptions from multiple prescribers, suggesting misuse or abuse of the drugs. The study identified a group of “extreme” patients who averaged 10 prescribers through a 10-month period. When researchers looked at those who had paid cash for their prescriptions, the average rose to 15 prescribers per patient. Researchers concluded that improvements in healthcare information technology should focus on prescription monitoring programs that allow physicians to pull up a patient’s prescription history. Doctor shoppers are exploiting the lack of good data management. McDonald says, “Ultimately, healthcare providers are the front-line defense against prescription drug diversion” (McDonald & Carlson, 2013).

Fraud

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:

  • Fraudulent prescriptions written for a fictitious patient on a legitimate prescription pad stolen from a prescriber’s office
  • Legitimate prescription that has been altered to obtain additional amounts of a drug
  • Legitimate prescription pad with an altered call-back phone number to verify the prescription
  • Fraudulent prescription called in by the drug abuser, who gives his or her own call-back number
  • Fraudulent prescription created by a computer for a fictitious doctor or copied from a legitimate doctor

It is incumbent on pharmacists and pharmacy technicians to be cautious about filling prescriptions for controlled substances and to look for signs of fraud or suspicious patient activity (DEA, 2000).

Healthcare Professionals

Drug diversion isn’t only a problem in patients, however. Pharmacists, doctors, nurses, and other medical professionals often have access to prescription drugs, including opioid analgesics, and while these individuals usually have greater knowledge than the public, they are still 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. “Recommended clinical practices include protecting access to prescription pads, adhering to strict refill policies, and thoroughly documenting when prescribing narcotics. Prescribers can also curb drug diversion by adhering to prescribing principles for opioids and other controlled substances” (HSS CMS, 2014). Clinicians should be aware that the Affordable Care Act has ushered in changes to Medicaid, Medicare, and other health care programs, including more stringent penalties for submitting false claims and statements related to the ordering and prescribing of prescription drugs (CMS, 2014).

Attempting to obtain a controlled substance by misrepresentation, fraud, forgery, or deception is a felony in most states and punishable by a prison term and fines. In addition, the U.S. Department of Health and Human Services, Office of Inspector General (HHS OIG) uses a range of law enforcement tools that can impose various legal sanctions and actions on physicians and other providers, such as recoupment, restitution, civil monetary penalties, suspension or loss of provider license, exclusion from participation in Medicaid and other Federal health care programs, and imprisonment (CMS, 2014).

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 (2011) 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).

Nurses must be trained to recognizing substance misuse and abuse among fellow nurses because substance abuse on the job and untreated addiction disorder jeopardizes patient safety. When nurses have been given guidelines and a means of reporting suspected substance use, it can result in earlier detection of nurses with substance use disorders and their appropriate treatment. Without such guidelines, nurses are more likely to cover up for colleagues.

Dunn (2005) found that general symptoms of substance use problems among nurses include the following:

  • Defensiveness
  • Isolation
  • Irritability
  • Difficulty following through on work assignments

Signs and symptoms of a prescription drug substance use disorder among nurses can include the following:

  • Coming to work on days off
  • Volunteering for overtime
  • Incorrect narcotic counts
  • Volunteering to administer medications
  • Waiting to be alone to open a narcotics cabinet
  • Lacking witnesses to verify the wasting of unused medications

Negative impacts on patient safety may result from any of the following:

  • Impaired judgment
  • Slowed reaction time
  • Diverting drugs from patients who need them
  • Neglect of patients
  • Nursing errors (NCSBN, 2011)

Martin and colleagues found that nurses whose substance abuse problems are detected early and treated have a higher likelihood of successful treatment outcomes (NCSBN, 2011).

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:

  • Role strain, including burnout, work overload, feeling of insignificance, and inadequate support at work
  • Problems of daily living, such as loss of a significant other, poor coping skills, insecurity, and isolation
  • Enabling by peers and managers, such as overlooking symptoms out of loyalty and fear of job loss
  • Attitudes toward drugs and drug use; eg, that substance use is an acceptable means of coping with life
  • Faith in drugs for promoting healing due to witnessing positive effects of drugs on patients
  • Sense of entitlement, that the nurse must continue to work, leading to rationalization
  • Special status of nurses as invulnerable to illnesses of patients
  • Professional training about drugs leading to self-diagnosis and self-medication for pain or stress/fatigue from workplace demands (Clark & Farnsworth, 2006)
  • Lack of education regarding substance use disorder, including lack of understanding about the addiction process and how to recognize signs and symptoms of abuse
  • Lack of controls and security of controlled substances and their ready availability
  • Physician prescribing practices, such as obtaining prescriptions from physician friends without proper assessment and diagnosis protocols (NCSBN, 2011)

Of these risk factors, the top four are access to drugs, attitude, stress, and lack of education about addiction. Nursing is a highly stressful profession impacted by staffing shortages, difficult schedules, and long shifts (NCSBN, 2011).

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