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Continuing Education for Health Professionals

WV: Best Practices for Prescribing Controlled Substances and Preventing Drug Diversion, 3 units

Module 1

Abuse of Controlled Substances

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 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% ); moreover, an estimated 11.8 million people misused opioids in the past year, including 11.5 million pain reliever misusers and 948,000 heroin users. Additional information is gathered in NSDUH on the misuse of pain relievers in the past year. 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 pain relievers 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).

Defining the Problem

Health professionals face a dilemma because they need prescription drugs for patients in pain but they also need to prevent the diversion and misuse of the drugs. Among the prescription drugs diverted and misused are opioid analgesics, powerful painkillers that are 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. 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, as well as a rising incidence of newborns experiencing withdrawal syndrome due to opioid use and misuse during pregnancy.

West Virginia’s SB437, the Governor’s Substance Abuse Prevention Bill, passed in March 2012, was a response to the state’s need for additional education about drug diversion and abuse mitigation. More recent legislation, Senate Bill 273, also known as the Opioid Reduction Act, became effective June 7, 2018. Introduced at the request of Governor Jim Justice, the legislation sets limitations on opioid prescriptions and authorizes a “nonopioid directive” patients can put in their medical files, formally notifying healthcare professionals they do not want to be prescribed or administered opioid medications (WVDHHR, 2018).

The following are some statistics for West Virginia:

  • In 2016 West Virginia had the highest rate of opioid-related overdose deaths in the United States—a rate of 52.0 deaths per 100,000 population, which is up from 1.8 deaths per 100,000 in 1999.
  • The peak number of overdose deaths was 733 in 2016. The majority of these deaths were from synthetic opioids and heroin.
  • Since 2010, deaths related to synthetic opioids quadrupled from 102 to 435 and deaths related to heroin rose from 28 to 235.
  • In 2013 West Virginia providers wrote 110 opioid prescriptions per 100 persons (2.8 million prescriptions). The average U.S. rate for opioid prescriptions was 70 per 100 persons in the same year (NIDA, 2018b).
  • West Virginia Department of Health and Human Resources (DHHR) county-level Neonatal Abstinence Syndrome (NAS)* data for 2017 shows the overall incidence rate of NAS was 50.6 cases per 1,000 live births (5.06%) for West Virginia residents (WVDHHR, 2018).

* Neonatal Abstinence Syndrome (NAS) is a withdrawal syndrome that occurs after prenatal exposure to drugs is discontinued suddenly at birth.

 

Drug Overdoses

In 2016 alone, drug overdoses killed more Americans than the entire Vietnam War and car crashes, gun violence, and HIV/AIDS ever did in a single year. In total, more than 170 people are estimated to die from overdoses every day in the US, and most of the deaths are linked to opioids.

Source: Lopez, 2017.

What is the role of nurses in the problem of prescription drug diversion, misuse, and abuse? Because nurses are the health professionals who treat the most patients, they 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 nurses. Educated nurses can be instrumental in changing patterns of misuse and abuse of prescription drugs for individuals, colleagues, and communities, and thereby reduce the public health epidemic.

Glossary of Terms

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).

Substance use disorder/abuse/nonmedical use: 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.” The DSM-5 no longer uses the terms substance abuse and substance dependence. Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. A diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacologic criteria.

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 clinician 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).

Loss of tolerance: when a person stops taking a drug or class of drugs after taking it for a long time, loss of tolerance occurs. Serious adverse effects, including overdose, can occur if the person takes the previously tolerated dose of the drug (SAMHSA, 2018).

Recovery: a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, with help, overcome their SUDs and regain health and social function. Although abstinence from all substance misuse is a cardinal feature of recovery lifestyle, it is not the only healthy, prosocial feature. Patients taking FDA-approved medication to treat OUD can be considered in recovery (SAMHSA, 2018).

Relapse: a process in which a person with OUD who has been in remission experiences a return of symptoms or loss of remission. A relapse is different from a return to opioid use in that it involves more than a single incident of use. Relapses occur over a period of time and can be interrupted. Relapse need not be long lasting (SAMHSA, 2018).

Remission: a medical term meaning a disappearance of signs and symptoms of the disease. DSM-5 defines remission as present in people who previously met OUD criteria but no longer meet any OUD criteria (with the possible exception of craving). Remission is an essential element of recovery (SAMHSA, 2018).

Return to opioid use: one or more instances of opioid misuse without a return of symptoms of OUD. A return to opioid use may lead to relapse (SAMHSA, 2018).

Tolerance: alteration of the body’s responsiveness to alcohol or other drugs (including opioids) such that higher doses are required to produce the same effect achieved during initial use. Tolerance develops when someone uses an opioid drug regularly, so that their body becomes accustomed to the drug and needs a larger or more frequent dose to continue to experience the same effect (SAMHSA, 2018).

Controlled Substances

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 has five schedules, known as schedules I, II, III, IV, and V.

 

Source: US DEA, 2018a.

Controlled Substances, 2018

DEA Schedule

Medical use/abuse potential

Examples of abused drugs

Schedule I

No accepted therapeutic use. Lack of safety even under medical supervision. High potential for abuse; abuse may lead to severe psychological or physical dependence

Heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”)

Schedule II

Accepted therapeutic use. Highly restricted. High potential for abuse; abuse may lead to severe psychological or physical dependence

Amphetamine (Dexedrine, Adderall), methamphetamine (Desoxyn), methylphenidate (Ritalin), amobarbital, glutethimide, pentobarbital, and hydrocodone (Vicodin, Lortab), oxycodone (OxyContin, Percocet, Tylox)

Schedule III

Accepted therapeutic use. Highly restricted. Less high potential for abuse; abuse may lead to moderate or low physical dependence or high psychological dependence.

Products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine), and buprenorphine (Suboxone), benzphetamine (Didrex), phendimetrazine, ketamine, and anabolic steroids such as depo-testosterone

Schedule IV

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.

alprazolam (Xanax), carisoprodol (Soma), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion)

Schedule V

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.

Cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC, Phenergan with Codeine), and ezogabine

 

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.

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