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Continuing Education for Health Professionals

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

Module 3

Prescription Drug Abuse and Misuse

Because of changes in pain treatment, prescriptions of opioid analgesics have increased dramatically from the 1990s. This has resulted in their greater availability for nonmedical users (NIDA, 2018a).

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. 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 (eg, fentanyl, fentanyl analogs, 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 per 100,000 in 2015 to 4.9 in 2016. Overdose deaths involving natural and semisynthetic opioids (eg, morphine, codeine, hydrocodone, oxycodone) increased from 3.9 per 100,000 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).

The State of West Virginia is facing a significant drug abuse problem. In 2013 West Virginia providers wrote 110 opioid prescriptions per 100 persons (2.08 million prescriptions). In the same year, the average U.S. rate was 70 opioid prescriptions per 100 persons. In 2016 West Virginia had the highest rate of opioid-related overdose deaths in the nation (SAMHSA, 2017a).

“Other opiates accounted for the highest percentage of treatment admissions in West Virginia in 2010 (34.9%), which was 4 times higher than the national percentage (8.7%)” (WVBHHF, 2013). The most prevalent drugs involved in overdose deaths in the state are fentanyl, heroin, hydrocodone, oxycodone, morphine, methadone. Raleigh, Kanawa, and Cabell counties accounted for 29% of the reported deaths from oxycodone from 2001to 2015 (WVBPH, 2017).

In recent years the number of individuals using heroin has increased dramatically; in West Virginia in 2014–2015, an annual average of about 6,000 individuals aged 12 or older (0.36% of all individuals in this age group) had used heroin in the past year. In 2013 through 2015, heroin has become the second leading opioid contributing to overdose deaths. There were 3.4 times more heroin reported deaths in 2011–2015 than in the previous 10 years (WVBPH, 2017).

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 also 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, using data from 2013. 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).

West Virginia University’s chief economist, John Deskins, said the opioid epidemic in West Virginia has cost the state’s economy nearly $1 billion. The estimate includes more than $322 million in productivity loss due to fatalities, more than $316 million in productivity lost in people who are not working at peak levels because they are addicts, and more than $320 million in resources tied up in the opioid crisis that could be devoted to solving other problems (WVUToday, 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, 2018b).

Analysis of the impact of West Virginia overdose fatalities in 2016 published in the West Virginia Medical Journal shows that the public health tragedy affects families, communities, and state resources. The number of children in foster care has climbed by 63%, the number of children requiring early intervention services has risen 36%, and the number of autopsies has increased by 53%. Fourteen percent of all West Virginia infants are born substance-exposed (Gupta & Mullins, 2018).

What Drugs Are Most Diverted or Abused?

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:

  • 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). (SAMHSA, 2017b; NIDA, 2018a)

One way to understand the scope of the problem of prescription drug misuse and abuse is to look at data on drug-related hospitalizations and 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).

Who Are the Drug Abusers?

People of all ages, genders, and backgrounds use illicit or prescription drugs nonmedically. During 2015 an estimated 2,038,000 persons in the U.S. aged 12 years or older had a substance use disorder involving prescription pain relievers, with an estimated rate of 0.8 per 100 persons (CDC, 2017a).

  • During 2015, nearly 48 million people in the United States aged 12 years or older used illicit drugs or misused prescription drugs in the past year, with an estimated rate of 17.8 per 100 persons. Among males, the estimated rate was 20.5; among females, it was 15.3. By race and ethnicity, the estimated rates were 20.7 for non-Hispanic blacks, 17.9 for non-Hispanic whites, and 17.2 for Hispanics. (CDC, 2017a)
  • During 201 an estimated 3.3 million people aged 12 or older were current misusers of prescription pain relievers. (SAMHSA, 2017b)
  • In 2016 an estimated 239,000 adolescents aged 12 to 17 were current misusers of pain relievers, which corresponds to 1.0% of adolescents. An estimated 631,000 young adults aged 18 to 25 misused pain relievers in the past month, which represents 1.8% of young adults. For comparison, in 2013 the rate of past-year nonmedical pain reliever use among youth aged 12 to 17 was 4.6. For young adults ages 18 to 25, the rate was 8.8%. (SAMHSA, 2017b)
  • In 2016, 11.5 million people aged 12 or older misused prescription pain relievers in the past year compared with 948,000 people who used heroin. The majority of prescription pain reliever misusers had misused prescription pain relievers in the past year but had not used heroin (10.9 million). Approximately 641,000 people had misused prescription pain relievers and also used heroin in the past year. (SAMHSA, 2017b)
  • Overall, more males than females misuse prescription drugs in all age groups except adolescence (12–17 years); adolescent girls exceed boys in the nonmedical use of all prescription drugs, including pain relievers, sedatives, and stimulants. Among nonmedical users of prescription drugs, females 12 to 17 years old are also more likely to meet substance use disorder criteria for prescription drugs. Additionally, while more men than women die of prescription opioid overdose, the rate of overdose is increasing more sharply in women than in men. (NIDA, 2018a)

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.
In 2015 among people 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:

  • 40.5% reported they obtained drugs free of charge from a relative or friend.
  • 36.4% reported they obtained drugs through a healthcare provider via prescription or by stealing.
  • 34% reported they obtained drugs from one doctor.
  • 9.4% reported they bought or stole drugs from a relative or friend.
  • Only 1.7% reported getting drugs from more than 1 doctor.
  • Only 4.9% reported buying drugs from a dealer or stranger.

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).

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 study by McDonald and Carlson 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).

Recent data show, however, the majority of opioids are obtained by prescription from one physician, not from "doctor shopping” (Dixon, 2018).

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 (US DEA, n.d.).

Healthcare Professionals

Drug diversion isn’t only a problem in patients, however. Pharmacists, doctors, nurses, and other health care 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).

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 (NCSBN, 2014, 2011). The behavior that results from this disease has far-reaching and 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 (NCSBN, 2014).

The 2017 Annual Drug Diversion Digest analyzed publicly available drug diversion incidents involving healthcare workers. The study analyzed 365 diversion incidents reported in online news stories; of the 365 incidents, 306 had data for the type of institution involved. Most diversion incidents occurred at hospitals or medical centers (37.25%). Long-term care settings, which include assisted living, nursing home, rehab facilities, respite care, and hospice facilities, were involved in 26.80% of incidents. Medical practices accounted for 16.67%, pharmacies had 13.73%, ambulance services had 2.61%, and other institutions (eg, school nurse and doctor’s offices and jail medical offices) had 2.94% (Protenus, 2018).

The same study included data for the drug diverter’s role in healthcare for 361 incidents. Nurses were the most common drug diverters, accounting for 41% of the diversions. Doctors were the second most common drug diverters (20.32%), pharmacists (6.65%), and pharmacy technicians (5.26%). In 12.19% of diversion cases, the role of the drug diverter in the healthcare organization was unknown. Of the 365 incidents, 267 included information on the drug type; 91.76% of the incidents involved opioids (Protenus, 2018).

The lack of diversion reporting by healthcare facilities in America is nothing new. This has gone on for decades, and can negatively impact innocent patients while providing no effective rehabilitation for the offender, putting them sadly closer to personal devastation or even death due to their addiction.

 

John Burke, President
International Health Facility Diversion Association
(Protenus, 2018)

Nurses must be trained to recognize 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.
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
  • Absences from the unit for extended periods
  • Frequent trips to the bathroom
  • Arriving late or leaving early
  • Excessive number of mistakes including medication errors

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, 2014, 2011)

Nurses whose substance abuse problems are detected early and treated have a higher likelihood of successful treatment outcomes (NCSBN, 2014, 2011).

Nurse managers and colleagues should also watch for subtle changes in appearance over time and [for] 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 (NCSBN, 2014).

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.

 

NCSBN, 2014

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
  • 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

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/) (NCSBN, 2014, 2011).

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