Pharmacists and Physicians

A thoughtful public awareness campaign targeting the physician community needs to be implemented with the collaboration of physician groups and associations such as the American Medical Association, and state doctors and nurses associations. Physicians and medical health care providers need to become aware of the impact of PDM. Targeting pediatricians and doctors who work at campus student health centers may help counter the growing problem of "academic doping."

As the front line dispensers of prescription drugs, pharmacists play a vital role in disseminating information. They can educate their patient population about the proper use and disposal of prescription drugs, as well as increase awareness of the problem of prescription drug abuse and misuse. In partnership with the appropriate state-level organizations, pharmacists can develop informational flyers and procedures for broadening patient awareness concerning prescription drug abuse and misuse. These state pharmacist associations also have a role to play in educating their own members and offering training. Additionally, they can review current procedures regarding the dispensation of advice concerning prescription drugs.

State and national public awareness campaigns

A number of commendable state and national public awareness initiatives provide useful models that other communities and states might wish to emulate. The following are just two of many outstanding pictures of practice.

In 2006, Dr. Lynn R. Webster, President of the Utah Academy of Pain Medicine, founded "Zero Unintentional Deaths," a statewide educational campaign to educate doctors, chronic pain sufferers and statewide communities about the increasingly serious issue of unintentional overdose deaths with prescription medications. The ZeroDeaths.org campaign calls consumers’ attention to six principles to help reduce unintentional overdose deaths from prescription medications.

Nationally, the U.S. Drug Enforcement Administration (DEA) has opened a toll-free international hotline where people can anonymously report suspected illegal sales or abuse of pharmaceutical drugs. The number, 1-877-Rx-Abuse, is also open for anyone with information about suspicious Internet pharmacies. Online reports can also be made at the DEA website using the Unlawful Internet Pharmaceutical Sales Reporting Form: https://www.deadiversion.usdoj.gov/webforms/jsp/umpire/umpireForm.jsp.

Promoting Safe Storage

The 2008 Partnership Attitude Tracking Survey (PATS) found that 58% of teens surveyed said that prescription pain relievers are easy to get from parents’ medicine cabinets.^xxi Moreover, SAMHSA's 2007 National Survey on Drug Use and Health (NSDUH)^xxii found that the majority of the legal prescription drugs abused by teenagers were obtained from within their homes or from the homes of friends or relatives.

Parental behavior has changed as a result of a number of public policies on safety, such as the use of seatbelts, bicycle helmets, child car seats, and gun locks. Changing behavior to lock up medications should be no different. Public awareness efforts that emphasize the safe storage of prescription medications can prevent theft and misuse.

The national Lock Your Meds campaign, sponsored by the National Family Partnership, educates parents on safe storage practices and encourages them to use word of mouth to compel others in their community to also take action. Their Home Medicine Inventory Card helps people record the name and amount of medications in the home and regularly check to see that nothing is missing. Their website is: http://cmnfp.pictco.org.

About 70 percent of Americans visit their primary care physician at least once every two years. Doctors are in a unique position to identify prescription drug abuse when it exists, help the patient recognize the problem, set recovery goals, and seek appropriate treatment. Unfortunately, many physicians get little to no training in drug abuse prevention.

A 1999 survey^xxiii of primary care physicians found that there was a general lack of training in medical school about addiction and the signs of substance abuse. This leads to difficulty discussing substance abuse with patients and an inability to recognize the signs of addiction. The survey revealed that 46.6 percent of physicians had difficulty discussing prescription drug abuse with patients and only 32.1 percent carefully screened their patients for substance abuse. The majority of the physicians surveyed did not feel prepared to diagnose substance abuse.

Pharmacists also require more specialized training in identifying and managing prescription drug abuse. While pharmacists play a key role in dispensing prescription medications, only about half of pharmacists receive training on the identification of prescription drug misuse, abuse, and diversion. The absence of training deters efforts to curb prescription drug abuse.

Training in the use of screening tools and brief intervention strategies will help physicians and other health care professionals, as well as school and community based prevention providers, identify those who are at risk for prescription drug abuse and misuse. Once that identification is made, resources and services can be directed towards the individual.

While there is a wide range of alcohol and other drug prevention programs and curriculum available for schools, these often do not include instruction about the risks of prescription drug abuse and misuse. Like their counterparts in the health professions, school-based prevention providers, including school nurses, require dedicated training in this specialized form of drug abuse.

Finally, all health, education, and community members can benefit from tools that enable them to recognize misuse and abuse of prescription drugs. Each sub-group of the population may exhibit different signs of prescription drug abuse and misuse. Training in the recognition of these signals is essential for identifying individuals needing assessment and treatment services.

The following strategies and approaches are highlighted in this section:

• Physician and pharmacist training.
• How professional organizations are responding.
• Physician screening for prescription drug abuse and misuse.
• Brief intervention to reinforce behavior in low risk individuals.
• Recognizing abuse and misuse in different populations.

Strategies and Approaches to Foster Training and Education

Physician and pharmacist training:

Medical professionals and prescribers need to receive more specialized training in identifying and managing prescription drug abuse. While pharmacists play a key role in dispensing prescription medications, only about half of pharmacists receive training on the identification of prescription drug misuse, abuse, and diversion. Additionally, a study of an internal medicine resident clinic found that 57 percent of survey respondents rated their chronic non-malignant pain training as "fair" or "poor". This lack of training is a detriment to efforts to curb prescription drug abuse, as well as efforts to effectively treat chronic pain.

Continuing medical education (CME) should include training for practitioners and pharmacists in recognizing opioid abuse in patients. Also, to equip health care providers with the skills needed for monitoring pain management, they should be trained to interpret and use Prescription Monitoring Program data.

Prescribers also should receive training related to abuse-deterrent formulations, including instruction that these medications have risks despite their abuse-deterring qualities. Abuse-deterrent medication training for pharmacists should highlight that prescriptions for abuse-deterrent medications must only be filled with those medications and must not be substituted with traditional formulations.

How professional organizations are responding

In addition to the federal Substance Abuse and Mental Health Services Administration (SAMHSA), many non-governmental organizations are keen to develop and implement training about prescription drug abuse. Organizations such as The American Academy of Family Physicians have taken steps to make doctors aware of practices such as doctor shopping. In addition, several state chapters have held seminars to educate physicians on appropriate pain management and how to screen for substance abuse.

The American Society of Interventional Pain Physicians also assists in preventing diversion while maintaining the availability of prescription drugs for medical treatment. The society has devised guidelines for use of controlled substances in the management of pain, which include information on how to conduct a comprehensive evaluation to select patients for drug therapy, and how to use a "controlled substance agreement" as part of patient care.

To reduce the incidence of abuse and misuse, the Federation of State Medical Boards of the United States advocates model guidelines for physicians on evaluating the use of controlled substances for pain control. The guidelines include information on:

• evaluating a patient for drug treatment;
• writing the treatment plan;
• obtaining informed consent and agreement for treatment;
• reviewing the course of treatment periodically;
• consulting with other health care professionals;
• keeping accurate medical records; and
• complying with controlled substances laws and regulations

Other concerned organizations include the Federation of State Medical Boards and individual state medical boards, the American Academy of Physician Assistants, the American College of Nurse Practitioners, major pain associations (e.g., the American Pain Society, the American Academy of Pain Management), the Association for Medical Education and Research in Substance Abuse, the Pain & Policy Studies Group, and Utah’s Zero Unintentional Deaths.

Physician screening for prescription drug abuse and misuse

The first defense against prescription drug abuse is proper assessment by primary care physicians, including assessing the risk of abuse in an individual, making a proper diagnosis, and instituting careful record keeping practices.

Screening for prescription drug abuse can be incorporated into routine medical visits by asking about substance abuse history, current prescription and over-the-counter drug use, and reasons for use. Screening also can be performed if patients present with specific symptoms associated with problem use of a medication.

A version of the CAGE questionnaire has been adapted for use by physicians as one screening tool to determine prescription drug abuse:^xxiv

1. Have you ever felt the need to Cut down on your use of prescription drugs?
2. Have you ever felt Annoyed by remarks your friends or loved ones made about your use of prescription drugs?
3. Have you ever felt Guilty or remorseful about your use of prescription drugs?
4. Have you Ever used prescription drugs as a way to "get going" or to "calm down?"

It should be noted that a screening instrument is a tool used as an indicator, not as a diagnosis. Proper training in the use of screening tools will enable health professionals to determine an individual’s risk to determine if a referral for treatment assessment is necessary. Screening serves as an effective tool for identifying at-risk populations and efficiently using limited resources.

A wider screening program would provide the public health and education system workforce (including public health nurses, emergency room physicians, health educators in secondary and higher education settings, etc.) training and education on adequate screening tools that can be used to recognize/identify prescription drug problems among adults and youth.

Brief intervention to reinforce behavior in low risk individuals

Screening provides an opportunity to offer a brief intervention, particularly when screening results do not indicate a severe problem requiring further treatment assessment. Brief intervention is a tool that doctors, health educators, school nurses and other prevention providers can use with individuals who are identified in screening as needing some intervention, but whose use has not triggered a referral for further treatment assessment. These individuals may benefit from the use of brief intervention to help them modify their use of prescription drugs to avoid abuse or misuse.

In cases where an individual is unready for a referral, or does not admit that AOD use is an issue, motivational interviewing or brief intervention strategies can be helpful intermediary strategies. Brief intervention is a low-intensity, short-duration technique that focuses on increasing insight and awareness regarding substance. It often uses a motivational interviewing style that incorporates a readiness to change model. It also includes feedback about the screening results and advice for the participant.

Physicians and other health care providers should receive training in brief intervention strategies in the context of prescription drug abuse and misuse. Professional organizations that promote screening, should also delineate procedures for brief intervention when screening indicates a low level of risk for abuse or misuse.

Recognizing abuse and misuse in different populations.

Identifying abuse and misuse depends on the context and the population. Parents, for example, might look for different signs of misuse in their children than they would for their elderly relatives.

The Office of National Drug Control Policy suggests that parents concerned that their teen might be abusing prescription and/or over-the-counter drugs look for constricted pupils, slurred speech, or flushed skin. More direct evidence of abuse will come from signs around the house such as missing pills, unfamiliar pills, or empty cough and cold medicine bottles or packages. Parents should be alert to your teen with legal prescriptions running out of pills quickly, losing pills, or requesting refills.

A college age population might exhibit similar behaviors, but without parental oversight it becomes incumbent on others to recognize signs of abuse or misuse. Physicians at campus health clinics, for example, might question students who suddenly manifest symptoms of ADHD or who ask for specific drugs by name. In addition, they should question students who request an increase in the dosage of these medications, or who report "lost" pills.

Seniors citizens are often left without regular supervision. In addition to screening by their primary care physician, they should know how to self-monitor their risk. Substance Abuse and Mental Health Services Administration suggests that seniors be aware of these signals that may indicate a medication-related problem:

• Memory trouble after having taking medicine
• Loss of coordination (walking unsteadily, frequent falls)
• Changes in sleeping habits
• Unexplained bruises
• Being unsure of yourself
• Irritability, sadness, depression
• Unexplained chronic pain

• Changes in eating habits
• Wanting to stay alone a lot of the time
• Failing to bathe or keep clean
• Having trouble finishing sentences
• Having trouble concentrating
• Difficulty staying in touch with family or friends
• Lack of interest in usual activities