Drug Diversion Module

Slide 1: 

1 Drug Diversion: Abuse of Controlled Drugs http://www.ubyssey.bc.ca/photos/061205drugs.jpg

Program Content : 

2 Program Content Controlled Drugs Scheduling of drugs Challenges in therapeutic management Epidemiology of abuse Drug Diversion Scope Mechanisms Regulations Federal law The pharmacist’s role Assessment http://www.brighamandwomens.org/publicaffairs/Images/Pill_bottle_and_pills.jpg

Controlled Drugs : 

3 Controlled Drugs The Federal Controlled Substance Act (CSA) of 1970 stratifies drugs into categories based on medical utility and potential for abuse Department of Health and Human Services (DHHS) and Food and Drug Administration (FDA)

Scheduling Controlled Substances : 

4 Scheduling Controlled Substances Schedule I No legitimate medical use High abuse potential Ecstasy Heroin Schedule II Accepted medical use High abuse potential Oxycontin® Ritalin® Morphine Schedule III Accepted medical use Less abuse potential than I or II Vicodin® Schedule IV Accepted medical use Less abuse potential than I, II, or III Valium® Xanax® Schedule V Accepted medical use Lowest abuse potential Robitussin AC®

Pain : 

5 Pain Malignant pain: precipitated by cancer Non-malignant pain: acute or chronic and not of a malignant origin Opioids are the most common treatment modality http://www.alphachimp.com/clients/blog/pain-map.jpg

Opioids : 

6 Opioids Opioids bind to specific opioid receptors in the central nervous system and in other tissues µ, ?, d (mu, kappa, and delta) Binding causes inhibition of ascending pain pathways Modulates perception and response to pain Significant increase in use for non-malignant pain Abuse results in heightened pleasure Opioid abuse has increased 7x faster than cocaine use and 94x faster than heroin use

Attention Deficit Hyperactivity Disorder (ADHD) : 

7 Attention Deficit Hyperactivity Disorder (ADHD) Neurobehavioral developmental disorder characterized by a persistent pattern of impulsiveness and inattention, with or without a component of hyperactivity Typically treated with central nervous system stimulants (CNS) http://www.awildride.net/blog/Fotolia_337066_S.jpg

Central Nervous System Stimulants : 

8 Central Nervous System Stimulants Amphetamine-like drugs that block the reuptake of dopamine and norepinephrine into the presynaptic neurons Methylphenidate (Ritalin®), Dextroamphetamine salts (Adderall®), etc. Schedule II Abuse produces euphoria and may be used to promote wakefulness and attention (studying)

Central Nervous System Depressants : 

9 Central Nervous System Depressants Used primarily for anxiety and sleep disorders Benzodiazepines, barbiturates Slow brain function by modulating the activity of GABA Schedules II – IV Abused for the calming effect http://www.ipmc.cnrs.fr/~duprat/neurophysiology/images/brain2.jpg

Addiction Medicine : 

10 Addiction Medicine Subspecialty in medicine that deals with the treatment of addiction Aspects of addiction fall within the fields of public health, psychiatry, and internal medicine Focus on cognitive behavioral therapy, detoxification and rehabilitation

Challenges in Therapeutic Management : 

11 Challenges in Therapeutic Management More than half of physicians find it difficult to discuss prescription abuse with their patients Some physicians ( 30 + %) avoid prescribing opioids for fear of scrutiny by regulatory agencies Patients may be under-treated for pain

Epidemiology of Abuse : 

12 Epidemiology of Abuse There have been dramatic increases in the use of prescription medication Consumption of controlled drugs in the U.S. far exceeds that of other countries 15.1 million people admit to abusing prescription drugs Between 1992 and 2003 there was a 212% increase in the number of 12 – 17 year olds using controlled prescription drugs http://i160.photobucket.com/albums/t174/stanley203/pillhead.jpg

Epidemiology of Abuse : 

13 Epidemiology of Abuse Abuse = using a prescription drug that was not prescribed for the individual or was taken solely for the experience and not a therapeutic effect Most people who abuse prescription drugs use opioids, central nervous system depressants, or central nervous system stimulants Many are polysubstance abusers

Drug Diversion : 

14 Drug Diversion The diverting of legally obtainable drugs into illegal channels OR The acquisition of a controlled substance by an illegal method This can be both intentional or unintentional Intentional: a patient, physician, pharmacist, etc. knowingly diverts a drug for purposes other than for which it was intended Unintentional: a healthcare provider is negligent in identifying potential diversion or is deceived by a patient or other healthcare professional

Scope of the Problem : 

15 Scope of the Problem The number of new opioid abusers increased by 225% between 1992 and 2000 New tranquilizer abusers increased by 150% New sedative abusers increased by 130% New stimulant abusers increased by 172% Abuse of controlled drugs is responsible for 23% of drug-related emergency department admissions In 2002 controlled prescription drugs were implicated in 30% of all drug-related deaths Opioids were the cause in 19% of the deaths

Sources of Drug Diversion : 

16 Sources of Drug Diversion Patients Physicians Pharmacists

Mechanisms of Prevention : 

17 Mechanisms of Prevention Twenty states have enacted Prescription Drug Monitoring Programs Medicaid reviews Physicians and pharmacists as gatekeepers More extensive training of healthcare professionals to detect abuse

Mechanisms of Treatment: Patients : 

18 Mechanisms of Treatment: Patients Behavioral: not specifically designed for addiction Individual and group counseling Cognitive behavioral therapy (CBT) Pharmacological: alleviates withdrawal symptoms and cravings Methadone Levo-alpha-acetyl-methadol (LAAM) Naltrexone Buprenorphine

Mechanisms of Diversion: Patients : 

19 Mechanisms of Diversion: Patients Fraudulent prescriptions Impersonating physicians Altering prescriptions Pressuring or deceiving physicians Doctor shopping

Mechanisms of Diversion: Patients : 

20 Mechanisms of Diversion: Patients When a prescription for a controlled substance is presented, 27% of pharmacists suspect that it could be for purposes of abuse or diversion

Fraudulent Prescriptions : 

21 Fraudulent Prescriptions A prescription that was not issued by a licensed prescriber Includes forged prescriptions or rxs written on stolen blanks May contain errors Misspellings Dosage mistakes Inappropriate refills May not contain a DEA number A pharmacist who dispenses a prescription that they suspect might be fraudulent is liable and is in violation of the law

Fraudulent Prescription Characteristics : 

22 Fraudulent Prescription Characteristics Prescription looks "too good"; the prescriber's handwriting is too legible  Quantities, directions or dosages differ from usual medical usage  Prescription does not comply with the acceptable standard abbreviations Prescription appears to be photocopied  Directions written in full with no abbreviations Prescription written in different color inks or written in different handwriting

Controlled Substance Prescription Rules : 

23 Controlled Substance Prescription Rules All prescriptions for a controlled substance MUST contain: Date of issue Patient's name and address Practitioner's name, address and DEA registration number Drug name Drug strength Dosage form Quantity prescribed Directions for use Number of refills (if any) authorized, and Manual signature of prescriber

Common Fraudulent Tactics : 

24 Common Fraudulent Tactics Changing a refill of “1” to “4” Quantity changed from "12" to "120" Changing a “0” to an “8” Adding zeros Altering a post-dated Rx to display a current date Adding refills

Examples of Fraudulent Prescriptions : 

25 Examples of Fraudulent Prescriptions

DEA Number : 

26 DEA Number DEA = Drug Enforcement Administration A DEA number is given to health care practitioners, allowing him or her to write for controlled substances 2 letters First letter represents the type of registrant Second letter represents the last name 6 numbers, 1 check digit

Verifying a DEA number : 

27 Verifying a DEA number Use 1st six digits to figure out 7th (check digit) STEP ONE Add 1st, 3rd, & 5th digits = (Sum 1) STEP TWO Add 2nd, 4th, & 6th digits Multiply this sum by 2 = (Sum 2) STEP THREE Add (Sum 1) and (Sum 2) = (Sum 3)

Verifying a DEA number : 

28 Verifying a DEA number The last digit of (Sum 3) is the 7th (check digit) of the DEA number Example: Dr. Andreas (a licensed practitioner) DEA number: CA5271957 Step One: 5 + 7+ 9 = 21 Step Two: 2+1 +5 = 8 * 2 = 16 Step Three: 21 + 16 = 37 Check digit: 7 (Correct)

Impersonating Physicians : 

29 Impersonating Physicians Phoning in a prescription for oneself or another while claiming to be a physician or a physician’s representative The perpetrator may or may not know the physician’s DEA number The perpetrator may make an error in requesting the prescription Mispronunciation Requesting an inappropriate dose or unavailable dosage form Attempting to phone in a CII

Altering Prescriptions : 

30 Altering Prescriptions Changing the strength of the drug Changing the quantity dispensed Adding refills Changing the date Any alteration on a prescription for a controlled drug invalidates the prescription The only exception is if the change was made by the prescriber who has then initialed it Although it is unintentional, negligence on the part of the pharmacist (by not recognizing an obvious forgery) is considered passive drug diversion on the part of the pharmacist

Doctor Shopping : 

31 Doctor Shopping Patients may visit multiple physicians and present with the same complaint When a physician refuses to comply with the drug request, the patient will go elsewhere Even once a patient finds a physician who they are able to pressure or deceive, they may still visit multiple practitioners These patients may opt to pay for the Rxs with cash so as to avoid an insurance complication (early refills, duplicate medications, etc.)

Potential Characteristics of a Drug Diverter : 

32 Potential Characteristics of a Drug Diverter Persons who are intentionally trying to deceive a pharmacist may: Be exceptionally talkative Try to distract the pharmacist Have an elaborate story about a hardship or a reason for the prescription Act nervous Remain very close to the pharmacy instead of wandering around the store

Mechanisms of Diversion: Physicians : 

33 Mechanisms of Diversion: Physicians Access to controlled substances causes healthcare providers to be vulnerable to diverting drugs Most diversion perpetrated by physicians in unintentional Usually secondary to deception by a patient Failure to ask patients about meds prescribed by other prescribers Hesitation in asking about drug abuse or prescription compliance

Mechanisms of Diversion: Pharmacists and Pharmacies : 

34 Mechanisms of Diversion: Pharmacists and Pharmacies 30% of pharmacies have experienced a robbery of controlled drugs within 5 years Only 28.4% of pharmacists validate the prescriber’s DEA number

The Pharmacist’s Role : 

35 The Pharmacist’s Role Look for mistakes or irregularities on written prescriptions Verify with the prescriber Pay attention to nervous or unusual behavior by the patient Note the payment method (cash vs. insurance) Check for appropriateness of dose, number of refills, correct DEA number, early refills

The Pharmacist’s Role : 

36 The Pharmacist’s Role Do not be intimidated by patients who attempt to pressure you into filling an Rx that looks fraudulent Do not fill controlled drugs early Verify all controlled substances (when logistically possible) If there is something alarming about the prescription, ask the patient to return after you have contacted the physician

Remember!!! : 

37 Remember!!! The pharmacist is responsible for dispensing controlled drugs by valid prescription only Failure to identify a reasonably fraudulent or altered rx confers liability onto the pharmacist ALL controlled substances must be HAND SIGNED and contain a DEA NUMBER – No exceptions!!!!

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