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MEDICATIONS OF CONTROVERSY Challenges, Risks and Strategies

MEDICATIONS OF CONTROVERSY Challenges, Risks and Strategies. Alan Lembitz M.D. COPIC. I have no relevant financial relationships to disclose. Disclosure. Risks. Today we are going to talk about:. Overview. Scope of Problem. Safe prescribing practices.

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MEDICATIONS OF CONTROVERSY Challenges, Risks and Strategies

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  1. MEDICATIONS OF CONTROVERSY Challenges, Risks and Strategies Alan Lembitz M.D. COPIC

  2. I have no relevant financial relationships to disclose Disclosure

  3. Risks

  4. Today we are going to talk about: Overview Scope of Problem Safe prescribing practices Tools- PDMP, Agreements, Consents, Screening Tools, Diagnostic Tools, Documentation

  5. PART 1 • OPIOIDS

  6. Being a medical caregiver means putting your self in suffering’s way Rita Charon M.D.

  7. CDC declares painkillers at epidemic levels Opioids, Anxiolytics and Sedatives

  8. Rates of prescription painkiller sales, deaths and substance abuse treatment admissions (1999-2010) SOURCES: National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009

  9. Distribution of Opioid Users “All the rest”uncontrolled painpseudo-addiction Addictionabuse Controlledchronic pain

  10. 1 2 3 Overview Top Reasons for paid claims in Primary Care: Delay or failure to diagnose (65+%) Improper treatment of known medical condition Medication Errors

  11. Risk by diagnosis • Heads • Hearts • Bellies • Bugs- Severe Infectious Diseases • Failure to DX CA • Underappreciated severity of trauma • COPIC data

  12. OxyContin in increasing doses beginning at ½ tabTID (20 mg) and increasing to 80mg tabs 6 per dayin 4 doses – These are the complete notes

  13. Opiates from poppies Sumerians isolated opium from 3000 B.C. Given with hemlock to put people to death China 800 AD Europe 1300 Opiates

  14. In 1806 Serturner isolated the morphine alkaloid and named it after the god of dreams, Morpheus Heroin detailed for cough medicine in 1898 Works thru at least 4 receptors throughout the body Profound effect is the mu receptor CNS Controlled Substances Act in 1970 DEA enforces Opiates

  15. Pain out of proportion to findings ? FX ? Necrotizing fasciitis Vascular, inc. mesenteric Compartment syndrome Don’t miss the CA Be sure of the DX

  16. Pain diagrams Accuracy of diagnosis Symptom magnification Objective pre- procedure, or pre-treatment functionality Objective post-procedure or post-treatment assessment of functionality 16

  17. Addiction Compulsive use causing personal harm Psychological dependence Rare in terminally ill or pain management Usually preexisting abuse Physical dependence Abstinence syndrome think French connection Not psychologic addiction Decrease dose 50% Q 3 days Addiction vs. tolerance vs. dependence • Tolerance • Decreased effectiveness over time • Actually rare - if more needs there may be a reason • Don’t label a tolerant patient addicted

  18. Addiction A maladaptive pattern of substance use leading to impairment or distress, but has not met the criteria for Substance Dependence, having ≥ 1 of the following: • Recurrent substance use resulting in failure to fulfill major role obligations at work, home, school • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent problems caused by the substance use

  19. Biggest risk factor is a personal or family history of drug/ETOH abuse Journal of pain v109 pg 113-130 2009 Psych problems Poor coping skills Sexual abuse Opioid addiction risk factors

  20. Faces of addiction

  21. Criteria of chronic illness • Genetics • Pathogenesis • Precipitants • Environmental determinants • Gender specifics • Complications • Relapse-Remission

  22. Key to identifying alcohol abuse • CAGE: cut back, annoying, guilt, eye opener • Drinks per week: 7 or 14? • Binge per year: 5 (4)? ASK

  23. Biggest risk factor is a personal or family history of drug/ETOH abuse Journal of pain v109 pg 113-130 2009 SOAPP

  24. It’s about the documentation Evaluate for coexisting psych problem Tip of the iceberg potential ACTIONS MUST MATCH THE DOCUMENTATION Overdose- accidental vs. intentional

  25. Responsible prescribing Regulation increasing Stings Documentation Pharmacist is the trigger work with them DEA

  26. Street value

  27. Dilaudid 4mg #240 No addressNo datePmNo legitimatepurpose Street value of this Rx: $7,000plus

  28. Powerful tool Use it don’t lose it Password sacred Notification Prescription Drug Monitoring Program

  29. Which of the following is NOT appropriate for a pain agreement? • No diversion allowed • May request a tox screen at any time • Notify us by Thursday if scripts are lost or destroyed • Can only go to 1 pharmacy

  30. An Agreement not a Contract May specify one pharmacy Treaters may discuss DX and RX No diversion Danger of abrupt withdrawal Pregnancy Urine or Serum tox screens may be a condition of the agreement. Lost, wet, left, stolen not acceptable excuses Compliance with scheduled appointments and referrals Breach may result in termination, cessation of therapy or referral to addiction specialist Opioid agreements

  31. Indications Risks Prohibition of activity if impaired Withdrawal Addiction definition and potential Physical Dependence Tolerance and Possible Increases in dosages or reduction in effect Long-term consent

  32. Clear discussion of philosophy Pain agreements help guide your partners A covering prescriber on a routine script- little risk Align your partners

  33. Chronic narcotics without cause No formal relationship No physical exam Suggest different pharmacies Prescribe for sex or sharing Prescribe to family CMB – red flags

  34. Example of the office visit notes

  35. OxyContin 40mg 2-bidDilaudid 8mg qidSoma 1 qid

  36. DEA examplesNew patient:Prescribed Dilaudid4 mg #240 plusXanax Do you believe this doctordid an exam of the head, heart and lungs?

  37. Hassle factors • HIPAA • Records release • Labeling addict can be an issue • Weekend and night calls

  38. Always • Contact the previous physician • Ask the patient about previous alcohol and drug use, or psychiatric or drug related hospitalizations. • Document a thorough and thoughtful exam • Consider a drug screen

  39. PART 2 • MEDICAL MARIJUANA • RECREATIONAL MARIJUANA

  40. SCOPE OF MMJ • Numbers of registrants • Characteristics of registrants • Age • Primary Dx • The Dispensaries

  41. MAJOR QUESTIONS TO CONSIDER • Do I certify for MMJ? • Informed Consent • Screen for contraindications • Know and review the science • Following CMB regulations • Bona fide physician patient relationship • Diagnosis established by history and examination • Documentation • Recommendation for follow-up • Practical Logistics- forms and registry

  42. MAJOR QUESTIONS TO CONSIDER • My patient is on MMJ registry and actively using, does this change my practice and prescribing for them?

  43. MAJOR QUESTIONS TO CONSIDER • What if my patient was inappropriately certified for the registry? • CMB unprofessional conduct- license and duty to report • Specific clinical examples • Minors • Psychiatric contraindications • Occupations involving public safety

  44. MAJOR QUESTIONS TO CONSIDER • Do I have vicarious liability if I certify, or if I know my patient is using MMJ, or if they are taking opioids, etc? • Chart documentation of discussion • Informed consent is a process, but a form may be required if significant risk and non-compliance with recommendations

  45. DRIVING UNDER INFLUENCE • Law Enforcement considerations • Available testing and reliability

  46. SPECIAL SITUATIONS • Physicians who personally are on the registry • CPHP • CMB • COPIC

  47. SUMMARY • Certifying my own patients- how to do this in compliance and consistent with sound medical practice • What to do about your patient who someone else certified for the registry • What about other physicians who certify out of compliance with sound practice • Vicarious liability • DUI is not just alcohol

  48. Boundary discussions are often about your own conflict Can be you or the patient with the problem Discuss what your concern is Boundaries- Are your issue

  49. Clarify boundaries And negotiate I don’t give unlimited narcotics but I want to help you. What can we work out…. My role is to help people not just give out narcs… Can we come up with a short term plan today and then work on something long term? Boundaries—Providers role

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