Event 3: Identifying Suspected Abuse or Diversion of Opioids

 Identifying Suspected Abuse or Diversion of Opioids

Sarah calls Dr. Bauer to replace Charlie’s lost prescription, which raises a red flag when they return to the Corner Pharmacy.

Test Your Knowledge

Risk Factors for Opioid Abuse or Diversion

Question 1

Which of the following is not a risk factor for opioid abuse, diversion, or opioid use disorder?

Incorrect
Incorrect
Correct. The African American race is not a risk factor for opiate abuse or opiate use disorder. The others are risk factors.
Incorrect
Incorrect

Question 2

Receiving a prescription for an opioid before high school graduation is a risk factor for development of later opioid misuse?

Correct. According to a 2015 study of 12th graders published in the journal, Pediatrics, receiving a legitimate prescription for opioids is independently associated with a 33% increased risk of future opiate misuse. However, most teenagers who receive a prescription for opioids will not develop a problem.
Incorrect
Reference

Miech R, Johnston L, O'Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse.  Pediatrics. 2015 Nov;136(5):e1169-77.

Question 3

Which of the following would make you most concerned for abuse or diversion in a patient prescribed opioids for pain?

Incorrect
Incorrect
Incorrect
Correct. All of these signs may indicate misuse or diversion in a patient who is being prescribed opioids. Running out of medications early, requesting specific medications by name, and requests for dose increases may be signs of misuse, but may also indicate uncontrolled pain. Lost or stolen prescriptions may have been diverted or may have been a sign of carelessness. All of these behaviors should result in increased monitoring on the part of the providers. However, forging a prescription is clearly an illegal act and indicates that no more controlled substances should be prescribed. Involving the police sometimes may also be appropriate.
Incorrect
Reference

Miech R, Johnston L, O'Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015 Nov;136(5):e1169-77.

Identifying Opioid Use Disorder

Question 1

Which of the following signs would make you most concerned about opioid use disorder (formerly referred to as addiction) in a patient taking opioids for pain?

Incorrect
Incorrect
Correct. Any individual who is taking opioids consistently will develop physical withdrawal symptoms if he or she stops. Tolerance is also an expected result of ongoing opioid use. Neither of these alone indicates opiate use disorder. However, if an individual is unable to control his or her use and continues to take higher doses than intended, then this may indicate opiate use disorder.
Reference

Miech R, Johnston L, O'Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015 Nov;136(5):e1169-77.

Definition: Prescription Opioid Misuse

  • Use in another way than as prescribed
  • Borrowing or lending
  • Taking more often and running out early
  • Taking for symptoms other than those prescribed (anxiety, insomnia, etc.)

We will now review the official definitions of opioid misuse, abuse, diversion, and opioid use disorder.  First, opioid misuse. Misuse means using a prescription in any other way than which it is was originally prescribed. Unfortunately many patients do this.  Consider the last time you questioned a patient about how they take their medication. I am sure that many of them respond that they take this medication one way and another medication this way. Opioid misuse refers to this act, when taking opioids.

Opioid misuse can also mean borrowing or lending your medication, taking medications more often and running out early, or taking them for symptoms other than what was prescribed, such as anxiety, insomnia.

Lastly, some well-intentioned patients may offer some of their opioid medications to family members or friends who have not been prescribed them, not realizing that this is illegal. This is also a form of opioid misuse.

Definition: Prescription Opioid Abuse

Abuse refers to the fact of using a medication for the experience of feeling "high". Therefore opiate abuse means that the patient is taking the medication to get that high feeling.

Definition: Opioid Use Disorder

Opioid Use Disorder was once referred to as addiction. Addiction is now not commonly utilized as a health care diagnosis, due to the stigma attached to that word. Opioid use disorder is a mental health disease, and thus should only be treated by mental health specialists. The Diagnostic and Statistical Manual of Mental Disorders (or DSM-V) identifies a number of characteristics that may be used to diagnose opioid use disorder. These include:

  • When opioids are often taken in larger amounts or over a longer period of time than intended
  • When there is a persistent desire or unsuccessful efforts to cut down or control opioid use
  •  A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects
  • Craving, or a strong desire to use opioids
  • When there is recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home
  • When there is continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids
  • Important social, occupational or recreational activities are given up or reduced because of opioid use 
  • Recurrent opioid use in situations in which it is physically hazardous 
  • Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids. 
  • *Tolerance
  • *Withdrawal

*This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Reference

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

Definition: Diversion

Diversion is selling or sharing a prescription medication, and it is a type of misuse. This is also considered a crime and a patient can be prosecuted for such.

Current State of Opioid Misuse, Abuse, Diversion, etc. in the United States

  • More people died from drug overdoses in 2014 than in any other year on record
    • Six out of ten involved an opioid
  • From 2000-2014, nearly half a million people died from drug overdoses
    • 78 Americans die every day from an opioid overdose

Reference

Substance Abuse and Mental Health Services Administration (SAMHSA). Opioids. [updated 2016 Feb 23; cited 2016 Sep 09]. Available from: http://www.samhsa.gov/atod/opioids

Rate of Overdoses Involving Opioids

Since 1999, the rate of overdoses involving opioids nearly quadrupled.

This graph depicts the dramatic increase in opioid-induced overdose rates from the early 2000s until 2014. As you can see, since 1999 the rate of overdoses involving opioids has nearly quadrupled.  Unfortunately many of these overdoses are due to the dramatic rise in opiate misuse, abuse, and opioid use disorder.

Image
A graph depicting the increase of overdose death from opioids from 2000 to 2014
Courtesy of Centers for Disease Control and Prevention

Reference

Centers for Disease Control and Prevention. Increases in drug and opioid overdose deaths — United States, 2000–2014. MMWR 2015; 64;1-5 [update 2016 Jan 01; cited 2016 Sep 09]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w

Sources of Misuse, Abuse, Diversion, Etc

What is most surprising to us is where these medications are coming from.  Results from the 2013 and 2014 National Survey on Drug Use and Health found that 50.5% of people who misused prescription painkillers got them from a friend or relative for free, while 22.1% of them got them from a doctor. This was surprising to us as healthcare practitioners, as we believed that these medications came directly from us. However, these medications are still reaching the general public through us – therefore the rational use of opioids must again be emphasized. As these people use opioids repeatedly, their tolerance increases and they may not be able to maintain the source for the drugs, as they are not receiving these medications directly from healthcare providers. This can cause them to turn to the black market for these drugs and even switch from prescription drugs to cheaper and more risky substitutes like heroin.

  • In the 2013 and 2014 National Survey on Drug Use and Health (NSDUH) found: 
    • 50.5% of people who misused prescription painkillers got them from a friend or relative for free
    • Only 22.1% got them from a doctor
  • As people use opioids repeatedly, their tolerance increases 
    • Potentially can lead to heroin use

Risk Factors for Opioid Abuse and Diversion

There are several risk factors for opiate abuse that have been identified.  The most significant risk factor is having a personal history of substance abuse, also including non-opioid substances such as alcohol.  A history of psychiatric illness, especially untreated and uncontrolled, is also a strong risk factor.  It is important to note, however, what risk factors are not present on this list. These include items such as race or ethnicity, or socioeconomic background. Opioid abuse can affect anyone and everyone. On the other hand, specific risk factors for diversion of opiates have not been identified.

  • Abuse: 
    • Young age
    • Male gender
    • History of depression, bipolar disorder, and other psychiatric illness
    • Family history of substance abuse
    • Personal history of substance abuse
  • Diversion: need more information

Prescribing clinicians also have a few tools available to them, to reduce potential opioid misuse, abuse and diversion. These include: scrutinizing the clinical situation (i.e. searching for red flags), which we will discuss soon, and utilizing tools such as opioid contracts, random urine drug screenings, pill counts, and again the prescription drug monitoring program (where available).

Opioid contracts are formal agreements between patients and prescribing clinicians. These agreements usually include points that ensure the patient will only receive prescriptions for controlled substances from the one provider, only use one pharmacy, and that they cannot receive early refills, etc. These contracts are not universally created, and physicians have the opportunity to customize these to their population. Urine drug screenings can detect the presence of controlled substances, and/or other drugs of abuse. Within this module we will not go through these tools extensively.

Again the important take home message when utilizing these tools is to communicate both limits and expectations with patients at the initiation of opioid therapy. So, for example, if the patient does start asking for early refills, the prescribing clinician has a plan already in place.

  • Tools available to prescribing clinicians: 
    • Scrutinize the clinical situation (i.e. search for red flags)
  • Utilize: opioid contracts, random urine drug screenings, "pill counts", and prescription drug monitoring programs (where available)
    • Note: will not review in this module
    • Setting limits and expectations is important

Reference

Edlund MJ, Steffick D, Hudson T, Harris KM, et al. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007 Jun;129(3):355-62.

Red Flags for Prescribers

It is often difficult to providers to distinguish a patient with actual pain from a patient who is misusing or addicted to opioids. Awareness of some of these “red flags” for opiate misuse will be helpful.  Some of these behaviors may indicate uncontrolled pain; however, a pattern of repeated concerning behaviors should raise a red flag that the issue of addiction or misuse needs to be addressed.  Again it must be emphasized that these are red flags, and cannot be confirmed without interprofessional communication.

Red flags include:

  • Frequent requests for early refills
  • Claims of lost or stolen prescriptions
  • Visits to ER or other providers for opioids
  • Calls or comes in after hours
  • Use of street drugs

Clinical Pearl 3

Next: Managing Suspected Abuse or Diversion of Opioids 

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