Education & Advocacy: Engaging the Medical Community - Brian Fingerson and Dallas Gay

1. Engaging
the
Medical
Community
Brian
Fingerson,
RPh,
President,
Kentucky
Professionals
Recovery
Network
Dallas
Gay,
Co-­‐chair,
Medical
AssociaBon
of
Georgia
FoundaBon’s
“Think
About
It”
Campaign

2. Disclosure
• Brian
Fingerson,
BSPharm,
R.Ph.,
FAPhA,
declares
no
conflicts
of
interest,
real
or
apparent,
and
no
financial
interests
in
any
company,
product,
or
service
menBoned
in
this
program,
including
grants,
employment,
giOs,
stock
holdings,
and
honoraria
• Dallas
Gay
has
no
financial
relaBonships
with
proprietary
enBBes
that
produce
health
care
goods
and
services.

3. Learning
Objec:ves
1. Describe
the
impact
of
changing
aQtudes
concerning
Rx
drug
abuse.
2. Define
the
roles
clinicians
play
to
posiBvely
impact
this
epidemic.
3. Demonstrate
programs
that
are
posiBvely
impacBng
the
clinical
community
regarding
opioids
use
and
abuse.

4. Engaging
the
Medical
Community
24
April
2014
Dallas
Gay
Brian
Fingerson,
RPh

5. Disclosure
• Brian
Fingerson,
BSPharm,
R.Ph.,
FAPhA,
declares
no
conflicts
of
interest,
real
or
apparent,
and
no
financial
interests
in
any
company,
product,
or
service
menBoned
in
this
program,
including
grants,
employment,
giOs,
stock
holdings,
and
honoraria

6. Deadly
Epidemic:
Rx
Drug
Overdoses
• In
the
past
11
years,
deaths
from
overdose
increased
more
than
400
percent
among
women,
compared
with
a
265
percent
rise
among
men.
• Americans
consume
80
percent
of
opiate
painkillers
produced
in
the
world,
according
to
the
American
Society
of
IntervenBonal
Pain
Physicians.

7. Millions
of
Opioid
Prescrip:ons
Go
to
'Doctor
Shoppers'
• Nearly
2%
of
all
US
opioid
prescripBons,
totaling
an
esBmated
4.3
million
prescripBons
each
year
and
4%
of
all
opioids
by
weight,
are
purchased
by
paBents
presumed
to
be
"doctor
shoppers,"
according
to
a
new
study.
In
the
first
naBonal
esBmate
of
opioid
medicaBons
obtained
in
the
United
States
by
the
doctor
shoppers
—
pa:ents
who
receive
painkiller
prescrip:ons
from
mul:ple
doctors
without
informing
the
doctors
of
their
other
prescrip:ons
—
researchers
found
that
they
obtained,
on
average,
32
opioid
prescrip5ons
per
year
from
10
different
prescribers.

8. "But
Doc!
I
Really
Hurt!
“

10. Dopamine Pathways – Pleasure pathways
nucleus
accumbens
hippocampus
striatum
frontal
cortex
substantia
nigra/VTA
cocaine
heroin
nicotine
amphetamines
opiates
THC
PCP
ketamine
heroin
alcohol
benzodiazepine
s
barbiturates
alcohol

11. Many Things Are Happening During
the Transition Between Voluntary
Drug Use and Addiction…

12. Compulsive
Drug Use
(Addiction)
Voluntary
Drug Use

13. Pain
Management
vs.
Pa:ent
Management
• Acute
Pain
• Chronic
Pain
• The
Pa5ent
with
the
Pain

14. The
Interna:onal
Associa:on
for
the
Study
of
Pain

15. WHO
3-­‐step
ladder
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± procedures
3 severe
2 moderate
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
1 mild
ASA
Acetaminophen
NSAIDs

16. "It
ain't
what
you
don't
know
that
gets
you
into
trouble.
It's
what
you
know
for
sure
that
just
ain't
so."
Mark
Twain:

17. Things
we
“know”
that
aren’t
so
• If
there
is
real
pain,
developing
opiate
dependence
is
rare-­‐
Not
True!
• If
is
a
legiBmate
Prescribed
Drug
it
is
safe-­‐
Not
True!
• Even
if
they
had
past
issues
with
drugs
(or
alcohol)
if
they
need
it
then
they
ought
to
get
it,
just
be
careful-­‐
Haven’t
seen
this
work
too
well

18. Risk
Factors
for
opiate
abuse
• History
of
alcohol
or
drug
abuse
– History
of
physical/sexual
abuse
– History
of
depression/anxiety
– Current
chao:c
living
environment
– History
of
criminal
ac:vity

19. Risk
Factors
for
opiate
abuse
– Prior
failed
treatment
at
a
pain
management
program
– Regular
tobacco
use
– Regular
alcohol
use
– MulBple
injuries
or
surgeries
– Family
history
of
drug
abuse

20. Sir
William
Osler
“It is more important to know
what kind of patient has a
disease…
than what kind of disease
a patient has”

21. Defini:ons
Acute
Pain
– Acute
pain
is
the
normal,
predicted
physiological
response
to
a
noxious
chemical,
thermal
or
mechanical
s:mulus
and
typically
is
associated
with
invasive
procedures,
trauma
and
disease.
It
is
generally
:me-­‐limited.

22. Acute
Pain
• Broken
bones
• Dental
“issues”
• Incisions
• Burns
• Kidney
Stones
• Childbirth
• Damaged
or
disrupted
Bssue

23. SOMETIMES
YOU
THINK…
• You
are
darned
if
you
do
and
• You
are
darned
if
you
don’t
• Write
that
Rx

24. As
a
healthcare
professional
• You
have
a
legal
and
ethical
responsibility
to
uphold
the
law
and
to
help
protect
society
from
drug
abuse.
• You
have
a
professional
responsibility
to
prescribe
controlled
substances
appropriately,
guarding
against
abuse
while
ensuring
that
your
pa:ents
have
medica:on
available
when
they
need
it.

25. Office
staff
training
also:
• Train
staff
to
recognize
and
alert
you
to
quesBonable
paBent
demeanor.

26. Common
Characteris:cs
of
the
Drug
Abuser:
• Unusual
behavior
in
the
waiBng
room;
• AsserBve
personality,
oOen
demanding
immediate
acBon;
• Unusual
appearance
-­‐
extremes
of
either
slovenliness
or
being
over-­‐dressed;
• May
show
unusual
knowledge
of
controlled
substances
and/or
gives
medical
history
with
textbook
symptoms
OR
gives
evasive
or
vague
answers
to
quesBons
regarding
medical
history;

27. Common
Characteris:cs
of
the
Drug
Abuser:
• Reluctant
or
unwilling
to
provide
reference
informaBon.
Usually
has
no
regular
doctor
and
oOen
no
health
insurance;
• Will
oOen
request
a
specific
controlled
drug
and
is
reluctant
to
try
a
different
drug;
• Generally
has
no
interest
in
diagnosis
-­‐
fails
to
keep
appointments
for
further
diagnosBc
tests
or
refuses
to
see
another
pracBBoner
for
consultaBon;

28. What
You
Should
Do
When
Confronted
by
a
Suspected
Drug
Abuser
• DO:
• perform
a
thorough
examinaBon
appropriate
to
the
condiBon.
• document
examinaBon
results
and
quesBons
you
asked
the
paBent.
• request
picture
I.D.,
or
other
I.D.
and
Social
Security
number.
Photocopy
these
documents
and
include
in
the
paBent's
record.

29. What
You
Should
Do
When
Confronted
by
a
Suspected
Drug
Abuser
• Do:
• call
a
previous
pracBBoner,
pharmacist
or
hospital
to
confirm
paBent's
story.
• confirm
a
telephone
number,
if
provided
by
the
paBent.
• confirm
the
current
address
at
each
visit.
• write
prescripBons
for
limited
quanBBes.

30. What
You
Should
Do
When
Confronted
by
a
Suspected
Drug
Abuser
DON'T:
• "take
their
word
for
it"
when
you
are
suspicious.
• dispense
drugs
just
to
get
rid
of
drug-­‐seeking
paBents.
• prescribe,
dispense
or
administer
controlled
substances
outside
the
scope
of
your
professional
pracBce
or
in
the
absence
of
a
formal
pracBBoner-­‐paBent
relaBonship.

31. How
to
Discuss
Drug
Issues
with
a
Pa:ent
SuggesBons
from
Greg
Jones,
MD
Medical
Director
at
the
KY
Physicians
Health
FoundaBon

32. Why
bother?
The
paBent
is
the
one
With
the
problem

33. Usual
Way
of
Discussing
Addic:on
Issues
•
Never
ask-­‐
Probably
most
common
way
• Do
you
have
a
drinking
or
drug
Problem?
• Or
You
don’t
have
a
drinking
or
drug
problem
do
you?
• How
much
do
you
drink?
• How
much
drug
do
you
use?

34. “I’ve
never
had
a
problem
with
drugs.
I’ve
had
problems
with
the
police.”
Keith
Richards

35. Dr.
Jones’
1st
law
of
Addic:on
Medicine
The
level
of
Denial
is
proporBonal
to
the
obvious
and
measurable
damage
done
by
their
drinking
or
drug
use.
*Corollary-­‐
Denial
increases
if
confronted
with
the
evidence

36. Dr.
Jones’
2nd
law
of
Addic:on
Medicine
There
is
an
inverse
and
proporBonal
relaBonship
between
the
degree
of
convicBon
a
paBent
has
in
their
dx
and
the
likelihood
it
exists

37. So
what
on
Earth
am
I
supposed
to
do!
• Ask
the
quesBons
• And
in
the
course
of
your
usual
Hx
taking
• Any
hint
of
judgmental
or
disapproving
aQtude
and
the
useful
conversaBon
is
over

38. What
to
Ask
• Ask
do
you
drink?
Or
use
drugs?
• Ask
when
was
the
last
Bme
you
….
• Are
you
concerned
about
your
drinking
or
drug
use?
• Have
you
considered
doing
something
different
with
your
drinking
or
drug
use?
• Ever
have
Bmes
you
drank
or
used
more
than
you
intended
too?

39. Then….
• Do
you
recall
how
old
you
were
when
you
first
used
alcohol
or
another
drug?
• Do
you
recall
any
of
your
family
members
having
issues
with
alcohol
or
other
drugs?
• “How
many
Bmes
in
the
past
year
have
you
had
X
or
more
drinks
in
a
day?”,
where
X
is
5
for
men,
4
for
women
• Used
to
get
high?

40. What
if
they
complain
of
Pain?
• Ask
what
is
the
pain
prevenBng
them
from
doing?
Not
–
How
bad
is
the
pain?
• Pain
scales
are
not
helpful.
• Ask
about
things
they
are
able
to
do.
• Ask
how
they
first
came
to
have
the
pain.
• Ask
how
long
the
pain
has
been
present.
• Ask
about
prior
evaluaBons.
• Ask
about
prior
treatment.

41. Red
Flags
• The
“Call
Brand”
• AnyBme
they
menBon
or
ask
for
a
specific
drug
by
name…
• Having
more
than
one
doctor.
• Having
more
than
one
pharmacy.
• Being
on
more
than
one
class
of
controlled
substance.
• They
brought
their
films.
• Work
or
disability
related.

42. Get
A
KASPER
i.e.
Use
your
PDMP!
• How
many
classes
of
drugs
• How
many
prescribers
• Overlapping?
• How
many
Pharmacies?
• Amount
and
frequency?

43. Prescrip:on
Painkiller
Prescribing
Dropped
Ader
New
Kentucky
Law
Implemented
• The
law
requires
prescribers
to
register
with
the
state’s
prescripBon
drug
monitoring
database,
and
gives
law
enforcement
easier
access
to
it.
• Rates
of
prescribing
for
oxycodone
and
hydrocodone
have
dropped.
• Between
August
2012
and
May
2013,
the
number
of
hydrocodone
doses
decreased
by
9.5
percent,
and
oxycodone
doses
dropped
by
10.5
percent.

44. So
you
are
fixin’
to
Rx
a
controlled
substance
–
eyes
OPEN!

45. And….
• UBlize
your
local
pharmacists
• Thank
you!

46. For
further
informa:on:
Brian
Fingerson,
RPh
KY
Professionals
Recovery
Network
(KYPRN)
202
Bellemeade
Road
Louisville,
KY
40222-­‐4502
O/H:
502-­‐749-­‐8385
Fax:
502-­‐749-­‐8389
Cell:
502-­‐262-­‐9342
kyprn@ax.net
for
email
www.kyprn.com
Ques:ons?

47. April 22-24, 2014 | Atlanta, Georgia

48. Dallas Gay has no financial relationships
with proprietary entities that produce health
care goods and services.

49. 1. Describe the impact of changing
attitudes concerning Rx drug abuse.
2. Define the roles clinicians play to
positively impact this epidemic.

69. “PrescripBon
drug
safety
educaBon
is
best
received
and
understood
by
paBents
when
it
is
delivered
at
the
places
where
they
go
for
their
health
care.
Northeast
Georgia
Health
Systems
is
commixed
to
parBcipaBng
in
the
‘Think
About
It’
prescripBon
drug
safety
educaBon
program.
We
believe
that
this
program
will
reduce
the
incident
of
drug
diversion
and
abuse
that
has
become
an
epidemic
in
our
country.”
-­‐Carol
Burrell
CEO
of
Northeast
Georgia
Health
Systems

70. “Physicians
have
a
major
role
to
play
in
reducing
the
supply
of
unused
prescripBons
and
also
helping
their
paBents
understand
the
need
to
safeguard
their
medicines.
The
‘Think
About
It’
program
has
caused
me
to
more
closely
evaluate
how
I
prescribe
to
paBents
in
order
to
reduce
the
supply
of
prescripBon
drugs
that
might
otherwise
be
diverted
from
their
intended
use
to
some
form
of
abuse.”
-­‐Dr.
Pierpont
F.
Brown,
M.D.,
F.A.C.S.

72.  Make The Four Steps a part of every RX
 Put The Four Steps in the Rx bag
 Increase the availability of disposal sites
 Display Rx safe storage boxes in stores

73.  Expand Education Higher Education Programs
 Provide Resources and Education to Healthcare
Professionals
 Foster Implementation of Community
Involvement
 Advocate for Public Policy Changes