Pharmacy Track National Rx Drug Abuse Summit Brian Fingerson

1. Risk,
Recognize,
Resolve:
Addic2on
in
the
Pharmacy
Profession
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

2. Learning
Objec2ves
• 1.
Iden=fy
risk
factors
for
pharmacy
professionals
that
may
influence
the
development
of
the
disease
of
addic=on.
• 2.
Iden=fy
the
signs
and
symptoms
of
the
disease
of
addic=on.
• 3.
Describe
the
resources
available
to
pharmacy
professionals
when
a
colleague
may
need
assistance
with
addic=on
or
substance
abuse
issues.
• 4.
Describe
the
structure
of
accountability
added
to
the
recovery
person
by
monitoring
with
a
Pharmacist
Recovery
Network.

3. Disclosure
Statement
Brian
Fingerson
has
no
financial
rela=onships
with
proprietary
en==es
that
produce
health
care
goods
and
services.

4. Brian
Fingerson,
RPh
• President,
KYPRN
–
Kentucky
Professionals
Recovery
Network
since
1986
• Clients/professions
include:
Accountants,
Pharmacy,
Den=stry,
Physical
Therapy,
Veterinary
Medicine,
Respiratory
Care,
Optometry,
Chiroprac=c,
Social
Work
• Work
with
these
professionals
through
their
licensing
Boards

5. What
do
you
know?
Self-­‐Assessment
Ques2ons
T
or
F
• In
a
diagnosis
of
addic=on
using
DSM
IV
criteria,
one
must
exhibit
any
two
out
of
seven
of
the
criteria
within
the
past
six
months.
• Gene=cs
is
the
sole
determining
factor
as
to
whether
someone
becomes
addicted
to
a
substance
or
process.
• The
prognosis
for
someone
who
is
addicted
to
a
substance
includes
these
three:
1)
get
sober;
2)
get
locked
up;
or
3)
die.
• Alcoholism,
chemical
addic=on,
is
a
disease,
the
very
nature
of
which
renders
the
vic=m
incapable
of
recognizing
the
severity
of
the
symptoms,
the
progression
of
the
disease,
or
of
accep=ng
any
ordinary
offers
of
help.

6. And
why
should
we
learn
about
addic2on
in
pharmacy
professionals?
Crit
Care
Med.
2007
Feb;35(2
Suppl):S106-­‐16
Baldisseri
MR.
Cri=cal
Care
Medicine,
University
of
Pidsburgh
School
of
Medicine,
Pidsburgh,
Pennsylvania,
USA.
OBJECTIVE:
The
objec1ve
of
the
ar1cle
is
to
present
the
available
data
from
the
literature
on
substance
use
disorders
in
healthcare
professionals.
Prevalence,
risk
factors,
treatment
op1ons,
and
reentry
into
clinical
prac1ce
are
discussed.

7. Crit
Care
Med.
2007
Feb;35(2
Suppl):S106-­‐16
Baldisseri
MR.
• INTRODUCTION:
Impairment
of
a
healthcare
professional
is
the
inability
or
impending
inability
to
prac5ce
according
to
accepted
standards
as
a
result
of
substance
use,
abuse,
or
dependency
(addic5on).
The
term
substance
use
disorder
can
be
divided
into
substance
abuse
and
dependence
(addic1on).
Substance
abuse
results
in
adverse
social
and
professional
consequences.
Addic5on
manifests
as
physiologic
and
behavioral
symptoms
related
to
a
maladap1ve
paLern
of
substance
use.
• MAIN
RESULTS:
It
is
es1mated
that
approximately
10%
to
15%
of
all
healthcare
professionals
will
misuse
drugs
or
alcohol
alcohol
some
1me
during
their
career.

8. Why
do
people
take
drugs
“recrea2onally”
in
the
first
place?

9. People
Take
Drugs
To:
• Feel
good
(sensa2on
seeking)
• Feel
be[er
(self-­‐medica2on)

10. A
major
reason
people
take
a
psychoac2ve
drug
is
they
like
what
it
does
to
their
brains

11. Prolonged drug use changes
the brain in fundamental and
long-lasting ways

12. Reward Pathway
Frontal
Cortex
Wow!!!
Addiction
is a Opiates
brain disease Alcohol
Cocaine
Amphetamines
Marijuana

13. Young adults
may
be less
likely to develop serious alcohol
and other drug problems
if the age of first use is
delayed beyond childhood or
adolescence

14. AA
Grapevine
e-­‐poll
Ques2on:
At
what
age
did
you
have
your
first
drink?
Total
Responded:
7947
0-­‐11
2308
votes
(29.04
%)
12-­‐18
5110
votes
(64.3
%)
19-­‐26
420
votes
(5.29
%)
27-­‐40
52
votes
(0.65
%)
41
or
older
57
votes
(0.72
%)

15. Addic2on:
One
Defini2on
• A
primary,
chronic,
neurobiological
disease,
with
gene2c,
psychosocial,
and
environmental
factors
influencing
its
development
and
manifesta2ons.
It
is
characterized
by
behaviors
that
include
one
or
more
of
the
following:

16. Addic2on
behaviors:
• Impaired
control
over
drug
use
• Compulsive
use
• Con2nued
use
despite
harm
• Craving

17. Fr
Vernon
Johnson’s
defini2on
of
addic2on
• “”Alcoholism,
chemical
addic2on,
is
a
disease,
the
very
nature
of
which
renders
the
vic2m
incapable
of
recognizing
the
severity
of
the
symptoms,
the
progression
of
the
disease,
or
of
accep2ng
any
ordinary
offers
of
help.”

18. DSM
IV:
Diagnosis
of
Addic2on
(3
out
of
7
in
past
12
months)
1. Tolerance
2. Withdrawal
Loss
of
Control:
3. Used
more
and
longer
than
planned
4. Unsuccessful
a[empts
to
quit
or
control
use
5. Excessive
2me
spent
obtaining,
using,
or
recovering
from
use
6. Important
ac2vi2es
given
up
7. Con2nued
use
despite
adverse
consequences

19. DSM-­‐V

20. Risk
as
a
healthcare
professional?
 Don’t
know
of
anyone
yet
whose
reason
for
becoming
a
pharmacist
was
drug
access.
But…
maybe
so?

21. Risk
Factors
• General
Public
=
10%
• Pharmacists
and
some
other
health
care
professionals
=
HCP
=
12-­‐16%

22. So…Why
an
increased
risk
factor?
• Access
to
drugs
• Stress
• Knowledge
• Family
history
=
1
parent
20-­‐25%
chance,
2
parents
30-­‐50%

23. And
how
can
this
be,
you
say?
• Dean
Dabney
in
JAPhA,
May/June
2001
• Vol.
41,
No.
3
• Use
of
Mind
Altering
or
Poten2ally
Addic2ve
Prescrip2on
Drugs
(PAPD)

24. Who
was
asked?
• It
was
a
random
sample
of
licensed,
prac2cing
pharmacists
who
were
members
of
APhA
in
the
fall
of
1996.

25.
And
what
did
the
study
show?
• 40%
indicated
using
PAPD
without
1st
obtaining
an
Rx
• 20%
reported
5
or
more
life2me
episodes
• 6%
reported
10
or
more
life2me
episodes
• 6%
iden2fying
as
being
drug
abusers
• Drugs
obtained
by
stealing
drugs
from
employers
or
forging
Rx

26. DENIAL – not just a river in Egypt*
Yes – it has been said before!
• Don’t
• Even
• Know
• I
• Am
• Lying

27. Denial
from
Knots
by
R.D.
Lang
• There
must
be
something
the
ma[er
with
him
because
he
would
not
be
ac2ng
as
he
does
unless
there
was.
Therefore
he
is
ac2ng
as
he
is
because
there
is
something
the
ma[er
with
him.

28. Denial
con2nued:
• He
does
not
think
there
is
anything
the
ma[er
with
him
because
one
of
the
things
that
is
the
ma[er
with
him
is
that
he
does
not
think
that
there
is
anything
the
ma[er
with
him.
• Therefore
we
have
to
help
him
realize
that,
the
fact
that
he
does
not
think
there
is
anything
the
ma[er
with
him
is
one
of
the
things
that
is
the
ma[er
with
him.

29. HCP
good
at
“cover
up”
and
if
confronted
will
deny
• Denial
is
not
just
a
river
in
Egypt
• Paranoia
and
irritability
• Depression
• Use
of
large
quan22es
of
alcohol
–
more
than
normal
or
more
than
others
present
• Blackouts

30. Blackouts
-­‐
Once
a
person
has
had
one
Fr
Vernon
Johnson
• 1)
You
can
never
tell
how
much
of
the
chemical
it
will
take
to
put
you
into
the
blackout
again.
• 2)
You
can
never
tell
how
long
the
blackout
will
last.
• 3)
There
is
no
connec2on
between
our
value
system
and
what
we
will
do
in
a
blackout.

31. Problems
seen:
• Slurred
speech
–
frequent
drunkenness
• Personal
problems
• Paren2ng
problems
• Sexual
dysfunc2on
or
promiscuity
• Insomnia
• Having
ONLY
friends
who
like
to
party

32. Problems
con2nued:
• Frequent
promises
to
cut
back
• Avoiding
social
func2ons
unless
“altered”
• Memory
problems
• Mood
swings
• Blaming
of
behavior
on
others
• Withdrawal
into
isola2on

33. Impairment
signs/symptoms
in
the
workplace:
• Changes
in
the
manner
in
which
pa2ents
and
colleagues
are
treated
• Deteriora2on
of
personal
appearance
and
hygiene
• Loss
of
interest
in
work,
or….
• “Super
Pharmacist”
or
Super
whatever

34. Workplace
con2nued:
• Poor
record
keeping
• Problems
with
concentra2on
• Med
errors
or
whatever
• Absenteeism
or
tardiness,
esp.
on
day
following
days
off
• Pa[ern
of
frequent
job
changes

35. Workplace
con2nued:
• Paranoia
• Frequent
trips
to
the
bathroom
• Mood
swings
• Periods
of
unemployment

36. Am
I
an
alcoholic?
• 1.
Have
you
ever
decided
to
stop
drinking
for
a
week
or
so,
but
only
lasted
for
a
couple
of
days?
2
-­‐
Do
you
wish
people
would
mind
their
own
business
about
your
drinking-­‐-­‐
stop
telling
you
what
to
do?
3
-­‐
Have
you
ever
switched
from
one
kind
of
drink
to
another
in
the
hope
that
this
would
keep
you
from
gesng
drunk?
4
-­‐
Have
you
had
to
have
an
eye-­‐opener
upon
awakening
during
the
past
year?

37. Am
I
an
alcoholic?
• 5
-­‐
Do
you
envy
people
who
can
drink
without
gesng
into
trouble?
6
-­‐
Have
you
had
problems
connected
with
drinking
during
the
past
year?
7
-­‐
Has
your
drinking
caused
trouble
at
home?
8
-­‐
Do
you
ever
try
to
get
"extra"
drinks
at
a
party
because
you
do
not
get
enough?

38. Am
I
an
alcoholic?
• 9
-­‐
Do
you
tell
yourself
you
can
stop
drinking
any
2me
you
want
to,
even
though
you
keep
gesng
drunk
when
you
don't
mean
to?
10
-­‐
Have
you
missed
days
of
work
or
school
because
of
drinking?
11
-­‐
Do
you
have
"blackouts"?
12
-­‐
Have
you
ever
felt
that
your
life
would
be
be[er
if
you
did
not
drink?

39. p9
CAGE-­‐AID
• Cut
down
• Annoyed
• Guilty
• Eye
opener
CAGE-AID: CAGE Questions
Adapted to Include Other JAMA 252:1905-1907, 1984
Drugs Am J Med 82:231-235, 1987

40. CAGE-­‐AID
1.
Have
you
felt
you
ought
to
cut
down
on
your
drinking
or
drug
use?
2.
Have
people
annoyed
you
by
cri=cizing
your
drinking
or
drug
use?
3.
Have
you
felt
bad
or
guilty
about
your
drinking
or
drug
use?
4.
Have
you
ever
had
a
drink
or
used
drugs
first
thing
in
the
morning
to
steady
your
nerves,
get
rid
of
a
hangover,
or
get
the
day
started?
Screen
posi5ve
score
=
1+or
2+

41. CRAFFT
Ques2ons
5. Have
you
ever
ridden
in
a
CAR
driven
by
someone
(including
yourself)
who
was
“high”
or
had
been
using
alcohol
or
drugs?
6. Do
you
ever
use
alcohol
or
drugs
to
RELAX,
feel
beder
about
yourself,
or
fit
in?
7. Do
you
ever
use
alcohol/drugs
while
you
are
by
yourself,
ALONE?
8. Do
your
family
or
FRIENDS
ever
tell
you
that
you
should
cut
down
on
your
drinking
or
drug
use?
9. Do
you
ever
FORGET
things
you
did
while
you
were
using
alcohol
or
drugs?
10. Have
you
goden
into
TROUBLE
while
you
were
using
alcohol
or
drugs?
Screen
posi5ve
score
=
2+

42. But
I
can’t
be
one!!!!!!!!!!

43. If…then
three
courses
of
ac2on:
• Sober
up
• Get
locked
up
• Get
covered
up
=
PUAD

44. Do
they
have
to
reach
this
level?

45. It
is
this
serious
folks!

46. To
whom
do
I
turn
for
help?
 Do
you
call
the
professional’s
licensing
Board?
 Board
balances
regula2on
with
compassion
 Is
it
a
bad
person
in
need
of
punishment
or
an
ill
person
in
need
of
care?

47. There
is
an
op2on
in
some
states
 You
could
call
your
state’s
recovery
program
 I
publish
my
office/
home
phone
number
 The
website
www.usaprn.org
has
a
directory
of
state
programs

48. Referral
by:
• Board
• Self
• Colleague
or
employer
• Family
• Interven2on
• ***anonymous

49. Why
do
they
ask
for
help?
• Liver
• Lover
• Livelihood
• Law

50. Then
what
happens?

51. Evalua2on
• KYPRN
uses
addic2ons
psychiatrists
and
some2mes
a
residen2al
3-­‐5
day
assessment
• Results
of
evalua2ons
will
determine
to
a
large
extent
what
type
of
treatment.
It
may
be
AA/NA,
IOP,
Long-­‐term
residen2al
or
other
or
a
combina2on

52. Yes…Rehab
does
work!

53. Goals
of
Addic2on
Therapy:
• Reduc2on
or
elimina2on
of
denial
• Increased
self
care
• Treatment
of
medical
and
psychiatric
problems
• Treatment
of
co-­‐morbid
family
• Educa2on
to
protect
himself
or
herself
from
substance
abuse
disease

54. Contracts
• For
a
specific
length
of
2me
–
usually
5
yrs
• Shared
with
employer
–
if
per2nent
• May
limit
number
of
hours
worked
• Approved
prac2ce
site
or
type
• CAPTASA,
U
of
Utah,
SE
PRN

55. Other
things
• Mee2ng
documenta2on
forms
• Medica2on
use
lists
• Monthly
self-­‐report
form
• Urine
Drug
Screens

56. Pharmacist
may
have:
• Modifica2on
of
prac2ce
type
• Prac2ce
monitoring
by
peers/others
• Protocols
for
required
mood-­‐altering
drugs
for
a
legi2mate
medical
problem
• Consequences
should
she
return
to
substance
use

57. Conclusion
• Substance
abuse
by
HCP
is
a
condi2on
that
has
become
increasingly
recognized
over
the
past
20+
years.
We’ve
worked
hard
to
develop
treatment
protocols
and
support
programs.

58. Treatment
does
work!
 The
vast
majority
of
Pharmacists
who
successfully
complete
treatment
and
par2cipate
in
a{ercare
monitoring
CAN
and
DO
successfully
return
to
prac2ce.
 HIRE
THE
RECOVERING
PROFESSIONAL

59. “The
alcoholic
is
like
a
tornado
roaring
through
the
lives
of
others.”
page
82
From
the
book:
“Alcoholics
Anonymous”

60. Page
82
also
says:
“Hearts
are
broken.”
Our
goal
is:
Recovery
From
the
book:
“Alcoholics
Anonymous”
Recovery:
by
Mike
Vye

61. Not
this:

62. True
or
False
• “Alcoholism,
chemical
addic2on,
is
a
disease,
the
very
nature
of
which
renders
the
vic2m
incapable
of
recognizing
the
severity
of
the
symptoms,
the
progression
of
the
disease,
or
of
accep2ng
any
ordinary
offers
of
help.”
• TRUE

63. True
or
False
• In
a
diagnosis
of
addic2on
using
DSM
IV
criteria,
one
must
exhibit
any
2
out
of
7
of
the
criteria
within
the
past
6
months.
• FALSE

64. True
or
False
• Gene2cs
is
the
sole
determining
factor
as
to
whether
someone
becomes
addicted
to
a
substance
or
process.
• FALSE

65. True
or
False
• The
prognosis
for
someone
who
is
addicted
to
a
substance
includes
these
three:
1)
get
sober;
2)
get
locked
up;
or
3)
DIE
• TRUE

66. Have
you
ever
wondered?

67. Ques2ons?
• Brian
Fingerson,
RPh
• 202
Bellemeade
Road
• Louisville,
KY
40222-­‐4502
• 502-­‐749-­‐8385
• Email
=
kyprn@a[.net

68. Thank
you
Thank
you
Thank
you
Thank
you