1. Cory Phillips
PharmD Candidate
BUCOP
http://www.dps.state.ia.us/DNE/oxycontin.shtml http://3-ecom-.mcguffmedical.com/products/4528.aspx

2.  Controlled prescription drug abuse by Americans has
nearly doubled from
 7.8 million in 1992 to 15.1 million in 2003
 ED visits involving nonmedical use of opioid
analgesics
 Increased 111% from 2004 to 2008 (CDC, SAMHSA)
 Deaths due to prescription drug abuse
 Increased 55% from 1999 to 2003
 >36,000 people died of drug overdoses in 2008 (CDC)
 Economic costs
 Overall cost of painkiller abuse > $70 billion a year
 Lost productivity costs ~ $42 billion a year
 Criminal justice costs ~ $8.2 billion a year
Morbidity and Mortality Weekly Report. Center for Disease Control and Prevention. Emergency Department Visits Involving Nonmedical Use of
Selected Prescription drugs: United States, 2004-2008; 59(23). www.cdc.gov/mmwr. Accessed Feb 20, 2012.
Controlled Prescription Drug Abuse at Epidemic Level: The National Center on Addiction and Substance Abuse (CASA) at Columbia University. J
Pain & Palliative Care. 2006; 20(2): 61-61. http://www.casacolumbia.org. Accessed Feb 20, 2012.

3.  Higher degree of purity
 Made under strict rules and regulations
 Known dose
 Safer
 Can avoid accidental overdosing
 Legally available
 Easy to obtain
 Hard to detect in routine urine drug testing
 Less social stigma
 Less percieved potential harm
 Certain legal biases in their favor
 Illicit drug abuse – felony
 Prescription drug abuse- misdemeanor
 Prescription drugs are profitable
 Cash most important factor in diversion of pain medications
Chandra A, Ozturk A. Health Professionals Beware of Prescription Pain Medication Abuse and
Diversion. Hospital Topics. 2004; 82: 34-36.

4.  The Drug Abuse Warning Network (DAWN)
 Public health information system that tracks the impact of drug
use, misuse, and abuse in the US by monitoring drug-related
hospital ED visits
 DAWN describes nonmedical use of Rx or OTC drug as
 Taking a higher-than-recommended dose
 Taking a drug prescribed for another person
 Documented misuse or abuse
 Addiction (APS, AAPM, ASAM)
 A primary, chronic, neuroiologic disease, with
genetic, psychosocial, and environmental factors influencing its
development and manifestations…
 Characterized by behaviors that include one or more of the
following
 Impaired control over drug use
 Compulsive use
 Continued use despite harm
 Cravings
Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids
Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.

5. Category MOA Drug Classes Indications Common AEs
Opioids Antagonists at Prescription Acute or Analgesia, sedation, euphoria,
(narcotics) opioid receptors (μ, pain relievers chronic pain respiratory depression, physical
κ, δ) relief dependence, GI dysmotility,
pruritis
Sedative- Enhance effect of Sedatives, Sleep aide, CNS depression, slurred speech,
Hypnotics GABA-mediated BZDs, BARBs, insomnia, ataxia, incoordination, stupor,
chloride channels “downers” or seizure coma, cardiac dysrhythmia
sleeping pills disorders
Stimulants Enhance release of Amphetamine Narcolepsy, HTN, tachycardia, seizure,
catecholamines s,“uppers” or ADHD, hyperthermia, agitation,
(DA & NE); “speed”, short-term anorexia, ischemia,
stimulation of prescription weight rhabdomyolysis
peripheral α-and β- diet pills reduction
adrenergic receptors
Tranquilizers Enhance effect of Anxiolytics, Anxiety and CNS depression (less
GABA-mediated BZDs, muscle panic compromise in mental status
chloride channels relaxants disorders than with sedative-hypnotics),
and central DA slurred speech, ataxia,
receptors incoordination, stupor, coma,
cardiac dysrhythmia
Hernandez SH, Nelson LS. Prescription Drug Abuse: Insight into the Epidemic. Clin Pharma & Thera. 2010;
88(3): 307-317.

6. Hernandez SH, Nelson LS. Prescription Drug Abuse: Insight into the Epidemic. Clin Pharma &
Thera. 2010; 88(3): 307-317.

7.  Illicit drug abuser  Patient
 Prescription drug abuser  Neighbor
 Druggie  Healthcare Worker
 Junkie  Employee
 Stoner  Colleague
 Drug Addict  Friend
 Abuser  Family member
 Abusing patient  Spouse
 Grandmother
 Mother
 Father
 Child
Cory Phillips

8.  Multidisciplinary approach
 Assessment of substance use history
 Set realistic goals for therapy
 Evaluate and treat comorbid psychiatric disorders
 Recognizing specific drug abusive behaviors
 Use written agreements (controversial)
 Patient may not be mentally competent for agreement
 Guidelines for prescribing
 Consider the therapeutic impact of tolerance
 Apply pharmacological principles to treating pain
 Use 12-step programs
 Urine toxicology screens
Kirsh KL, Passik SD. Palliative Care of the Terminally Ill Drug Addict. Cancer Investigation. 2006;
24: 425-431.

9.  Choose an opioid based on ATC dosing
 Choose LA agents when possible
 Limit or eliminate the use of SA or “breakthrough” doses
 Use non-opioid adjuvants when possible and monitor for
compliance with those medications
 Use nondrug adjuvants whenever possible
 Relaxation techniques
 Distraction
 Biofeedback
 Transcutaneous Nerve Stimulation (TNS)
 Communication about thoughts and feelings of pain
 Limit the amount of medication given at any one time
 Utilize pill counts and urine toxicity screens as necessary
 If compliance is suspect or poor, refer to an addiction specialist
Kirsh KL, Passik SD. Palliative Care of the Terminally Ill Drug Addict. Cancer Investigation. 2006;
24: 425-431.

10.  Cross-sectional, multivariable, descriptive analysis
 Age, gender, race, financial status, employment, current
smoking, drinking, past-year illicit drug use, depression, chronic
pain.
 Veterans (N= 6,377)
 Mean age 56.5 yo
 Majority caucasian, unmarried, and unemployed
 Found associations between prescription drug abuse and
 Younger age
 Depression or probable depression
 Smoking
 Illicit drug use
 Chronic pain
 Younger individuals using illicit drugs or having a history of
addiction or a mental illness at higher risk of abusing
prescription drugs
Becker WC, Fiellin DA, Gallagher RM, Barth KS, Ross JT, Olsin DW. The Association Between
Chronic Pain and Prescription Drug Abuse in Veterans. Pain Med. 2009; 10(3): 531-536.

11.  Listening  Considerations
 Clinical judgment  Prescriber creditials
 Screening for abusers  Indication
 Controlled substance
 Identifying the problem  Non-controlled substance
 Identifying and treating co-  Abuse potential
morbidities  Potential for harm
 Exhibiting  Alternative therapies
empathy/understanding  Tolerance
 Aiding in therapy  Behaviors
modification  Past medical history
 Education on addiction  Life expectancy
 Safe and effective opioid
 Referral to addiction services, prescribing?
counseling, recovery centers,
support groups, etc…
Hale, KM, Murawski MM, Huerta J. Pharmacist Roles in Combating Prescription Drug Abuse.
JAPhA. 2009; 49(5): 589-590.

12.  Appearances may be decieving
 Common characteristics
 Escalated use
 Continually running out of medication before scheduled follow-up
 Frequently “losing” medication
 Inability to clearly describe drug use pattern
 Pseudoaddiction behaviors
 Provider shopping
 Pharmacists can identify from observation or databases
 Frequent local ER visits
 Several prescribers
 No regular PCP or they are ‘out of town’
 Seek treatment after hours or times when the clinic is typically busy
 Scamming
 Present as complimentary then, if resisted, threatening
 Request of specific controlled substance
 Avoid physical examination, history taking, diagnostic testing, or
provide a vague medical history
Gerhardt AM. Identifying the Drug Seeker: The Advanced Practice Nurse’s Role in Managing
Prescription Drug Abuse. JAANP. 239-243.

13. What are we doing
wrong? What can we do better?
 Seek to help first
 Lying to patients
 Listen first, refuse later
 Hanging up on patients  What is the context in which this
patient is asking for this
medication?
 Not listening to patients  Does he/she have a home
pharmacy?
 Gossiping about patients  Can I verify the patient?
 Is this a chronic pain/cancer
 Not differintiating patient?
between patients who  Does the patient need a dose
reduction or increase?
need help and true  Does the patient need to be
weaned off this med?
addiction or diversion  Does the patient need to see
his/her doctor?
 GIVE THE BENEFIT OF THE
DOUBT
Cory Phillips

14.  Active surveillance of abused and misused prescription
opioids using poison center data: A pilot study and
descriptive comparison
 Poison Center data timely, geographic, and specific indicator
of opioid abuse
 Poison Center data comparable to DAWN
 Hydrocodone (55% v 39% cases); Oxycodone (39 % v 35% cases)
 Poison Center highest rates of abuse in 18-25 yoa
 DAWN ED visits highest in 35-44 yoa
 Involve 2 substances (2nd being ETOH)
 Kentucky leads nation in highest misuse and abuse rates
(DEA) followed byVirginia
 Researched-Abuse, Diversion, and Addition-Related
Surveillance (RADARS®) Study
 Abuse localized in rural, suburban, and small urban areas
 Hydrocodone and ER/IR oxycodone most widely abused
drugs in the country
 Abuse of all opioids grown throughout this study (3 ½ years)
Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison Center Data: A Pilot Study and
Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.
Cicero TJ, Dart RC, Inciardi JA, Woody GE, Schnoll S, Munoz Alvaro. The Development of a Comprehensive Risk-Management Program for Prescription

15. Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids
Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.

16. Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids
Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.

17.  Pharmacists (1st line)
 Study on knowledge, attitudes, and professional practices of
pharmacists regarding addiction
 Questionnaire (25 items; 484 pharmacists; Florida)
 67.5% had participated in 2 h or less of addiction/substance abuse
education in pharmacy school
 29.3% had no addition education
 53.7% had never referred a patient to a drug treatment center
 Closer monitoring and relations with pain patients
 Increased awareness, education, and rehabilitation efforts
 Abuse-deterrent and tamper-resistant opioid formulations
 May be costly
 Need more studies
 Risk-Management Programs (last-line)
 Drug Enforcement Agency (DEA)
Controlled Prescription Drug Abuse at Epidemic Level: The National Center on Addiction and
Substance Abuse (CASA) at Columbia University. J Pain & Palliative Care. 2006; 20(2): 61-61.
http://www.casacolumbia.org. Accessed Feb 20, 2012.

18. Schneider, JP, Matthews M, Jamison RN. Abuse-Deterrent and Tamper-Resistant Opioid
Formulations: What is their Role in Addressing Prescription Opioid Abuse? CNS Driugs. 2010;
24(10): 805-810.

19.  NIDA Web Page for healthcare professionals
 Publications, clinical practice, research
 www.nida.nih.gov/medstaff.html.
 Commonly Abused Prescription Drugs
 Street names for Rx drugs, DEA schedule, intoxication
effects, and potential health consequences
 www.nida.nih.gov/DrugPages/PrescripDrugsChart.html
 The NIDA Research Report- Prescription Drugs: Abuse and
Addiction
 www.nida.nih.gov/ResearchReports/Prescription/Prescriptio
n.html
 Monitoring the Future
 An ongoing study of the behaviors, attitudes, and values of
American secondary school students, college students, and
young adults
 Provides information on the latest drug use trends
 www.monitoringthefuture.org.
Volkow ND. Teen Prescription Drug Abuse: A Major Health Concern. Tn Med. 2009: 28-29.

20.  Vanderbilt Addiction Center
 http://www.mc.vanderbilt.edu/root/vumc.php?site=add
ictioncenter
 Parthenon Pavillion
 http://www.usnodrugs.com/Tennessee/Nashville/Parth
enon_Pavilion_CMC
 The Ranch
 http://www.recoveryranch.com/
 Cumberland Heights
 http://www.cumberlandheights.org/home.aspx

21.  Who will you turn away?
 Who will you turn in?
 Who will you help?
http://www.sheknows.com/sheknows-
cares/articles/806066/emotional-support-for-
breast-cancer-patients-and-survivors-fosters-hope
 Who will you help?
 Who will you turn away?
 Who will you turn in?
http://opioids.com/oxycodone/oxycon.html

22. 1. Becker WC, Fiellin DA, Gallagher RM, Barth KS, Ross JT, Olsin DW. The Association Between Chronic Pain and
Prescription Drug Abuse in Veterans. Pain Med. 2009; 10(3): 531-536.
2. Chandra A, Ozturk A. Health Professionals Beware of Prescription Pain Medication Abuse and Diversion. Hospital
Topics. 2004; 82: 34-36.
3. Cicero TJ, Dart RC, Inciardi JA, Woody GE, Schnoll S, Munoz Alvaro. The Development of a Comprehensive Risk-
Management Program for Prescription Opioid Analgesics: Researched Abuse, Diversion, and Addiction-Related
Surveillance (RADARS). Pain Med. 2007; 8(2): 157-170.
4. Controlled Prescription Drug Abuse at Epidemic Level: The National Center on Addiction and Substance Abuse
(CASA) at Columbia University. J Pain & Palliative Care. 2006; 20(2): 61-61. http://www.casacolumbia.org. Accessed
Feb 20, 2012.
5. Gerhardt AM. Identifying the Drug Seeker: The Advanced Practice Nurse’s Role in Managing Prescription Drug
Abuse. JAANP. 239-243.
6. Hale, KM, Murawski MM, Huerta J. Pharmacist Roles in Combating Prescription Drug Abuse. JAPhA. 2009; 49(5):
589-590.
7. Hernandez SH, Nelson LS. Prescription Drug Abuse: Insight into the Epidemic. Clin Pharma & Thera. 2010; 88(3):
307-317.
8. Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison
Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.
9. Kehoe Jr WA. Substance Abuse: New Numbers Are a Cause for Action. Ann Pharma. 2008; 42: 270-272.
10. Kirsh KL, Passik SD. Palliative Care of the Terminally Ill Drug Addict. Cancer Investigation. 2006; 24: 425-431.
11. Lafferty L, Hunter TS, Marsh WA. Knowledge, Attitudes, and Practices of Pharmacists Concerning Prescription
Drug Abuse. J Psychoactive Drugs. 2006; 28(3): 229-232.
12. Morbidity and Mortality Weekly Report. Center for Disease Control and Prevention. Emergency Department Visits
Involving Nonmedical Use of Selected Prescription drugs: United States, 2004-2008; 59(23). www.cdc.gov/mmwr.
Accessed Feb 20, 2012.
13. Schneider, JP, Matthews M, Jamison RN. Abuse-Deterrent and Tamper-Resistant Opioid Formulations: What is
their Role in Addressing Prescription Opioid Abuse? CNS Drugs. 2010; 24(10): 805-810.
14. Volkow ND. Teen Prescription Drug Abuse: A Major Health Concern. Tn Med. 2009: 28-29.
15. Wysowski DK. Surveillance of Prescription Drug-Related Mortality Using Death Certificate Data. Drug Safety.
2007; 30(6): 533-540.