Toxic medicine symposium, cherney powerpoint, oct 27, 2011
1. Psychoactive Drug Usage in California Skilled Nursing Facilities Christopher Cherney Nursing Home Administrator October 27, 2011 South San Francisco, California October 27, 2011 Toxic Medicine Symposium, South San Francisco, California
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4. Remember When… Smoking on an airplane was accepted, and legal? October 27, 2011 Toxic Medicine Symposium, South San Francisco, California
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7. Restraint Reduction Percentage of U.S. nursing home residents restrained daily 1991 21.1% 2007 5.0% Source: CMS S&C 09-11, November 2008 Non-restraining fall prevention devices October 27, 2011 Toxic Medicine Symposium, South San Francisco, California
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Hinweis der Redaktion
----- Meeting Notes ----- Thanks first to the Ombudsman program. As a former ombudsman I understand and appreciate your mission. Thanks to CANHR. I have been a long supporter of CANHR, and honor its efforts to combat unnecessary drug use in long-term care facilities. Thanks as well to all of you in attendance here today. To me, your presence signals a genuine and vital interest in thinking about this issue of psychoactive drug use in the elderly, especially those who are demented. For the past 14 years, I have been a licensed and practicing nursing home administrator. In today’s presentation I will focus on the nursing home, which is my arena of experience and expertise.
And so…..I’ll begin my presentation with five conclusions, five takeaways. Throughout the presentation I will flesh out these key ideas. Tony already has made reference to the movement aspect of our work to reduce psychoactive drug use. I will speak about the physiological dangers of psychoactive drug administration. The term “least medicating” is intended to mirror the term “least restrictive” which nursing home providers use universally when referring to the application of physical restraints. That is, we start with the least restrictive approach and move toward more restrictive approaches. Just so, I propose that we advocate for a “least medicating” approach that in turn leads toward approaches involving medication.
I hope to make a strong case today that when it comes to psychoactive drug use in nursing homes, existing regulations and requirements are, in fact, excellent tools for immediately reducing the use of these drugs. I have been a provider for the past 14 years and I am not here today to blame providers. Rather, I am here as a kindred spirit. And I wish to emphasize that we must recognize and support ourselves, even as ask ourselves to think seriously about how we can improve the care we provide to persons with dementia.
So, to start our conversation I want to take us back to a time not too long ago when during a flight from New York City to Los Angeles, Americans of all ages could be constantly exposed for 7 hours to carcinogenic, second-hand smoke. Do you remember that time? Not too long ago? For most, but not all, it was accepted as NORMAL. Societally speaking, it was accepted as THE WAY THINGS WERE. And, again, it wasn’t that long ago. Of course, a small cadre of dedicated advocates worked tirelessly to ban smoking on US airplane flights.
And, by 1990 the advocates had succeeded: most in-flight smoking had been banned by 1990. By 1998, smoking in US commercial airplanes was forbidden. Today, in many states, smokers are essentially second-class citizens, and are being increasingly excluded from smoking in restaurants, bars, college campuses, health care facilities, parks, and commercial buildings. Today, especially here in California, NORMAL is now: no second hand smoke. Within 20 years there has been a shift in the WAY THINGS ARE. FROM smoking around other persons as acceptable TO smoking around other persons as a scientifcally-proven health hazard, and legally forbidden.
As with smoking on airplanes, it wasn’t too long ago when about 20% of nursing home residents were routinely physically restrained in US nursing homes. It was THE WAY THINGS WERE.
But, thanks to a lot of hard work, persistence and agitation by advocates and providers such as those in this room today, we changed the norm over the course of about 20 years. Now, as Tony mentioned earlier today, only about 5% of US nursing home residents are restrained daily. In some states, but not California, the number of residents restrained daily is close to zero. We deserve to feel proud about this development.
As we convene here today to discuss toxic drugs in the Toxic Medicine Symposium, I suggest that, just like the movement to eliminate secondhand smoke, and just like the movement to reduce physical restraints in US nursing homes, our efforts to reduce psychoactive drug use in the elderly rises to the level of a MOVEMENT. I make that claim with a sense of excitement, and with a sense of justifiable hope.
Even so, we are at the beginning of our movement. We are identifying and confronting hidden problems. But, really, this movement is only just now taking off. Public opinion is still squarely on the side of taking pills to cure us of our ailments. Especially when those pills are prescribed by trusted, talented, and dedicated physicians. So our efforts here today are part of the process of shifting public opinion. FROM a belief that psychoactive drugs can work wonders TO a belief that, in the elderly, many psychoactive drugs ARE TOXIC , CAUSE HARM and endanger health and safety.
So, yes, we are living in a pill-popping culture. Pharmaceutical revenues go up every year. Sometimes 18% year over year. The average US elder fills 31 prescriptions per year. That’s right: 31 prescriptions per year. The average non-elder adult American fills 11 prescriptions per year.
Drug manufacturers are the most profitable US industry. Drug manufacturers also spend more on political lobbying than any other industry. That has been the case for the past 15 years. In 2010, the pharmaceutical industry spent $240 million on lobbying. The industry has 1,570 lobbyists (www.opensecrets.org) So that is our context : Namely, we are at the beginning of a movement to reduce psychoactive drug use, in a culture where prescription drug use is high, and accepted as NORMAL, even for our elders. So let’s now step into the world of the nursing home, and get a sense for the lay of the land with respect to psychoactive drug use there.
In California, the state requires that informed consent be obtained before administering psychoactive medications. This morning, Tony spoke about informed consent in the nursing home. I want to emphasize that the state makes obtaining informed consent the RESPONSIBILITY OF THE PHYSICIAN . In my view, this requirement mirrors our society’s projection of power, authority and responsibility onto the shoulders of physicians. Right here, in California law, is an embodiment of that trust in physicians. This morning, Tony spoke about the elements of informed consent, which I have reproduced here. I want to make the important point that the state statutes recognize the PHYSICIAN as the person RESPONSIBLE for informing about, and obtaining consent for, the use of psychoactive drugs in nursing homes. State statutes codify the physician’s centrality .
As Tony also referenced this morning, the state requires nursing home staff to verify documentation of informed consent. As of THIS YEAR , the state has been more strictly enforcing this requirement, most especially for psychoactive drugs that are first ordered in acute hospitals, before patients are admitted to nursing homes. I applaud the state’s shift in enforcement. So far, the shift in enforcement appears to have caught many hospital physicians by surprise. Many nursing home doctors also are surprised. Many doctors believe, even today, that a nurse or social worker can and should obtain informed consent for psychoactive drugs. But, we know from a review of the laws today that, in fact, informed consent is the responsibility of the PHYSICIAN. I look forward to state enforcement of this requirement as a means by which some physicians will come to learn that they are responsible for obtaining informed consent for psychoactive medications.
Now let’s look at the federal requirements. Let’s pay close, strict attention to the language here. The law provides residents a RIGHT to be free from drugs administered for CONVENIENCE. Let ’s look closely at the definition of convenience. Pay careful attention : LESSER is a comparative. It requires a comparison. You can’t know LESSER without a referent. LESSER effort becomes apparent only when compared to MORE effort. Every case is different, of course, but I think that we can all make educated guesses about what MORE effort entails, especially after learning about some of the treatment options offered by The Beatitudes in Phoenix. Furthermore, the Guidelines to Surveyors for this F-tag state unambiguously that “behavioral symptoms…should not be “covered up” with sedating drugs.” To me, the clear intention of the law here is to ensure that drugs aren ’t being administered just because it’s easier to prescribe and administer drugs, than to engage in other, presumably more effortful, interventions.
So here’s an example, to make the point clearly. This example is, in my experience, extremely common. We will discuss three of these cases in detail in my afternoon breakout session. Within hours of admission to a nursing home, psychoactive drugs routinely are administered in response to resident behaviors. Namely, yelling, screaming, and attempts to exit the facility. Now let’s go back and look at the language of the federal requirements with this example in mind. To me, the law is clear that the drugs should not be administered just to “cover up” behaviors like yelling. Or just because administering drugs is the easiest, most convenient thing to do. And, for those who might be thinking that a diagnosis of schizophrenia suffices, or that a doctor ’s order suffices, the Guidelines to Surveyors on this point are clear: “ Justifying drug use “solely on the basis of the doctor ordered it” “would render the regulation meaningless. The rationale [for drug use] must be based on sound risk-benefit analysis of the resident’s symptoms and potential adverse effects of the drug.” Which points us back again to the intention of the regulation: ensuring that we providers do not chemically restrain residents because it ’s the easiest thing to do.
But wait. There’s more. The federal requirements go further. The requirements explicitly state that resident’s must not be given unnecessary drugs. Namely, no resident should be given a psychoactive drug without adequate indication for use. As we’ve already learned, the indication for use cannot merely be facility convenience. Convenience is barred by the resident’s RIGHT to be free from psychoactive drugs if the reason for administering psychoactive drugs is that it requires LESSER effort from the facility. Again, the language here seems to me to be unambiguous: if drugging requires lesser effort, then non-drugging is by definition MORE effort. And therefore non-drugging interventions must logically come first. Now at The Beatitudes, they try non-drug interventions first. As such, I believe that the Beatitudes is in fact carrying out the true intent of the federal requirements. And I think the outcomes at The Beatitudes, where 8% of residents are administered psychoactive drugs, speak to what can be expected if the intent of the regulations is implemented with care and attention.
I read the federal requirements and I think to myself, “These regulations are almost bulletproof.” Remember the old TV ads for Master locks? They would shoot a bullet at the lock, and the lock would hold? I like to think of the federal requirements like a trusty Master lock. They are bulletproof. They are well-thought out. They are lengthy and rigorous. They go on for pages and pages and pages. Uses for anti-psychotics are narrowly limited to 11 specific conditions. The requirements are buttressed by science. They are an example of smart, scientifically-supported government regulations. I have to say, as a professional, and as an administrator, I ’m impressed.
I thought of the federal requirements when I recently watched the Steve Martin movie “The Man with Two Brains.” There’s a scene in the movie wherein Steve Martin’s character is pulled over by a police officer in a fictional foreign nation. He is asked to get out of the car, and is given a drunk test.
Extending the analogy, the state and federal requirements in combination, are akin to a “hard” drunk test that is only infrequently given.
Why are is this hard drunk test given only infrequently? Perhaps it is because the regulators are told in their Guidelines to Surveyors, with disclaiming language, that these 23 pages of interpretive guidelines are “NOT MEANT TO CAST A NEGATIVE LIGHT ON THE USE OF DRUGS” in nursing homes. To me, that’s interesting and contradictory language. I can see how this disclaiming language might confuse regulators. This language confuses me. To me, it would be like a disclaimer in a police manual on conducting sobriety tests in the field that concludes with the statement: “ It is important to note that field sobriety tests are not meant to case a negative light on the use of alcohol while driving.” And so, we look around, and see that despite robust regulations, many, many, many nursing home residents are being administered psychoactive drugs.
But I do not mean to imply that psychoactive drug use in nursing homes is merely a matter of the regulations needing to be enforced more strictly. No. While regulatory enforcement is part of the story, it’s not the whole story. Remember, We are embedded in a pill-popping culture And residents and responsible parties trust the doctors who prescribe these drugs. And so, while regulators appear to have been given an implicit green light to allow nursing homes to administer psychoactive drugs to residents, even when the regulations specify that drugs are a last option…. MANY factors feed into the operational reality that it is as easy to administer psychoactive drugs to nursing home residents as it is to administer aspirin to those same residents. Or, to say it in even clearer language: (quote above)
So here is what happen in California’s skilled nursing facilities, in my experience. And, if you are a provider, probably in your experience. And, if you are a regulator, it is probably your experience, too.
And so, psychoactive drugs are easily being administered in California nursing homes. And, for the most part, for reasons I’ve already discussed—namely a pill-popping culture that trusts the physician who prescribe those pills—there is a perception that nursing home residents are not being UNNECESSARILY drugged. That perception is borne out when you look at the number of unnecessary drug citations issued to CA nsg homes. Clearly, the hard drunk test is not being administered Only 2 of 133 citations referenced here were for unnecessary drugs.
I am sensitive to and respectful of the Department of Public Health’s mission, but clearly, what’s important to CDPH is abuse, neglect, and accidents. If we are judged by our record, then CDPH’s record is clearly a record of citing facilities for abuse, neglect, and accidents. And I salute and applaud that important work. Thank you Department of Public Health, for all your good work. So we see that psychoactive drugs are not front burner issues. They’re just not. Hopefully our gathering here today signals a shift in priorities. A shift toward treating unnecessary drugs as a front-burner issue. All of us must signal this shift in priorities—providers, physicians, regulators, residents and their families, and the media.
So how do we make psychoactive drug use a front-burner issue? How do we make people care about this issue? How do we shift the dialogue so that nursing home residents and their families start to comprehend that there is good reason to be cautious about the administration of psychoactive drugs? How do we change the perception that psychoactive drugs, instead of being beneficial medicinal agents, in fact may CAUSE HARM? Significant, long-lasting harm? How do we get the regulators to be clear in their minds that it is important and necessary to enforce these regulations? FIRST , we get educated about the long-term impact of these psychoactive drugs. Our presence here today in that regard is, to me at least, exciting. We are here to get educated. And I am here to tell you about a book that opened MY eyes to the LONG TERM impact of psychoactive drugs.
In short, Robert Whitaker has taught me more than any other person that psychoactive drugs damage the brain and make long-term outcomes worse. Psychoactive drugs induce brain pathology. They alter brain chemistry, by changing receptor sensitivity and receptor density.
Whitaker tells us that psychoactive drugs are harmful in the long term. Even so, we have witnessed a rapid increase in the use of psychoactive drugs in this country over the past 25 to 60 years. It is not just in the nursing home that we are seeing increasing use of psychoactive drugs. Psychoactive drug use is increasing exponentially in the population at large, including in children.
But here’s the big question : if psychoactive drugs work so well, then why have we witnessed over the past 55 years an explosion in mental illness in this country? Despite all the drugs for schizophrenia, bipolar illness, and depression, why are things worse? Much, much, much worse? This slide may be the most important slide in my presentation today. It tells the story of increasing mental illness during a time period when psychoactive drug use in this country exploded. It tells the story, basically, of how psychoactive drugs are themselves fueling an EPIDEMIC of mental illness in this country. Recall, Whitaker’s book is entitled “Anatomy of an Epidemic.” In my view, this is big news. And it is my belief that the persons who MOST need to know about the scientific data regarding long-term use of psychoactive drugs are PHYSICIANS.
I believe that we advocates, we providers, must assist in educating physicians. Because physicians are held in such high regard by patients, their families, regulators and the media (for the most part), we must assist in educating physicians that psychoactive drugs in the long term cause aggregate harm. As such, I am going to propose today, that as one concrete outcome of this symposium today, we pledge to snail mail a copy of Whitaker’s book to the medical director of every one of California ‘s 1,200 nursing homes.
I estimate that this effort will cost no more than about $15,000. It may cost less. There is a foundation that has been created to foster dissemination of Anatomy of an Epidemic. We are working with that foundation. As a first step in this process, I pledged $1,000 toward the effort, back in March, when we conducted a similar symposium in Oxnard, California. I encourage others here to think about making pledges toward this project. The Ventura County Ombudsman is coordinating this effort. We have already sent out the first 100 books.
Robert Whitaker is not the only voice on the matter of psychoactive drugs. Many, many others, including highly-credentialed researchers, are studying the impact of these drugs—most especially anti-psychotics. Their research studies are increasingly highlighting the dangers of these drugs. Here are just a few of these studies, referenced in a recent presentation given by Dr. Jonathan Evans, the incoming president of the AMDA.
So let’s say every medical director of every nursing home in California read Whitaker’s book. What would happen after that? How would nursing home practices change? Well, I think we’d see physicians hesitate to use drugs as a first resort. We’d see doctors start to think in terms of a “least medicating” approach. And, as I hope I’ve been able to explain today, this “least medicating” approach complies with long-established state and federal regulations.
But beyond educating physicians, we must engage our regulators to utilize existing regulations to help us reduce unnecessary drug use in nursing homes. And we advocates deeply appreciate the presence here today of many regulators. Your presence signals a willingness to listen, and an openness to engagement. Your work is valuable, and valued, and we can move this movement forward only in collaboration WITH you.
We must also develop non-medicating approaches in nursing homes. Providers like me are hungry for better treatment options. We want to know how to best serve our residents. We want to know what we can do before administering psychoactive drugs to our residents. And so, while I’d also like to propose that we fly every single one of us to visit Tena Alonzo’s nursing home in Phoenix, to see in person what she and her team are doing there, financial realities suggest that we’re going to have to invite Tena to come to us, as she did today, to teach us, and inspire us, and motivate us to do better by our residents. In turn, we’re going to have to become trainers ourselves, in non-medicating approaches.
To the providers in the audience, I can imagine that you are thinking what I have been thinking for most of my career: “But these drugs work! They really do!” Sure they may work. Especially in the short term. But Whitaker and others have taught me that, in the long term, these drugs in fact harm our elders, at least in the aggregate. We nursing home providers also know that families in general are in support of administering psychoactive drugs to their loved ones. But in light of the available scientific evidence, we now must educate ourselves so that, in turn, we can educate our residents and their families that, in keeping with long-standing nursing home regulations, psychoactive drugs should be a LAST RESORT option, not a first resort option.
Because I have been a provider myself for the past 14 years, I want to make sure that the providers are recognized today, by me, for the work they do each day. We are the ones who provide the care when the families no longer can. We are the ones who must deal with dangerous behaviors, and protect the health and safety of EVERYONE in the facility. We are the ones who must come up with real-time solutions to real-tough situations. We are the ones who don’t have in their toolkit the resources for 1:1 caregivers.
And so we must support the providers. We’ve got to come up with realistic and financially viable alternative approaches that providers can implement. Which is why it has been so valuable and important for us to listen to and learn from Tena Alonzo today. She provides us with realistic and financially viable alternative approaches that not only CAN be implemented, but ARE being implemented even today.
We must also support and help ourselves. We must take affirmative steps to turn the tide against administering drugs to our residents for convenience. We must be compassionate with ourselves, and patient, as we attempt to change processes that favor pill popping. Administering drugs is “the way things are”; don’t be surprised if you can’t change the way things are overnight. But we should get educated, and educate others. We should find out how we’re doing on informed consent, and on administering drugs as a first resort, rather than a last resort.
And so, to recap my main points.
Sadly, the story about psychoactive drug use in children eerily parallels the use of psychoactive drugs in adults and elders. There has been an exponential increase not only in the use of psychoactive drugs.
There has also been an exponential increase in the number of psychiatrically disabled children.
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