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Prescription Medication Misuse Screening and Mitigation

Prescription Medication Misuse Screening and Mitigation

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Prescription Medication Misuse Screening and Mitigation. Learning Objectives. Recognize the risk factors and patient risk categories for medication misuse Determine which tools to use to screen for medication misuse Identify strategies for mitigating a patient’s risk for medication misuse - PowerPoint PPT Presentation

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Prescription Medication Misuse: Screening and Mitigation

Prescription Medication Misuse Screening and Mitigation

This is a lecture on how to screen a patient for the risk of medication misuse and how to mitigate their risk.

Learning ObjectivesRecognize the risk factors and patient risk categories for medication misuseDetermine which tools to use to screen for medication misuseIdentify strategies for mitigating a patients risk for medication misuseDescribe patient centered drug testing and how it differs from employer directed drug testingPrescription Medication Misuse DefinitionTaking medications for non-intended uses, differently than prescribed, without a prescription or with interacting substances.

Medication misuse is taking a drug for something it wasnt intended for, taking more of a drug or taking it more frequently than prescribed, using it without a prescription or taking it with interacting substances.

Screening for PMM Risk AssessmentRisk factors for PMMUseful for risk stratifying patients Screening toolsWays to assess risk objectivelyPatient risk categories

In order to screen a patient for the risk of medication misuse, providers can look for several identified risk factors. Alternatively, there are several developed screening tools that can be used. The overall goal of screening is to determine what category of risk they should be grouped into to determine the level of intervention necessary.

Risk Factors for MisuseIllicit drug usePrevious substance use issuesHistory of substance abuse (particularly multi-substance)Positive abnormal urine drug screen previously (unexpected positive)History of DUI/DWIFamily history of drug abusePsychiatric Dysfunction PTSDDepressionAnxiety disorderSchizophreniaYounger age (less than 30, greater when less than 25)History of physical, emotional, or sexual abuseSmokingChronic pain

This is a list of the identified risk factors for medication misuse.

Odds Ratios for PMMHistory of nonopioid abuse2.34 (1.75-3.14)History of Alcohol abuse2.6 (1.12-6.26)History of Cocaine abuse4.3 (1.76-10.4)Smoking1.4 (1.1-1.8)DUI or drug conviction2.58 (1.01-6.59)Probable Depression2.4 (1.6-3.4)Mood disorder 3.5 (3.1-3.9)MDD3.2 (2.9-3.6)Bipolar disorder, type I4.7 (3.8-5.7)Anxiety disorder2.4 (2.2-2.8)PTSD2.45 (1.88-3.19)Chronic Pain1.9 (1.4-2.5)Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007;129:355-62.Ives TJ, Chelminski PR, Hammett-Stabler CA, Malone RM, Perhac JS, Potisek NM, Shilliday BB, DeWalt DA, Pignone MP. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46.Becker W, Fiellin D, Gallagher R, Barth K, Ross J, Oslin D. The association between chronic pain and prescription drug abuse in Veterans. Pain Medicine 2009; 10: 531-536.Martins S, Keyes K, Storr C, Zhu H, Chilcoat H. Pathways between nonmedical opioid use/dependence and psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions Drug and Alcohol Dependence. 2009: 1624.White AG, Birnbaum HG, Shiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Manag Care. 2009; 15: 897-906.

No audio present on this slide.

Risk Factors Limited Supporting EvidenceMostly based on studies of pain clinic patientsFollowed for opioid misuseSmall, limited studiesNot specific to Service MembersLimited conclusions, but the best available to project to other patients and other medications

One major limitation to those risk factors is that they were identified in chronic pain patients who were already treated with opioids and followed in a chronic pain clinic.

Screening Tools for PMMScreening for future misuse, predicative toolsSOAPP-ROpioid Risk ToolTools for screening for current misusePDUQPhysician administeredSelf report versionCOMMTailored history by a clinician

There are two groups of screening tools developed for medication misuse. The first group is for predicting who will misuse a medication in the future. The second group is to screen for current misuse.

Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R)Self report survey 24 questionsEach question scored 0-4 Score of 19 sensitivity 0.77 specificity 0.75 positive predictive value 0.62 negative predictive value 0.86.Butler S, Fernandez K, Benoit C, Budman S, and Jamison R. Validation of the Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R) The Journal of Pain, Vol 9, No 4 (April), 2008: pp 360-372Available for reprint for clinical use at PAIN.eduResearch use requires permission

The SOAPP-R is a well validated tool used to screen patients for their risk for misuse prior to starting them on an opioid. It is a 24 question self report survey that asks about most of the previously mentioned risk factors and also about several behavior patterns seen in misusers, like seeking early refills.

Opioid Risk ToolSelf report tool10 questions, maximum score of 26 (questions weighted differently based on predictive value)Score 8 is high riskPositive likelihood ratio 14.1, CI 5.35-38.4Score 3 is low riskPositive likelihood ratio 0.08, CI 0.01-0.62Less extensively evaluated

The Opioid Risk Tool or ORT is another self report survey. It focused on the most predictive risk factors for PMM and weighted them differently. It is less well validated than the SOAPP-R, but it is just another example of the many screening tools that are available.

Direct Comparison of Screening Tools for Future MisuseClinical history focusing on risk factors - sensitivity of 0.77 SOAPP-R 0.72ORT 0.45 Moore TM, Jones T, Browder J, Daffron S, and Passik SD. A Comparison of Common Screening Methods for Predicting Aberrant Drug-Related Behavior among Patients Receiving Opioids for Chronic Pain Management. Pain Medicine 2009; 10: (8) 1426-1433

In a direct comparison, a focused clinician history targeting risk factors for PMM was superior to both a SOAPP-R and the ORT.

Clinician Focused HistoryClinical history focusing on risk factors - sensitivity of 0.77Superior to self report screening toolsFocused on risk factors and comorbid disordersWhen combined with SOAPP-R sensitivity was 0.90Moore TM, Jones T, Browder J, Daffron S, and Passik SD. A Comparison of Common Screening Methods for Predicting Aberrant Drug-Related Behavior among Patients Receiving Opioids for Chronic Pain Management. Pain Medicine 2009; 10: (8) 1426-1433

A focused history was even more powerful when combined with a SOAPP-R.

Tools to Screen for Current MisusePDUQCOMMAll tools for this purpose targeted patients already prescribed frequently misused medications no study in the general population

Next we are going to discuss the two best described tools for screening patients currently receiving a prescription for an opioid for misuse.Unfortunately, they are only designed to screen patients who receive a prescription, which is a major limitation because the majority of misuse appears to occur through diversion rather than with a prescription.

Patient Drug Use Questionnaire(PDUQ)Clinician administered42 questions39 scoredA yes is scored as a one and a no as a zero Non addicted people scored less than 10 Substance abusers scored between 11 and 25 Substance addicted patients scored 15 or higher 15 or more is indicative of problematic behavior 10 or less is a safe score Compton P, Darakjian J, Miotto K. Screening for Addiction in Patients with Chronic Pain and Problematic Substance Use: Evaluation of a Pilot Assessment Tool. Journal of Pain and Symptom Management 1998; 16: 355

The PDUQ is a forty two question interview performed by a provider. It focuses on risk factors and aberrant behaviors. It is considered the gold standard of screening tools.

PDUQFor diagnosing CURRENT drug misuse Gold standardCertain questions more indicativeSelf report form less effectiveNo audio present on this slidePDUQ Most Predictive PointsPatient believes he/she addictedPhysician believes patient is addicted Multiple prescription providers Increases analgesic dose/frequency Early prescription refills Use analgesics for other symptoms Save/hoard unused medicationSupplement with alcohol/psychoactive drugs Prescription forgeryPatient has a route of administration preference Emergency room visits for analgesicsObtained analgesic from street source MD/DDS limited care Family believes patient addicted Family interaction sustaining patient analgesic use All of the above had a P