Medication Abuse Handouts by Rand L. Kannenberg

MEDICATION ABUSE:MEDICATION ABUSE:

Over-the-Counter & Prescription Over-the-Counter & Prescription Drug Abuse & Drug Abuse &

DependenceDependence

Rand L. Kannenberg, M.A., LAC, CCM, CCS

Table of ContentsDedication iAcknowledgements iiOTC and prescription drug statistics in the U.S. 1About the Presenter 2Program Description 3Objectives 4Agenda and Outline 5Schedules of controlled substances with accepted medical use 6Opioids and morphine derivatives 7-13Video #1 “Opioids” 14Opioids and sleep disordered breathing syndromes 15CNS depressants 16-

18Video #2 “Benzos” 19Dissociative anesthetics 20Stimulants 21-

24Anabolic steroids 25Cold and cough medications 26Video #3 “DXM” 27Weight loss pills 28-29Sleeping aids 30Online or e-pharmacies 31-

32Minors ordering on the Internet 33Street use 34“Pill mills” 35Identifying drug-seeking patients 36Case Study 1 37Case Study 2 38“Opiophobia” (underprescribing painkillers) 39Characteristics of overprescribing physicians 40How to approach physicians with concerns 41Types of fraudulent prescriptions 42Characteristics of forged prescriptions 43Other warning signs 44

Prescription fraud prevention techniques 45How to destroy unwanted medications 46Reasons for drug testing 47Types of drug testing 48Detection periods 49Alternatives to controlled drugs for anxiety 50Alternatives to controlled drugs for insomnia 51Alternatives to controlled drugs for ADHD 52Alternatives to controlled drugs for pain 53Suboxone versus Methadone or LAAM 54Warning signs of impaired professionals 55Guidelines for writing prescriptions 56Do these three things when writing prescriptions 57“Clinical Sobriety Checklist” (CSC)™ for medications 58Prescription drug interview questions 59-60CAGE questionnaire for prescription drugs 61Drug addiction test 62-66Substance dependence screening 67Substance abuse screening 68Substance intoxication effects 69-71Benzodiazepine withdrawal symptom questionnaire 72Clinical Opiate Withdrawal Scale (with example pictures) 73-87Stimulant withdrawal checklist 88Inpatient medical detoxification criteria checklists 89-91Social detoxification criteria 92Outpatient/home detoxification options 93-95Rapid detoxification 96The “4 Ds” of quitting medications 97Relapse prevention exercises 98-99Goal setting exercises 100-

101“National Medicine Abuse Awareness Month” 102References 103-

106

i

Dedication

Jay Balchunas

Task Force Officer January 18, 1970 - November 5, 2004

“On October 29, 2004, Task Force Officer John “Jay” Balchunas was fatally wounded in Milwaukee, Wisconsin. He died from his injuries on

November 5, 2004. Officer Balchunas was conducting surveillance as part of the Department of Justice/FBI Fall Threat Initiative prior to the

national elections.

Task Force Officer Balchunas was employed as a Narcotics Bureau Special Agent within the State of Wisconsin, Division of Criminal Investigation

(DCI). Prior to joining the State DCI, Task Force Officer Balchunas worked as a Milwaukee Police Officer for seven years and a Marquette

University Public Safety Officer before that. Additionally, Task Force Officer Balchunas was a dedicated Volunteer Firefighter with the New

Berlin Fire Department, achieving the rank of Lieutenant.

On the evening of October 29th, while walking to his car, Task Force Officer Balchunas was accosted by two assailants. A struggle ensued and one of the assailants shot Officer Balchunas in the abdomen. He underwent

several surgeries before succumbing to his injuries on November 5, 2004. Task Force Officer Balchunas was engaged to be married in the fall of 2005 and is survived by his fiancée, Luann Vogel, his parents,

Don and Mary Kay, his brother Dan, and his sister, Linda.”

DEA

ii

Acknowledgements

I would like to thank my new employers and friends in the field of medical education/professional development for their incredible support and

encouragement and in our respective personal lives as we attempt to end the pain and suffering of patients, clients and other people across the

country:

Tristan Colonna, President of MEDS-PDN

from Eau Claire, Wisconsin;and

Kristine Scheel, Program Planner of MEDS-PDN

from Waukesha, Wisconsin.

Thanks also to my eldest daughter,

Corrie Kannenberg University of Colorado at Boulder

for editing and proofreading this, my sixteenth seminar manual since I first started speaking on addiction in 1995.

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Statistics• Non-medical use of prescription medications ranks second only

behind marijuana in terms of illicit drug use in the U.S.

• Approximately 15 million Americans report using a prescription drug for non-medical reasons at least once a year.

• An estimated 48 million people 12 and older (20% of the population) have used prescription drugs for non-medical reasons at least once in their lifetimes.

• Nearly 14% of adolescents and more than 17% of adults over 60 have abused prescription drugs.

• 10% of teenagers ages 12-17 have abused cough medicine to get high.

• The number of first time misusers of tranquilizers went up nearly 50%.

• ER visits related to abusing pain killers alone have increased almost 165%.

• 5.2 million persons are nonmedical users of prescription pain killers.

• Among 12th graders, 9.5% have used Vicodin® and 5.0% have used OxyContin® without a prescription the past year.

• 55.7% of misusers of pain relievers report that they obtain them from a friend or relative for free.

Office of National Drug Control Policy (ONDCP) National Institute on Drug Abuse (NIDA)

The Partnership for a Drug-Free America™National Survey on Drug Use and Health (NSDUH)

Substance Abuse and Mental Health Services Administration (SAMHSA)

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About the PresenterRand Kannenberg has been the Executive Director of Criminal Justice

Addiction Services in Lakewood, Colorado since 1995. Additionally, he is a credentialed consultant with physicians in the emergency department and on the medical units at a Denver area medical center where he serves as the addiction preceptor. Mr. Kannenberg has provided nearly 400 substance abuse and corrections advanced-level training and continuing education workshops in 44 states as well as Italy, Puerto Rico and South Africa. In addition to speaking at seminars and other educational events, he has a private clinical practice specializing in forensic drug and alcohol assessments. Mr. Kannenberg is a Licensed Addiction Counselor, a Certified Case Manager, and an approved education provider by both NBCC and NAADAC.

Mr. Kannenberg is a Public Health Champion of the Year recipient as well as a Distinguished Career Award nominee. He has authored Sociotherapy for Sociopaths in 2003 and Case Management Handbook for Clinicians in 2004. NAADAC News’ reviews of these publications included, “Kannenberg’s fresh approach to treating psychoactive chemical abusing sociopaths should be in every counselor’s arsenal when treating a client of this nature,” and “Even if new to the profession or a seasoned veteran, this book is a helpful resource to all addiction counselors…An Addiction treatment facility’s library is not complete without the book.” Mr. Kannenberg and his work has been featured in numerous scholarly journals, academic and scientific research papers and reports, as well as in the local and national news media. CBS stated that his program is “credited with reducing the number of repeat drug offenders in three states.” Both ABC and NBC referred to him as an expert. And The Denver Business Journal reported, “Rand Kannenberg is a Licensed Addiction Counselor who gets called into the hospital when patients arrive with drug problems.”

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Program Description

• Recognize the three classes of commonly abused prescribed medications.

• Cite the three over-the-counter drugs used for non medical reasons.

• Name the three ways to identify and prevent drug-seeking patients.

• Take home three instruments for screening medication abuse and dependence.

• Take home three tools for the assessment and evaluation of medication withdrawal.

• Take home three clinical exercises for drug free goal setting and relapse prevention.

4

Objectives• List the most commonly abused

prescription and over-the-counter drugs

• Describe effective prevention techniques for the different types of fraudulent and forged prescriptions

• Describe the warning signs of health care workers and other professionals impaired by medications

• Summarize the alternatives to controlled drugs to treat various medical and psychological problems

• Identify and explain the differences between medication abuse and medication dependence

• Describe the effects of medication intoxication and how to administer written scales for withdrawal

At the end of this seminar the participant will be able to:

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Agenda & OutlinePart I

Social Implications: Community and Professionals

Part II

Clinical Strategies: Assessment and

Treatment

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Schedule II.(A) The drug or other substance has a high potential for abuse.

(B) The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with

severe restrictions.(C) Abuse of the drug or other substances may lead to severe psychological

or physical dependence.Schedule III.

(A) The drug or other substance has a potential for abuse less than the drugs or other substances in schedules I and II.

(B) The drug or other substance has a currently accepted medical use in treatment in the United States.

(C) Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence.

Schedule IV.(A) The drug or other substance has a low potential for abuse relative to the

drugs or other substances in schedule III.(B) The drug or other substance has a currently accepted medical use in

treatment in the United States.(C) Abuse of the drug or other substance may lead to limited physical

dependence or psychological dependence relative to the drugs or other substances in schedule III.

Schedule V.(A) The drug or other substance has a low potential for abuse relative to the

drugs or other substances in schedule IV.(B) The drug or other substance has a currently accepted medical use in

treatment in the United States.(C) Abuse of the drug or other substance may lead to limited physical

dependence or psychological dependence relative to the drugs or other substances in schedule IV.

U.S. Drug Enforcement Administration (DEA)

Schedules of controlled substances

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Opioids & morphine derivatives

hydrocodone(Schedules II, III, V)

Examples Hydrocodone with Acetaminophen, Vicodin®, Vicoprofen®,

Tussionex®, Lortab®, Tussend®, Hycodan®, Anexsia®

Nicknamesvike, Watson-387

Route of Administrationswallowed

Desired Outcomespain relief, euphoria

Adverse Reactionsdrowsiness, nausea, constipation, confusion, sedation, respiratory arrest,

unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death

National Institute on Drug Abuse (NIDA)


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oxycodone(Schedule II)

ExamplesRoxicet®, Oxycodone with Acetaminophen, OxyContin®, Endocet®,

Percocet®, Percodan®, Tylox®, Roxicodone®

NicknamesOxy, O.C., killer

Route of Administrationswallowed, snorted, injected






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codeine(Schedules II, III, V)

ExamplesEmpirin® with Codeine, Fiorinal® with Codeine, Fioricet® with Codeine,

Robitussin A-C®, Acetaminophen, Guaifenesin or Promethazine (Phenergan®) with Codeine, Tylenol® with Codeine, morphine methyl

ester, methyl morphine, Didrate® and Parzone® (dihydrocodeine), Papaverine® and Noscapine® (Codeine and Isoquinoline Alkaloid),

Cosanyl®, Cheracol®, Cerose®, Pediacof®

NicknamesCaptain Cody, schoolboy

Route of Administrationinjected, swallowed




National Institute on Drug Abuse (NIDA)U.S. Drug Enforcement Administration (DEA)

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morphine(Schedules II, III)

ExamplesDuramorph®, MS-Contin®, Roxanol®, Oramorph SR®, RMS®

NicknamesM, Miss Emma, monkey, white stuff

Route of Administrationinjected, swallowed, smoked






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hydro-morphone(Schedule II)

ExamplesDilaudid®, dihydromorphinone

Nicknames Dust, Juice, Smack, D, Footballs

Route of Administrationswallowed, injected






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opium(Schedules II, III, V)

Exampleslaudanum, paregoric, papaver somniferum,

extracts/fluid/poppy/tincture/granulated/powdered/raw, Parepectolin®, Kapectolin PG®, Kaolin®, Pectin P.G.®

Nicknamesbig O, black stuff, block, gum, hop

Route of Administrationswallowed, smoked






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other narcotics(Schedules II, III, IV)

ExamplesActiq®, Duragesic®, Sublimaze®, Fentanyl®, Demerol®, methadone, Darvon®,

Darvocet®, Stadol®, Talwin®, Paregoric®, Buprenex®, propoxyphene, Propacet®, Innovar®, Mepergan®, pethidine

NicknamesApache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8,

TNT, Tango and Cash

Route of Administrationswallowed, injected, smoked, snorted






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Video #1“Opioids”

(3 minutes & 8 seconds)

“Prescription Drugs: Killing More Than Pain”

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75% of chronic pain patients taking daily opioids have “sleep disordered breathing syndromes”

obstructive sleep apnea (loud snoring usually related to obesity and other health problems)

central sleep apnea (breathing stops during sleep)

Versus estimates of only 2% to 5% observed in general population.

Suggests:1.) Opioids impact brain control of respirations and breath size; and2.) Chronic pain patients taking daily opioids have “higher risk of morbidity and mortality”

Pain Medicine

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CNS depressants

barbiturates(Schedules II, III, IV)

Examples(methohexital) Brevital®, (thiamyl) Surital®, (thiopental) Pentothal®,

(amobarbital) Amyta®, (pentobarbital) Nembutal®, (secobarbital) Seconal®, (amobarbital/secobarbital) Tuinal®, (butalbital) Fiorina®, (butabarbital) Butisol®, (talbutal) Lotusate®, (aprobarbital) Alurate®,

(phenobarbital) Luminal®, (mephobarbital) Mebaral®

Nicknamesbarbs, reds, red birds, phennies, tooies, yellows, yellow jackets

Route of Administrationinjected, swallowed

Desired Outcomesreduced pain and anxiety; feeling of well-being; lowered inhibitions

Adverse Reactionsslowed pulse and breathing, lowered blood pressure, poor

concentration/fatigue, confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, sedation, drowsiness/depression,

unusual excitement, fever, irritability, poor judgment, slurred speech, dizziness, life-threatening withdrawal



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CNS depressants

benzodiazepines(Schedule IV)

Examples(estazolam) ProSom®, (flurazepam) Dalmane®, (temazepam) Restoril®, (triazolam)

Halcion®, (midazolam) Versed®, (alprazolam) Xanax®, (chlordiazepoxide) Librium®, (clorazepate) Tranxene®, (diazepam) Valium®, (halazepam) Paxipam®,

(lorazepam) Ativan®, (oxazepam) Serax®, (prazepam) Centrax®, (quazepam) Doral®, (clonazepam) Klonopin®

Nicknamescandy, downers, sleeping pills, tranks

Route of Administration injected, swallowed

Desired Outcomesreduced pain and anxiety, feeling of well being, lowered inhibitions

Adverse Reactionsslowed pulse and breathing, lowered blood pressure, poor concentration/fatigue,

confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, sedation, drowsiness/dizziness,

life-threatening withdrawal


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CNS depressants

flunitrazepamExample

Rohypnol (only manufactured and sold legally in Latin America and Europe)

Nicknamesforget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies

Route of Administrationinjected, swallowed, snorted

Desired Outcomesreduced pain and anxiety; feeling of well-being; lowered inhibitions

Adverse Reactionsslowed pulse and breathing, lowered blood pressure, poor concentration/fatigue,

confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, visual and gastrointestinal disturbances, urinary retention, memory

loss for the time under the drug's effects, associated with sexual assaults

National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)

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Video #2“Benzos”

(2 minutes & 46 seconds)

“Prescription Drugs: Killing More Than Pain”

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Dissociative anesthetics

Ketamine(Schedule III)

ExamplesKetalar®, Ketalar SV®, Ketaset®, Vetalar®, Vetaket®

Nicknamescat Valium, K, Special K, vitamin K, jet, super acid, green

Route of Administrationinjected, snorted, smoked

Desired Outcomes"K-Hole," an "out of body," or "near-death" experience

Adverse Reactionsincreased heart rate and blood pressure, impaired motor function, numbness,

nausea/vomiting, delirium, depression, respiratory depression and arrest, amnesia, long-term memory and cognitive difficulties, used as a date-rape

drug



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Stimulants

amphetamines(Schedule II)

ExamplesAdderall®, Adderall XR®, Dexedrine®, Dextrostat®, Biphetamine®,

Durophet®, Obetrol®

Nicknamesbennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers,

uppers

Route of Administrationswallowed, snorted, injected, smoked

Desired Outcomesawake, alert, active, aware, appetite suppression, energy, euphoria,

excitement, enthusiasm, enhancement of the senses

Adverse Reactionshallucinations, delusions, picking at the skin, preoccupation with one's own

thoughts, violent and erratic behavior, increased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight loss, heart

failure, nervousness, insomnia, rapid breathing, tremors, loss of coordination; irritability, anxiousness, restlessness, delirium, panic,

impulsive behavior

Criminal Justice Addiction Services



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Stimulants

cocaine(Schedule II)

ExamplesCocaine hydrochloride

Nicknamesblow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot


Desired Outcomesawake, alert, active, aware, appetite suppression, energy, euphoria,

excitement, enthusiasm, enhancement of the senses

Adverse Reactionsdysphoric crash, death from respiratory failure, strokes, heart failure,

increased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight loss, nervousness, insomnia, increased

temperature, chest pain, nausea, abdominal pain, seizures, headaches, malnutrition, panic attacks




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Stimulantsmethamphetamine(Schedule II)

ExampleDesoxyn®

Nicknameschalk, crank, crystal, fire, glass, go fast, ice, meth, speed


Desired Outcomesawake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm,

enhancement of the senses

Adverse Reactions inability to sleep, loss of appetite and weight, thin/gaunt, increased sensitivity to noise,

agitation, restlessness, irritability, aggressiveness, dizziness, confusion, impaired judgment, diarrhea and gastrointestinal complaints, difficulty breathing, headaches,

tremors or seizures, nausea and vomiting, numbness, profuse sweating, chills, muscle cramping, pain and tenderness, dehydration, low magnesium level, low potassium level,

grossly dilated pupils, chest pain, increased or decreased heart rate, increased blood pressure, fever or hyperthermia, impaired speech and language, mania, psychosis with hallucinations and delusions, anxiety, panic, fear of impending doom, depression and

suicidal ideation, poor hygiene and body malodor, missing teeth, bleeding gums, infected gums, dental caries/decay/cavities, dry mouth, removed enamel, teeth grinding, skin

aging and damage, dryness, roughness, wrinkles, broken veins, dermatitis around the mouth, skin ulceration and infection, acne or sores, hair loss from repetitious pulling




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Stimulants

methylphenidate(Schedule II)

ExamplesRitalin®, Methylin®, Concerta®

NicknamesJIF, MPH, R-ball, Skippy, the smart drug, vitamin R

Route of Administrationswallowed, snorted, injected

Desired Outcomesawake, alert, active, aware, appetite suppression, energy, euphoria, excitement,

enthusiasm, enhancement of the senses

Adverse Reactionsincreased heart rate, high blood pressure, increased metabolism, irregular heart beat,

weight loss, heart failure, nervousness, insomnia




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Anabolic steroids(Schedule III)

Examples(oxymetholone) Anadrol®, (oxandrolone) Oxandrin®, (methandrostenolone) Durabolin®,

(stanozolol) Winstrol®, (testosterone cypionate) Depo-Testosterone®, (boldenone undecylenate) Equipoise®, (nandrolone decanoate)

Deca-Durabolin®, (nandrolone phenpropionate) Durabolin®

Nicknamesroids, juice, arnolds, gym candy, pumpers, cycling, stacking, pyramiding, weight trainers

Route of Administrationinjected, swallowed, applied to skin

Desired Outcomesno intoxication effects excluding a general sense of feeling good about self while taking

the medication(s), increased size and strength of muscles, improved appearance, improved endurance, and decrease recovery time between workouts

Adverse Reactionselevated blood pressure and cholesterol levels, severe acne, premature balding,

reduced sexual function, testicular atrophy in males, prostate cancer in males, reduced sperm production in males, abnormal breast development in males (gynecomastia), masculinizing effects in females (more body hair including

development of beard, deeper voice, smaller breasts, fewer menstrual cycles), enlargement of the clitoris in females, may prematurely stop the lengthening of bones resulting in stunted growth in adolescents, psychotic reactions, manic

episodes, feelings of anger or hostility, aggression, violent behavior, blood clotting, liver cysts and cancer, kidney cancer


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Dextromethorphan (DXM) Examples

Alka-Seltzer Plus Cold & Cough Medicine®, Coricidin HBP Cough and Cold®, Dayquil LiquiCaps®, Dimetapp DM®, Robitussin® cough products, Sudafed® cough products, Triaminic® cough syrups, Tylenol Cold® products,Vicks 44

Cough Relief® products, Vicks NyQil LiquiCaps®

NicknamesCandy, CCC, Dex, DM, Drex, DXM, Red Devils, Robo, Robo-fizzing (if mixed with

sodas or alcohol), Rojo, Skittles, Syrup, Triple-C, Tussin, Vitamin D


Desired Outcomesauditory and visual hallucinations, dissociation, euphoria, heightened perceptual

awareness, lethargy, mania, perceptual distortion

Adverse Reactionsabdominal pain, blurred vision, brain damage, confusion, death, dehydration,

disorientation, delusions, dizziness, double vision, drowsiness, dry mouth, dry skin, dysphoria, fever, flaky skin, flushing of face, headache, hot flashes,

impaired judgment, involuntary muscle movement, itchy skin, loss of consciousness, loss of physical coordination, memory problems, nausea,

numbness of fingers and toes, panic attacks, paranoia, poor mental performance, profuse sweating, rapid heart beat, rigid motor tone, seizures,

slurred speech, tremors, vomiting

Substance Abuse and Mental Health Services Administration (SAMHSA)The Partnership for a Drug-Free America™

Tennessee Association of Alcohol and Drug Abuse Services (TAADAS)Community Anti-Drug Coalitions of America


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Video #3“DXM”

(1minute & 50 seconds)

“The OTC: Battling the Over-the-Counter High”

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Weight loss pills

Examplesbitter orange, chitosan, chromium, conjugated linoleic acid (CLA), county mallow (heartleaf), ephedra, green tea extract, guar gum,

hoodia

Nicknamessame as above


Desired Outcomes decrease appetite, block absorption of dietary fat, reduce fat, build muscle, increase calorie and fat metabolism, increase the feeling of

fullness

Adverse Reactionsconstipation, bloating, diarrhea, indigestion, high blood pressure, heart rate irregularities, sleeplessness, seizures, heart attacks,

strokes, death, vomiting, flatulence

Mayo Clinic

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Alli 60 mg (over-the-counter, reportedly 85% as effective as Xenical 120 mg which has required a prescription since 1999 ).

Made by GlaxoSmithKline.

Made available in 2007.

Company advertising states that users may expect 50% more weight loss than by dieting alone (i.e., 15 pounds instead of 10 pounds).

Blocks the breakdown and absorption of fat in the intestine.

May cause diarrhea, loose oily stools and loss of bowel control when fatty foods are ingested.

New users are encouraged to wear dark pants and carry a change of underwear and other clothes with them when they first start taking Alli.

http://www.myalli.com/

http://images.google.com/imgres?imgurl=http://www.myalli.com/~/media/Images/myalli/header/hdrImgMainWhatisalli%2520jpg.ashx&imgrefurl=http://www.myalli.com/whatisalli.aspx&h=320&w=320&sz=16&hl=en&start=2&tbnid=4aiYeu_dEQWGCM:&tbnh=118&tbnw=118&prev=/images%3Fq%3Dmyalli%26gbv%3D2%26svnum%3D10%26hl%3Den

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Sleeping aids

Examples(doxylamine) Unisom® Sleeptabs™, (diphenhydramine) Benadryl®,

AllerMax®, Banophen®, Diphenhist®, Genahist®, (dimenhydrinate) Dramamine®, Calm-X®, Dimetabs®, Triptone®

Nicknamessleepers, downers, sleeping pills


Desired Outcomessleep

Adverse Reactionsagitation, nervousness, excitability, not able to sleep, blurred vision, dizziness or fainting spells, irregular heartbeat, palpitations, chest pain,

muscle or facial twitches, pain or difficulty passing urine, seizures, drowsiness, dizziness, dry mouth, headache, loss of appetite, stomach

upset, nausea, vomiting, diarrhea, constipation, confusion, restlessness, incoordination, ringing in the ears, persistent and unusual rash or hives, wheezing, weakness, reddening of the skin, sensitivity to

light

Drug Digest

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Online or e-pharmacies fax broadcasting/blasting

“individuals in need of prescription drugs…”

“without a doctor’s recommendation…”

“by simply answering a set of questions…”

“save time and money because you don’t have to go to your doctor and the pharmacy…”

“the cheapest prescription drugs on the Internet…”

“Ultram,Soma,

Fioricet,Prozac,Buspar,

are the different drugs that are included in our weekly specials…”

“90 quantity for $51.99 and $84.99 for 180 quantity…”

http://www.suremedlink.com

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http://www.suremedlink.com

http://www.suremedlink.com/products.php?id=19





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Minors ordering on the Internet

Web sites to watch for:www.erowid.orgwww.dextroverse.orgwww.lycaeum.orgwww.myspace.com/dextromethorphan

and many thousands of others!

Community Anti-Drug Coalitions of America

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Street use

“pharming”

(taking handfuls of known or unknown tablets, capsules, powders and syrups in one

sitting)


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“Pill mills”

(Internet pharmacies that provide controlled

substances illegally)

DEA uses web crawler/data mining technology to identify, investigate and prosecute these so-called "pill mills"

They are addressed in the “White House's National Drug Control Strategy Focuses on

Prescription Drug Safety”


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Identifying Drug-Seeking

Patients

Escalating use(a pattern of overuse or escalation of use by

the patient)

“Doctor shoppers”(patients who use at least two physicians,

frequent emergency departments, call or go in off hours on nights/weekends/holidays, and/or claim to be from “out of town”)

“Scams”(applying enough pressure that a physician

who initially says “no” to a medication or a refill eventually changes the answer to a “yes” because it’s easier to write the prescription than confronting the patient)

American Family Physician

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Case Study 1The client is a 33-year-old white and Native American Indian female

referred by her private probation officer for a court ordered substance abuse evaluation. She is on probation for two years for felony possession of a controlled substance (Vicodin®). She is also on probation in another county for two years for felony prescription fraud (Vicodin®). She has lost custody of her children, is unemployed (only fired after the second conviction discussed below), is required to take non opioid pain medications only, is required to attend 12 step Narcotics Anonymous (NA) Meetings, has random and unannounced urine drug screens and attends weekly outpatient substance abuse therapy sessions.

She was first prescribed Vicodin® after having breast enhancement surgery. She took it as directed and never requested any refills. She was prescribed it again three years later for a hysterectomy and later that same year for rectal surgery. She “liked the feeling it gave [her]. It decreased [her] anxiety and made [her] feel calmer.” She and her husband moved in with his parents for five months while they were building a house. He left her and the children there alone for two weeks of business and hunting trips back to back. She had conflict with her in laws.

At the time she was working as an office manager for a neurologist and used his DEA number and called in the first false prescription to a Safeway® pharmacy. She took one tablet every four to five hours for three weeks, then one every two hours for three weeks, two every four hours for two to three weeks and finally two every two to three hours for three months. She called or faxed in approximately 15 prescriptions using four pharmacies (Target®, Safeway® and two others she won’t name because she has not yet been charged in those crimes). She initially ordered bottles with 30 tablets. She then increased to 60 tablets.

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Case Study 2The patient is a 43-year-old white female referred by her attending

physician on the medical unit at a local hospital. She is five days post operative with a lap assisted total abdominal colectomy and ileocectomy. A consultation was ordered with this clinician because the patient is increasingly confused and hallucinating. Her medical problems are secondary to a history of purging and laxative abuse (taking as many as 20-30 doses of laxatives a day since the age of 20 to lose weight or have a bowel movement). As a result of the laxative abuse she had slow transit constipation for years.

Three days after her surgery numerous prescription medications were located in her room and it was assumed that she was taking some or all of them on her own (Ativan®, Tylenol® with codeine, Vicodin®, Valium®, Ambien® and Klonopin®) in addition to what was being ordered by the hospitalist, the surgeon and administered by the nursing staff.

She receives the medications listed above from four physicians who do not know that other providers are treating the same patient for her lupus, fibromyalgia, osteoporosis, and arthritis. Her divorce is pending. Her 16-year-old recently ran away from a group home. Her 11-year-old lives with his father and her 6-year-old is currently staying with the patient’s sister. The patient was terminated from her job as a certified public school Kindergarten teacher for missing work. The employer had documentation that the patient had been diagnosed with Bipolar Disorder but she did not respond to corrective action plans. She reportedly took the following medications from various unknown prescribers: Seroquel®, Effexor®, Lamictal® and Adderall XL®.

At the time of the exam she was naked below the waist, had perplexed expression, her speech was nonsensical, she was hallucinating, and she was disoriented to person/place/date.She was diagnosed with Opioid and Sedative/Hypnotic/Anxiolytic Withdrawal Delirium (provisionally, ruling out Delirium related to medical conditions).

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“Opiophobia”

“Many health care providers underprescribe painkillers because they overestimate the potential for patients to become addicted to medications such as morphine and codeine. Although these drugs carry a heightened risk of addiction, research has shown that providers' concerns that patients will become addicted to pain medication are largely unfounded. This fear of prescribing opioid pain medications is known as ‘opiophobia.’”


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Characteristics of overprescribing

physicians“The 4 Ds” from the AMA:

1.) dated (out of date regarding knowledge of pharmacology,

differential diagnoses and management of various conditions);

2.) duped (vulnerable to manipulative patients);

3.) dishonest (willing to write prescriptions for controlled

substances in exchange for money or other favors); and

4.) disabled (impaired with a medical condition, psychiatric illness

and/or chemical dependency)


41

How to approach physicians with

concernsStart with provider first. If not successful,

then:

• Report to in house impairment program if available. If not available, then:

• Report to chief of appropriate clinical service. If at an office based practice instead, then:

• Refer to external impaired program. If not available, or if a complaint is required first, then:

• Report to state licensing board.

“Impaired Professionals”

42

Types of fraudulent prescriptions

stolen legitimate prescription pads with prescriptions written for real or fictitious patients;

physician prescriptions that have been altered by the patient;

prescription pads with a legitimate physician printed but with a different call back number answered by the patient or an accomplice;

patients calling in their own prescriptions using their own phone number as a call back confirmation;

patients using scanners or copiers to copy legitimate physician prescriptions; and

patients using computers to create prescriptions for nonexistent or legitimate physicians.

Office of Diversion Control

43

Characteristics of forged prescriptions

1. looks “too good” – handwriting too legible;

2. quantities, directions or dosages differ from what is usual, customary and reasonable;

3. does not comply with acceptable standard abbreviations or appears to be a “textbook presentation;”

4. appears to be photocopied;

5. directions written in full with no abbreviating; and

6. written in more than one color ink or in more than one handwriting.


44

Other warning signs

• significantly more prescriptions or larger quantities from one prescriber compared to what is received from his or her peers in the area;

• patients requesting refills daily, weekly or biweekly if the prescription was for a month;

• patients with prescriptions for antagonistic substances at the same time (i.e., depressants and stimulants on the same day or on close dates);

• patients dropping off or picking up prescriptions for other people;

• a number of patients with the same or similar prescription (even from the same physician in some cases) presenting at the same time or one after another; and

• patients not from the local area showing up with prescriptions from the same physician.


45

Prescription fraud prevention techniques

• know the prescriber and his or her signature;

• know the prescriber’s DEA registration number;

• know the patient or ask for identification;

• check that the date on the prescription is recent;

• call the prescriber for verification or clarification if any question or concern;

• call the local police or sheriff department if a forged, altered or counterfeited prescription is suspected;

• call the state pharmacy board; and

• contact the DEA at:http://www.usdoj.gov/dea/submit_tip_form.htm

(877) RXAbuse or (877) 792-2873


46

Don’t flush unwanted or leftover medications!

Do:• crush or dissolve tablets or capsules in warm

water;• mix with kitty litter, coffee grounds or dog

waste;• place in sealed plastic bag in covered trash

can;• remove and destroy prescription bottle label

before discarding.

Or:• ask if pharmacy or local hazardous materials

site accept leftover medications.

U.S. Department of Health and Human Services,Substance Abuse and Mental Health Services Administration

47

Reasons for drug testing

1. to establish a drug free workplace for prospective and current employees;

2. when any use on-the-job (or an employee coming to work under the influence of substances) is suspected;

3. after an employee accident or injury that may involve substances; and/or

4. to support employees currently or formerly involved in impaired professional programs.

Drug Test Coordinators, Inc.

48

Types of drug testing

• Pre-employment (part of application process)

• Random (“neutral selection” of employees or all employees)

• For-Cause (same as “probable cause” and “reasonable suspicion”)

• Periodic Announced (regularly scheduled annual exams)

• Post-Accident (on-the-job vehicle or other work related incident)

• Rehabilitation (part of treatment program and/or before return to work)

• Safety-Sensitive (testing of employees with safety-sensitive job duties)

Drug Test Coordinators, Inc.

49

Detection periods

amphetamines* 1-3 days(may not be detectable in urine until 4-6 hours after use)

barbiturates (short acting) 1 day

barbiturates (intermediate and long acting) 1-3 weeks

benzodiazepines 5-7 days

cocaine* 1-3 days(may not be detectable in urine until 2-6hours after use)

opioids 1-3 days(may not be detectable in urine until 2-6hours after use)

*prescription medications versus illicit forms of same or similar substances

“Impaired Professionals”Food and Drug Administration (FDA)

50

Alternatives to controlled drugs for

anxiety• Most antidepressants• (buspirone) Buspar®• Anticonvulsants: (valproic acid)

Depakote® and (gabapentin) Neurontin®

• Selected (antihypertensives) beta blockers

• Atypical neuroleptics: (olanzapine) Zyprexa®, (quetipine) Seroquel®, (risperidone) Risperdal®

• (hydroxyzine) Vistaril® or Atarax®


51


insomnia

• Sedating antidepressants: trazodone (Desyrel®), doxepin (Sinequan®), amitriptyline (Elavil®), nefazodone (Serzone®), mirtazepine (Remeron®)


52


ADHD• (pemoline) Cylert®• (bupropion) Wellbutrin®• (desipramine) Norpramin®• (venlafaxine) Effexor®• (clonidine) Catapres®• Selective serotonin reuptake

inhibitors


53


pain• nonsteroidal anti-

inflammatory drugs• acetaminophen• antidepressants• anticonvulsants• steroids• muscle relaxants


54

Suboxone® versus Methadone or LAAM

(buprenorphine HCI/naloxone HCI dihydrate)

a “partial agonist”

has Naloxone in it to prevent people from crushing and injecting it which would cause instant withdrawal instead of intoxication

may cause respiratory depression and death if injected and/or if combined with benzodiazepines or other CNS depressants

preferred over Methadone for patients addicted to prescription opioids (instead of heroin)

sublingual tablets (that are slow to dissolve with bad taste)

negative side effects/adverse reactions commonly reported more than placebo: headache, pain, nausea and sweating

must be in opioid withdrawal before starting and must have empty stomach

blocks effects of all other opioids but Fentanyl®

only available from physicians who have completed Reckitt Benckiser Pharmaceutical, Inc. training. They are listed at:

http://www.suboxone.com

Suboxone.com

55

Warning signs of impaired professionals

• Deterioration of personal hygiene• Increased absence from

professional functions or duties• Emotionally labile• Appears sleep deprived• Increased evidence of professional

errors• Shows a decreased concern for

patient well being• Unexplained “personal problems”• Increased patient complaints

“Impaired Professionals”

56

Guidelines for Writing Prescriptions

Building an alliance with the patient (informed consent means informing the patient of potential for physical dependency with certain medications)

How to document in the medical record (how the action to use medication was chosen; that the patient was informed, consented, and was competent to make the decision)

Duty to warn related to driving errors (patients must be informed of the risk of driving while taking certain medications, combining alcohol with certain medications, and both discussions should be documented in the record)

Using medication conjointly with therapies (use medication only as part of an overall treatment plan with other forms of therapy, including, but not limited to physical therapy, biofeedback, cognitive behavioral treatment, or even bibliotherapy)


57

Do these 3 things when writing prescriptions

1. Prescribe only the exact amount until the next appointment;

2. Write out the number (e.g., “thirty” instead of “30”); and

3. Use only one pharmacy and only one physician in the practice or program to write the refills (i.e., “one-doctor/one pharmacy” treatment plan).


58

“Clinical Sobriety Checklist” (CSC)™

for medications(Every blank in all three sections must be checked.)

(AA)_____awake_____alert

(Ox4)_____oriented to person_____oriented to place_____oriented to time_____oriented to events

(Walking/Talking)_____exhibits stable gait without ataxia (i.e., is coordinated and balance is steady

when standing or moving)_____conversive without slurred speech (i.e., communicates and word pronunciation is clear when speaking)

“These guidelines are intended to be tools to facilitate clinical decision making. They are not the

standard of care for each patient. No guideline can anticipate every situation, and the [clinician] should deviate from the guidelines when clinical judgment so indicates.”[1]

Adapted from “Clinical pathway for intoxicated patients,” Brown University. Retrieved from the World Wide Web at http://brown.edu/Administration/Emergency_Medicine/emr/pages/etoh.htm July 29,

2007. Copyright 2007 Rand L. Kannenberg

All rights reserved.1] “Clinical pathway for intoxicated patients.”

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_____legal, illegal, prescription and over-the-counter substance(s) used;

_____amount/route of administration/frequency/duration of use;

_____when started using;

_____why using/used;

_____last use;

_____blood alcohol level and time;

_____breath test result and time;

_____urine drug screen results and time;

_____CIWA score and time;

_____COWS score and time;

_____CAGE score;Kannenberg

Prescription drug interview questions

60

_____history of blackouts;

_____history of intoxication or withdrawal delirium;

_____history of intoxication or withdrawal seizures;

_____history of substance induced psychosis, mania, anxiety or depression;

_____longest time clean/sober,

_____history of addiction treatment;

_____history of addiction support;

_____history of addiction education;

_____history of substance related legal problems;

_____history of physical problems as a result of using; and

_____problems at home, work or school as a result of using.

Kannenberg

61

CAGE Questionnaire

for Prescription Drugs

Medication dependence is likely if the patient gives 2 or more positive answers:

1. Have you ever felt you should CUT down your use of prescription drugs?

2. Have people ANNOYED you by criticizing your use of prescription drugs?

3. Have you ever felt bad or GUILTY about your use of prescription drugs?

4. Have you ever used prescription drugs as a way to “get going” first thing in the

morning (EYE- opener)?

Ewing

62

Drug addiction test

Alcohol and Drug Addiction Test

Gorski and Kelley

63

1. Use to feel better: I use alcohol or drugs to get away from things that bother me or are hard to face.

2. Use to solve most problems: I use alcohol or drugs to try to solve most of my problems and things that bother me.

3. It takes more: It takes more or stronger kinds of alcohol or drugs to get the same feelings than it used to.

4. Memory loss: Sometimes after I have been using, I do not remember what happened.

5. Sneaking: Sometimes I hide from other people how much I'm using or drinking. This might be because I do not want people to know or because I do not want to share.

6. Dependence: I rarely do anything for fun unless I use alcohol or drugs.

7. Fast start: I use stronger alcohol or drugs or use a lot quickly at first to get a "good start."

8. Feel guilty: I feel guilty about using alcohol or drugs or about the things that I do when I use.

9. Do not listen: Other people complain or try to talk to me about my using but I do not listen.

10. Regular blackouts: I do not remember what happened and I get into trouble when I use alcohol or drugs.

11. Excuses: I use problems in my life as an excuse for using alcohol or drugs. I feel that I have to use to deal with these problems.

12. Using more than others: I use more than most people, so I hang around people who use as much or more so that I feel that I fit in.

Yes No

64

13. Feel bad: I feel bad about how my using hurts other people, but I don't know what to do about it.

14. Show off: I show off or get pushy with other people to feel better and prove that I am okay.

15. Promises: I promise to get my life in order and do better. I mean it, but it doesn't work out that way.

16. Control: I try to control my use, but it doesn't work.

17. Give up other things: I've stopped doing things that I used to do that didn't involve using alcohol or drugs.

18. Make changes: I change jobs, move, or leave a relationship to try to make my life better, but it doesn't make any difference.

19. Work and money troubles: I have problems on the job, owe money or can't work at all because of my using.

20. Avoid friends and family: I avoid old friends and family that do not use—unless I need something from them.

21. Neglect food: I do not eat healthy foods or eat at regular times, especially when I'm using.

22. Resentment: I feel like other people are out to get me, and I feel angry a lot.

23. Withdrawal: I need a drink or a drug in the morning or else I get the shakes or sweats because I feel terrible.

24. Can't make decisions: I can't make decisions about even small things. I just wait until things happen.

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25. Health problems: I am sick, have lost a lot of weight, or feel physically bad most of the time.

26. Decrease in amount to get high: It takes less for me to get high or doesn't matter how much I use because I can't get the effect I want.

27. Over the line: I do things I said I would never do or things that do not reflect the way I was raised.

28. Use all the time: I use whenever I can, and I don't try to have a normal life.

29. Find someone worse: I try to use with people who are worse off than I am so that I feel better.

30. Major damage: Even when I'm not using, I have a hard time thinking, remembering, and doing things that used to be easy.

31. Afraid: I feel like something terrible might happen to me, people are out to get me, and I have to be on guard at all times.

32. Give up: I don't try to change anything. I just wait to see what happens.

33. Using is everything: Getting something to use, using, and getting over using are my whole life.

34. Turn to God: I want God or religion to save me from my life.

35. I'm lost: I don't try to pretend my life is normal. I know I am an addict or an alcoholic. I believe that things will never change.

36. Desperation: I am willing to do anything to get better.

37. Confinement: I have been in jails and mental wards because of my using.

66

Scoring Sheet for Alcohol and Drug Addiction Test

Early Stage AddictionCount up the number of yes answers you checked in questions 1–12 and write the number below. Number of checks for questions 1–12 _____ If you have one or more checks in this section, there is a possibility that you are addicted to alcohol or drugs. This means that you use alcohol or drugs to try to solve problems and to make yourself feel better. While using alcohol or drugs will not really make things better, it will feel like it does. If you have any checks in this section, you have a possibility of becoming addicted if you keep using. The closer your score is to 12, the higher your chance of addiction. Middle Stage Addiction Count up the number of yes answers you checked in questions 13–24 and write the number below. Number of checks for questions 13–24 ____ Any number of checks in this section means that you are addicted and have started to have bad things happen to you because of your addiction. During this stage, you may try to do things to control your addiction. Some of these may work for a while, but not for long. For questions 13–24, the closer your score is to 12, the more addicted you are, and the worse things will get if you do not get help. Late Stage Addiction Count up the number of yes answers you checked in questions 25–37 and write the number below. Number of checks for questions 25–37 ____ Any number of checks in this section means that you are in the late stage of addiction. During this stage, you may have given up and thought that you could not do anything to change. Serious life problems, such as being sick, or going to jail or a mental ward, have happened or will happen to you if you do not try to get help. For questions 25–37, the closer your score is to 13, the more addicted you are. Your chances of dying are high if you continue to use.

67

Substance dependence screening

(requires 3 or more of the following in 12 consecutive months):

Increased Tolerance;Withdrawal;

Increased Quantity or Duration;Persistent Desire but Inability to

Decrease or Discontinue Use;Increased Time to Obtain or Recover;

Social/Occupational/Recreational Impairment;

Continued Use Despite Awareness of Related Physical or Psychological

Problems.

American Psychiatric Association (APA)

68

Substance abuse screening

(requires 1 or more of the following in 12 consecutive months):

Recurrent Use Resulting in Social/Occupational/Educational

Problems;Recurrent Use in Physically

Hazardous Situations;Recurrent Substance-Related Legal

Problems;Continued Use Despite Awareness of

Related Social or Interpersonal Problems.


69

Opioid Intoxication

A. Recent use of an opioid. B. Clinically significant maladaptive behavioral

or psychological changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that developed during, or shortly after, opioid use.

C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use: (1) drowsiness or coma (2) slurred speech (3) impairment in attention or memory

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.Specify if: With Perceptual Disturbances


70

Sedative, Hypnotic, or Anxiolytic Intoxication A. Recent use of a sedative, hypnotic, or

anxiolytic. B. Clinically significant maladaptive behavioral or

psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, sedative, hypnotic, or anxiolytic use.

C. One (or more) of the following signs, developing during, or shortly after, sedative, hypnotic, or anxiolytic use: (1) slurred speech (2) incoordination (3) unsteady gait (4) nystagmus (5) impairment in attention or memory (6) stupor or coma

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.


71

Stimulant Intoxication

A. Recent use of a stimulant.B. Clinically significant maladaptive behavioral or psychological

changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment; or impaired social or occupational functioning) that developed during, or shortly after, use of a stimulant.

C. Two (or more) of the following, developing during, or shortly after, use of a stimulant:

1) tachycardia (resting heart rate of over 100 beats per minute) or bradycardia (heart rate of under 60 beats per minute)

2) Pupillary dilation3) Elevated or lowered blood pressure4) Perspiration or chills5) Nausea or vomiting6) Evidence of weight loss7) Psychomotor (thought and physical movements)

agitation or retardation8) Muscular weakness, respiratory depression,

chest pain, or cardiac arrhythmias (irregular heart contraction)

9) Confusion, seizures, dyskinesias (bad or abnormal movements), dystonias (involuntary, sustained muscle contractions), or coma



72

Benzodiazepine withdrawal symptom

questionnaireFeeling unreal Very sensitive to

noise Very sensitive to light Very sensitive to smell

Very sensitive to

touch Peculiar taste in

mouth Pains in muscles Muscle twitching Shaking or trembling Pins and needles Dizziness

Feeling faint Feeling sick Feeling depressed Sore eyes Feeling that things are

moving when they are still

Seeing or hearing things that are not really there (hallucinations)

Unable to control your movements

Loss of memory Loss of appetite

Each moderate score is given a rating of 1 and each severe score a rating of 2. The maximum score possible is 40, unless

of course additional symptoms are included. Note also whether the symptoms occurred when the tablets were

reduced or stopped, or if the symptoms occurred when the tablets were the same. If the individual attains an overall

score above 20 seek specialist medical help. If the individual endorses a number of severe symptoms seek specialist medical help. If the individual reports a number of new

symptoms seek specialist medical help.

Tyrer, Murphy and Riley

73

For each item, write in the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.

WESSON, Donald R., CNS Medications Development, Oakland, California; Medications Development Committee, American Society of Addiction Medicine.

LING, Walter, Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles.

Patient’s Name:___________________________ Date: ______________

Clinical Opiate Withdrawal Scale

(COWS)

74

Resting Pulse Rate: (record beats per minute)

Measured after patient is sitting or lying for

one minute.

0 pulse rate 80 or below1 pulse rate 81-100

2 pulse rate 101-120 4 pulse rate greater than 120

Sweating:

Over past ½ hour not accounted for by room temperature or patient activity.

0 no report of chills or flushing1 subjective report of chills or flushing2 flushed or observable moistness on face3 beads of sweat on brow or face4 sweat streaming off face

75

http://www.aic.cuhk.edu.hk/web8/Horners_sweating.jpg

76

Restlessness:

Observation during assessment.

0 able to sit still1 reports difficulty sitting still, but is able to do so3 frequent shifting or extraneous movements of legs/arms5 Unable to sit still for more than a few seconds

Pupil Size:

0 pupils pinned or normal size for room light1 pupils possibly larger than normal for room light2 pupils moderately dilated5 pupils so dilated that only the rim of the iris is visible

77

http://www.opt.indiana.edu/ecco/graphics/dilate.jpg

78

Bone or Joint Aches:

If patient was having pain previously,

only the additional component attributed to opiates withdrawal is scored.

0 not present1 mild diffuse discomfort2 patient reports severe diffuse aching of joints/ muscles4 patient is rubbing joints or muscles and is unable to sit still because of discomfort

Runny Nose or Tearing:

Not accounted for by cold symptoms or allergies.

0 not present1 nasal stuffiness or unusually moist eyes2 nose running or tearing4 nose constantly running or tears streaming down cheeks

79

http://images.jupiterimages.com/common/detail/39/98/23119839.jpg

80

http://www.kellogg.umich.edu/theeyeshaveit/symptoms/images/tearing.jpg

81

GI Upset:

Over last ½ hour.

0 no GI symptoms1 stomach cramps2 nausea or loose stool3 vomiting or diarrhea5 Multiple episodes of diarrhea or vomiting

Tremor:

Observation of outstretched hands.

0 No tremor1 tremor can be felt, but not observed2 slight tremor observable4 gross tremor or muscle twitching

82

http://www.brainexplorer.org/brain-images/tremor.jpg

83

Yawning:

Observation during assessment.

0 no yawning1 yawning once or twice during assessment2 yawning three or more times during assessment4 yawning several times/minute

84

http://www.abc.net.au/science/news/img/health/yawning071204.jpg

85

Anxiety or Irritability:

0 none1 patient reports increasing irritability or anxiousness2 patient obviously irritable or anxious4 patient so irritable or anxious that participation in the assessment is difficult

Gooseflesh Skin:

0 skin is smooth3 piloerection of skin can be felt or hairs standing up on arms5 prominent piloerection

86

http://content.answers.com/main/content/wp/en/2/23/Goose_bumps.jpg

87

Total scores

with observer’s initials

Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe;more than 36 = severe withdrawal

88

Stimulant withdrawal checklist

A. Cessation of (or reduction in) stimulant use that has been heavy and prolonged.

B. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:

1) Fatigue2) Vivid, unpleasant dreams3) Insomnia or hypersomnia (an

excessive amount of sleepiness)4) Increased appetite5) Psychomotor retardation or agitation

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.



89

Adult Inpatient Medical Detoxification

Admission Criteria Checklist

Opioids• The patient is acutely intoxicated; OR• The patient meets the criteria for another opioid

induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR

• The patient is experiencing severe withdrawal (Clinical Opiate Withdrawal Scale is greater than 36); OR

• There is evidence that severe withdrawal is imminent; AND

• The patient has been unsuccessful at a less intensive level of service (or such a level is not currently an option because of safety); AND

• If the patient is voluntary, he or she has arranged for longer term treatment after inpatient medical detoxification; AND

• The patient requires close monitoring for a coexisting or co-occurring physical, emotional, behavioral, and/or cognitive condition; AND

• The patient does not require a medical admission; AND

• The patient does not require an inpatient psychiatric admission.

Exempla West Pines Behavioral Health Services

90



Sedatives, Hypnotics, AnxiolyticsThe patient is acutely intoxicated; OR• The patient meets the criteria for another sedative,

hypnotic or anxiolytic induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR

• The patient is in severe withdrawal; OR• There is evidence that severe withdrawal is

imminent; AND• The patient is not responsive to appropriate efforts

to maintain the dose of the substance(s) at therapeutic levels; AND

• There is evidence that the patient is in danger of seizures upon withdrawal; AND

• The patient requires close monitoring for a coexisting or co-occurring physical, emotional, behavioral, and/or cognitive condition; AND




91



Stimulants• The patient is acutely intoxicated; OR• The patient meets the criteria for another

stimulant induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR

• The patient is in severe withdrawal; OR• There is evidence that severe withdrawal is

imminent; AND• The patient requires close monitoring for a

coexisting or co-occurring physical, emotional, behavioral, and/or cognitive condition; AND




92

Social detoxification exclusion criteria

• Blood Pressure must be less than 180/110

• Pulse must be less than 130

• Temperature must be less than 102.5 degrees

• Respirations must be less than 30

Arapahoe House Detox-West

93

OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES USING

(CLONIDINE) CATAPRES® FOR OPIATES

CATAPRES® SUBSTITUTION FOR OPIOID WITHDRAWAL AT HOME

1. Oral 2. Patch

The clonidine patch comes in three strengths (#1, #2, #3) and delivers over one week the equivalent of a daily dose of oral clonidine.

Go to http://www.txpsych.org/guidelineopiates.htm for dosing guidelines.

3. Other useful medications for symptom control

Lomotil® for diarrheaKaopectate® after a loose stoolPro-Banthine® or Bentyl® for abdominal crampsTylenol® for headacheFeldene® or Naprosyn® for back, joint, and bone painMylanta® for indigestionPhenergan® suppositories for nauseaAtarax® for nauseaLibrium® for anxietyBenadryl® or Restoril® for sleepSinequan® for insomnia, anxiety, dysphoria

Go to http://www.txpsych.org/guidelineopiates.htm for dosing guidelines.

Federation of Texas PsychiatryKleber

94

OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES USING (DIAZEPAM) VALIUM® OR

(CLONAZEPAM) KLONOPIN® FOR ANXIOLYTICS/SEDATIVES/HYPNOTICS

VALIUM® OR KLONOPIN® SUBSTITUTION FOR ANXIOLYTIC/SEDATIVE/HYPNOTIC

WITHDRAWAL AT HOME

Sporadic or intermittent use of anxiolytic/sedative/hypnotics may not require a withdrawal regimen. These techniques are best suited for the chronic user (a patient who has been on a relatively stable dose continuously for six months or more). The longer-acting clonazepam can be used rather than diazepam (5 mg of diazepam = 1 mg of clonazepam).

Go to http://www.txpsych.org/guidelinesanxiolyticsedativehypnotic.htm for dosing guidelines.

Federation of Texas Psychiatry

Alexander and Perry

Schweize and Rickels

Dupont

Benzer, Smith, and Miller

95

OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES FOR COCAINE AND AMPHETAMINES

NO SPECIFIC SUBSTITUTES FOR STIMULANT WITHDRAWAL AT HOME ARE AVAILABLE

The following may be used to treat the symptoms only:

1. benzodiazepines- brief use to decrease anxiety, agitation, or insomnia

2. neuroleptics- useful for agitation, paranoid symptoms, hallucinations, or delusions

Federation of Texas Psychiatry

Fischman

Fischman and Haney

96

Rapid detoxification

“Rapid opioid detoxification with opioid antagonist [naltrexone, a derivative of naloxone] induction using general anesthesia has emerged as an expensive, potentially dangerous, unproven approach to treat opioid dependence…

These data do not support the use of general anesthesia for …rapid opioid antagonist induction.”

American Medical Association

97

The “4 Ds” of quitting medications

• Deep breaths(to deal with the tension from no longer using medication: with mouth closed and

shoulders relaxed, inhale slowly and deeply through the nose, to the count of 7, pushing the stomach out; hold the breath to the count of 7; exhale slowing through pursed lips to the count of 7; repeat this cycle 3-5 times)

• Drink water(to remove the medication from your system: drink 8-10 glasses of water a day for at

least a week, avoiding caffeinated beverages if possible)

• Delay(to handle the temptation to use medication: wait out a craving or urge to use

medication at least 1 minute, finding that it goes away whether or not the medication is used after no more than 5 minutes)

• Do something else(to handle the psychological and/or physical desire to use medication: do other

activities instead (review your most important reasons for quitting, talk to yourself, exercise, doodle, work on a hobby or crossword puzzle, take a shower, etc.)

American Lung Association (ALA) of Minnesota

98

Relapse Prevention

Exercise No. 1: Why Do I Want To Change?

Purpose. In this exercise, you will look at why you want to change. It is

important to ask yourself this question. If you only want to escape the problems that you are facing right now, this workbook will not help you. If you want to change your life, it will.

Instructions. Complete the following sentences.

The reason I decided to try to get sober and clean this time is . . . (Tell what happened that made you seek help, such as job, health, or legal problems.)

Unless I really want to give up alcohol and drugs, I will not get better. Things might get better for a short time, but this will not last. I want to change because . . .

Gorski and Kelley

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Exercise No. 2: Reasons for Relapse

Purpose. This exercise will show you why you have trouble with recovery. By knowing this, you will know more about what you need to change.

When someone is having trouble staying sober and clean, it is because that person is having trouble with one of four major areas of recovery:

Acceptance of their disease: People who are having trouble accepting their disease believe they can still use alcohol or drugs and learn to control their use.

Unable to stabilize: Every time they try to stop using, they become sick, feel crazy, or cannot think about anything except drugs or alcohol. Therefore, they use alcohol or drugs to feel better.

Cannot get comfortable being sober: When they stop using, they do not know how to change the way they live so they can enjoy sobriety.

Relapse: They get sober and clean, they attend AA or NA meetings and enjoy sobriety, but then something happens, and they become unhappy and start to use again.

Instructions. Answer the following questions.

True False________ I believe that I can learn to drink or use drugs and control my

use so that it will not hurt me. ________ I know that I should not use alcohol or drugs at all, but every

time I try to quit, I get sick and feel crazy, so I use alcohol or drugs to feel better.

________ I know I cannot use alcohol or drugs, but when I quit for a while, I always end up using again.

________ I know I cannot use alcohol or drugs, and I attend AA or NA and do everything I can to stay sober and clean. Sometimes I get very happy in recovery, but I still end up using again.

Gorski and Kelley

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Goal setting

Guidelines: Goals must be achievable and measurable.

There must also be a “who,” “what,” “where,” “why,”

“when/when/when” (start date, frequency, and duration), and “how”

for each goal.

Talk about what you WILL DO, not what you won’t do.

Short-term goals are those that can be accomplished while you are

still in treatment.

Long term goals are those that can only be accomplished after

successfully completing treatment (because the skill hasn’t been

learned yet or the opportunity to get involved in the behavior or

activity won’t be available until after graduation).

One of substance abuse goals must include continued treatment

and/or aftercare plans (in addition to regular attendance and

participation in this individual or group therapy, which is assumed).

Your criminal behavior goals must include legal alternatives to the

unlawful behavior that brought you into the system this time (if this

applies).

The antisocial behavior goals must include legal alternatives to two

(2) primary problem areas/patterns of negative thinking and acting

related to your use of prescription or over the counter medication.

Sign/date goal sheet the first time used and initial/date each

additional goal. Never write more than one (1) goal per session.

Review (update/delete/add) after three (3) goals, and do discharge

planning after six (6) goals (instead of writing new goals).

Kannenberg

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Client Name___________________________________________

Substance Abuse Goals:

Short Term ________________________________________________________________________________________________________________________________________________________________________ Long Term ________________________________________________________________________________________________________________________________________________________________________

Criminal Behavior Goals: Short Term ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Long Term ________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Antisocial Behavior Goals: Short Term ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Long Term ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Client and counselor signatures_______________________________ Date__________________

Kannenberg

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““National National Medicine Medicine

Abuse Abuse Awareness Awareness

MonthMonth”set by the United States Senate

for every

August August starting in 2007.

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