Ten Prescriptions Never to Write (To the Generalist)

1. Ten Prescriptions Never to Write(To the Generalist) Charlie Reznikoff Addiction Medicine, Hennepin County Medical Center 11-5-10

2. It takes 30 minutes to say ‘no’ and 30 seconds to say ‘yes’

3. If you do not treat the prescription of controlled substances as a medical endeavor, the patient will not either

4. Resident/Physician attitude towards treating addictions Saitz JGIM may 2002 p373

5. Bottom Line • Prescribe within your expertise • Prescribe for objective findings • Beware of short acting, rapid onset medications • Trust your instincts • Focus on function of the patient • Ask for help

6. Prevalence of Prescription Pill Misuse, USA 2009 National Survey on Drug Use and Healthhttp://www.oas.samhsa.gov/nhsda.htm

8. Tripling of overdose deaths in USA attributable to opioids between 1997 and 2007

9. Surpassing Suicide and MVC

10. All Treatment Admission for Opiates, by gender, 1998-2009, Minnesota Source: DAANES, PMQI 2010

11. All Opiates Treatment Admissions in Minnesota by race, 2000-2009 Source: DAANES, PMQI 2010

12. Ethnicity and pain medication use • Hispanics and African-Americans are more than twice as likely to not receive pain medication for broken leg bone • English as a second language was a secondary risk for pain under-treatment • Knox H Todd, et al, JAMA March 24, 1993, vol 269, page 1537 • Knox H Todd, et al, annals of emergency medicine January 2000, 35:1, page 11

13. Rising Rate of Addiction Treatments in USA Related to Opioids

14. An Iatrogenic Epidemic

16. Minnesota Poisoning Deaths

18. http://pmp.pharmacy.state.mn.us/

20. #10 Psychostimulants • Methylphenidate (Ritalin, Concerta) • Amphetamine salts (Adderall) • Dextroamphetamine (Dexedrine) • Methamphetamine (Desoxyn)

21. #10 Psychostimulants • Why not: • ADHD requires expertise to diagnose • Depression, intoxication, withdrawal, sleep disturbance, medical problems, TBI, mimic ADHD • Medications correct symptoms even if no ADHD • Frequently requested, abused and traded medication

22. Stimulant Misuse In High School

23. Why Abused? • Weight loss • All-night study sessions • Correcting toxic states of other drugs • Mood • Sports • Sex Margaret Talbot New Yorker 4-2009 p 32-43

24. #9 Meperidine (Demerol) • Why not: • Highly reinforcing • Neurotoxic metabolites cause seizures, serotonin syndrome, and delirium • Especially dangerous in renal failure • No more effective for biliary spasm • Easy, safe, effective alternatives (morphine)

26. #8 Carisoprodol (Soma) • “Muscle relaxant” • Rapid onset • Relatively brief half life • Metabolized to meprobamate

27. Meprobamate • AKA Miltown or Equanil • High addictive potential • Short acting, rapid onset barbiturate • Develop tolerance to intoxicating effects quicker than to the respiratory suppression effects • Barbiturate withdrawal life threatening

28. Use Caution with Butalbitol • (Fioricet and fiorinal) • Butalbitol is a barbiturate • Rapid onset and short-acting • Addictive • Dangerous withdrawal

29. #7 Methadone for pain • Why: • Half life variable • Half life >30 hours • Pain effect 4 hours, dosing needed TID • Peak levels days three or later • Traditional equianalgesic converters do not work • Many drug interactions (P450)

31. Typical scenario… • Monthly supply of methadone on first visit • Patient not adequately educated • Patient feels early inadequate relief • Patient increases dose • Overdose from respiratory failure on the third day

34. Centers for disease control and prevention

35. #6 Too Much Opiates • How: • Errors in conversion of opioids • Dose escalation without monitoring for sedation • Titrating dose to “pain” complaints and not function • Too many days of medications without proven safe behaviors of the patient

36. >100 mg morphine (or equivalent) a major risk factor for overdose

37. Long term, daily, short acting opioids in addicted and mentally ill (with HIV) Hermos et al, Archives of internal medicine vol 164 nov 22, 2004 p2361

38. #5 Alprazolam (Xanax) • Why: • Short-acting rapid onset benzodiazepine • Highly reinforcing • Highest street value of the benzos • Invisible to urine tox screen • Wicked withdrawal

39. Benzo tolerance • Memory impairment: no tolerance • Respiratory suppression: minimal tolerance • Anxiolysis: minimal tolerance • Motor impairment: partial tolerance • Muscle relaxation: partial tolerance • Euphoria: 2 weeks • Anti-epileptic effects: rapid tolerance

40. The most important contraindication to benzodiazepine use?

41. Contraindications • Elderly– hip fractures and death • Driving, using machinery • Use with opioids or alcohol • Pediatric • Cognitively impaired • Addiction (use with caution) • Learning or therapy

42. Benzos are Safe: Very High TI • Most patients • Do not misuse benzos • Do not find benzos reinforcing • Moderate spontaneously over time • Patients with addiction in self or first degree relative: • Do not spontaneously moderate use • Find benzo reinforcing Woods JH, Katz JL JAMA 12-16-88, p3476

43. #4 Any Controlled Substance Without Proper H&P and Documentation • “Oh by the way, doc…” • Both Doc and Patient are uncomfortable with the discussion, thus use of controlled substances is relegated to non-medical ghetto by both parties

44. 1/10,000 MDs per year lose their controlled substances registrations • Large quantities, large #prescriptions • Use of slang in the medical record • Illogical prescribing pattern or faulty reasoning • Known diversion by patient • Trading favors or money for prescriptions • No physical exam, assessment, plan, reasoning documented Federal register vol 71, no 172, page 52719 2006 http://www.erowid.org/chemicals/opiates/opiates_law3.pdf

45. Insist On A Proper Medical Visit • You are jeopardizing your own medical license • You are potentially committing a felony • You are endangering the patient • It does not matter what another doctor was willing to do for the patient • Explain this to the patient and insist on a proper medical visit

46. #3 Any Opioid Without Informed Consent • 1. overdose risk, esp with alcohol or benzos • 2. withdrawal risk if daily use for 4 weeks, w/d does not equal addiction • 3. driving risk and laws-- while it is safe to drive and work once opioid tolerant, state law is written such that driving with any controlled substance in your system is a DUI-- rarely enforced • 4. felony to share, trade, sell, or even to save controlled substances for future use that is not intended for this specific purpose • 5. 10% of high school seniors use opioids recreationally, risk of theft or use by family members or friends • 6. constipation • 7. addiction, I frame this as a side effect and not a moral failing • 8. failure to relieve pain, not all pain is amenable to opioids • 9. false sense of treating psychiatric illnesses, and thus avoidance of appropriate psychiatric care • 10. controlled substance-- given the DEA's posture and raising overdose poisonings, patients should be told that embarking on chronic controlled substance prescriptions has higher demands on them-- prescribing these cannot and should not be casual-- they should expect to have to spend time seeing a doctor and not merely phone in a script • 11. intended to improve function NOT erase all pain

47. Pain Contracts Do Not Help Patients(or prevent misuse)

48. #2 All Short-Acting Opioids • Which more apt to be misused or diverted? • 480 X 5 mg oxycodone per month equals • 60 X 40 mg oxycodone SA equals • 10 fentanyl patches

49. Multiple short acting doses per day

50. What is the quantity of acetaminophen in a single vicodin?