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Prescription Narcotic Misuse and Abuse Focus Groups


									Salt lake county prescription
     pain medication DATA

          Prepared for Salt Lake County
      Division of Substance Abuse Services

                   July 2009

• The Problem

• The Plan

• Who we talked to

• What we heard

• Overall Results

• Next Steps
                The Problem
  • A drop in illicit drug use between 2002 and 2007
  • BUT an upswing in non-medical prescription drug use and abuse

  • Utah is in the top 10 states for non-medical use of prescription drugs
  • In 2006:
        - 485 overdose deaths; of those 307 were from a non-illicit drug
        - 56% involved a prescription narcotic
        - 40% had a prescription for the drug that killed them

This data shows a clear need for local preventative entities
    to tackle the problem of prescription drug misuse and
                       The Plan
• Salt Lake County Substance Abuse Services and Neighborhood Action
  Coalition collected data for the Strategic Prevention Framework State
  Incentive Grant (SPF SIG) requirements.

• We conducted focus groups with community members, interviews with key
  community leaders, and surveys of healthcare professionals.

• Objective: Obtain knowledge and understand beliefs about prescription
  narcotic medication misuse and abuse in different populations in Salt Lake

• This new knowledge will be used to select strategies for prescription drug
  misuse/ abuse prevention programs in Salt Lake County. It may also be used
  to further understanding of this important and emerging issue.
             Key Informant
Study Design
   Semi-structured interviews were conducted with 12 knowledgeable
   experts with a broad understanding of prescription pain medication
   misuse and abuse.

Who We Talked To
   Key Leaders from:
    •   Project Reality
    •   University Neuropsychiatric Institute (UNI)
    •   Utah Poison Control
    •   Department of Pharmacy Services, University of Utah
    • Cornerstone Counseling Center (Prevention and Treatment Services)
    • Cottonwood Heights Police Department
            What we learned
                              Key Informant Interviews

   Increase in unintentional overdose deaths related to
   prescription drugs in Utah
   All age groups are affected BUT there are varying themes among
   ages and population

   Addiction issues appear in adults and teens following a legitimate prescription
   Problems can begin with family members/friends sharing with younger
   Group of well-educated and successful individuals addicted to pain meds
   Addiction issues in mothers who were prescribed pain medications at childbirth;
   eventually move on to heroin
           What we learned
                             Key Informant Interviews

  Everyone shares a piece of the blame in this multi-factorial

  There is a general lack of education among consumers and prescribers
  The issue is a social norm and does not discriminate based on age, SES, etc.
  Marketing of prescription drugs appears to be a bigger problem than we think
  There is a lack of product stewardship
  Overprescribing is rampant
            What we learned
                              Key Informant Interviews

  There appears to be a lack of collaboration among invested institutions like DOPL,
  health care providers, law enforcement, insurance providers, etc.
  There needs to be more monitoring by physicians with patients with long-term pain
  medication prescriptions
  Larger work load for case management with prescription drugs because of the HIPPA
  and confidentiality concerns
  Limited # of pain clinics means existing clinics disperse more drugs
  More addiction specialists or trained pain clinic personnel needed

Law Enforcement:
  “Reactive” instead of a “proactive” approach.
  Individuals “work the system” (i.e. M.D. shopping, fraud, etc.)
             What we learned
                                 Key Informant Interviews

   Prevention of prescription drugs is not officially a part of standardized curriculum due
   to lack of documented research

   All age groups are affected
   Increase in opiate use without gateway drugs such as alcohol is a new phenomenon
   One theory is that this new generation has been raised to believe that life should be
   pain free and therefore they are more vulnerable to seeking relief through pain
   Additional treatment groups for young adults needed to focus on Rx. issue
   Adults become addicted following a legitimate prescription
   Start out with opiates but switch to heroin because it’s cheaper
   Also seeing cross-addictions which include benzodiazepines (large amounts
   prescribed in Utah)
                 Focus Groups
Study Design
   Selection Criteria
   - Self or close relative had been prescribed prescription pain in past year

   Approved by both U of U IRB and State of Utah IRB
   Designed to target SPF SIG “Causal Factors”
   - Community Norms, Individual Factors, Availability/Sharing, Knowledge of Proper Use, and
   Criminal Justice/Enforcement

Who We Talked To
  Total of 7 focus groups : men and women from Salt Lake County
    3 with participants age 18-30
    2 with participants age 31-55
    2 with participants age 56+
     What we learned
                             FOCUS GROUPS

The drug misuse-abuse continuum is not well understood
 Most common definition of misuse was taking too much OR not using as
 prescribed or to treat a different pain that what the prescription was
 originally given for

 Another term that was used was “accidentally/unknowingly not using as

 Most common definition of abuse was using it to get high or for recreation

 Participants also identified evidence of abuse was when the use of the drug
 interferes with your life or when you become addicted where the
 medication is something you need (dependence)

 They also described it as “knowingly taking more than prescribed”
   What we learned
                           FOCUS GROUPS

     Many save ‘em, store ‘em, or give ‘em away
Most participants report they don’t discard unused (or oftentimes expired)
medications and they indicate they don’t know how to properly dispose of
them. In fact, many believe they can take them back to a pharmacy. Most
indicated they would not use a dropbox. Those reporting they would use
a dropbox suggested the best location would be the pharmacy.

Many report storing their medications in the kitchen, bedroom, medicine
cabinet, and even their vehicles, purses, and pockets.

Some participants say it is common to share prescriptions, but mostly
among family members.

There is a financial motivation for all of this – saving money on co-pays,
new prescriptions, and saving money for family members and friends.
   What we learned
                           FOCUS GROUPS

       Healthcare professionals provide a wide
 variety of prescription pain med use information
Many report that their physicians do not discuss the risks associated with
taking prescription pain medications, while some report they do have a
conversation with their physician. Physicians who DO explain medications
with their patients seemed to be the exception.

Some report the pharmacist just asks if you have questions regarding the
medication or asks if you have taken it before. The pharmacist is also
credited with asking more frequently about general risks and the specific
risk of combining alcohol use with the medication.

Much of the information about interactions and risks comes from the
information sheet patients receive from the pharmacy. Patients rely
heavily on the information contained therein.

Participants surmise the reason physicians are less likely to discuss these
risks are due to their detailed knowledge of the patient.
Study Design
   A survey based on a SPF SIG data collection document was mailed with a
   self-return stamped envelope to 668 healthcare professionals. The survey
   was anonymous and would have taken less than 10 minutes to complete.

Who We Talked To
  Family practice physicians, pharmacists, and dentists in Salt Lake County.
        What we learned

Survey Responses

• A total of 192 surveys were returned for analysis (29% response rate)

• Dentists (N = 32), Pharmacists (N= 54), and Physicians (N=106)

• Zip code 84107 had the most returned surveys (N=17)
What We Learned
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What We Learned
What We Learned
• Physicians & dentists participated in prescription drug training more so than

• Dentists generally have been trained in prescription drug misuse – less recently
  than physicians and pharmacists

• Pharmacists suspect “fraudulent prescriptions” less frequently than physicians and
  dentists suspect “doctor shopping”

• Physicians were more likely “not to report” doctor shopping than dentists or

• Of those who would report: dentists would report to physicians and pharmacists
  would report to law enforcement
• Physicians & dentists more frequently reported they didn’t know who they would
  report suspected “doctor shopping” to than pharmacists

• Most common reason given for not reporting was “they weren’t sure it was doctor
  shopping or a fraudulent prescription”

• When asked how often they discuss other medication use, all three groups
  indicate “they do it all or most of the time” but only physicians report discussing
  alcohol use interactions with medications regularly.

• When asked about discussing issues related to dosage and timing, and potential
  interactions with other medications, all three groups report doing it all or most of
  the time
Pharmacist Comments:

Not aware of any trainings.

Not sure when/where training is offered.

Very frustrating as a "witness" dealing with the court system (rx. fraud case).

Takes too much of my time in a hectic work environment and for what? The
   police/authorities don't have resources to do much against them. They typically
   still get away with it and go right back to doing it again (rx. fraud comment).

Co. policy - we don't notify police. But I would report to MD still.

I would be very interested in attending a training. Also, I worked in Rutland, VT as an
   intern where they currently have a narcotics Abuse Prevention plan including
   special rx. pads for controlled substances. Might be a good idea in Utah.
Pharmacist Comments:

It can be very difficult to decide when to call the police. We had a situation where we
    called the physician and they just said that they wouldn't see that patient anymore,
    but we wanted them to do more, but we just left it as it was.

Yes, I would like MD's to follow the 80% law and not give new rx.'s unless almost 100%
   is gone except when a patient is going on vacation or under difficult circumstances
   like they lose their medication. Also, patients seem to be abusing the 80% law by
   filling rx.'s nearly every month, so 80% law should be modified to 80% gone they fill
   once every few months instead of 80% gone every fill.

Often difficult to distinguish between use, misuse, and abuse. Pain is very subjective
   and no therapeutic ceiling for narcotics.

It is getting worse almost by the month! We pharmacists are now always in fear of being
     robbed - possibly of losing our lives! All pain clinics need to be closely checked. Their
     prescribing habits are getting out of hand.
Pharmacist Comments:

It's obvious you have no idea what goes on in an average pharmacy. Script fraud is an
    every day, all day experience. Knowledge of all aspects of the problem is an
    integral part of every pharmacist's life. It is do gooder liberal politicians that need

Make all controls be e-scripted, sent over secured network w/electronic signatures
  and finger scanners. Finger scanners are fairly inexpensive in comparison to the
  hassles of fraud.

We fill only 2 days early on narcotics. Many pharmacies fill at 80%, which allows too
  much misuse/abuse because it is usually 4-6 tabs per day therefore 6 days early is
  24-36 extra tabs.
Dentist Comments:

We query the database and we confront the patient.

There is a real problem in the state and there are not a whole lot of guidelines for rx.
  schedule II narcotics.

I use the drug database for suspected misuse, but have never had an agency nor a
    clinic to report to. I do share info with referred specialists.

Internet seminars "webinars" specifically on narcotic abuse would be convenient.
   They can be watched anytime without affecting busy schedules.
Physician Comments:

Unaware that there are trainings.

I've read the book on this subject by Dr. L Webster. I get a heck of a lot of real world
    training in misuse and abuse. I've not seen many programs that appear reputable
    or interesting.

Report to DOPL (mentioned in 16 comments) if needed, otherwise none.

Not sure. Sometimes I contact insurance fraud investigator.

DOPL: But usually discuss with patient first, report if high number of visits.

DOPL, and confront the patient with info and inform them of illegal act.

Hadn't thought about counseling re: risk of sharing rx.

I can't think of any good reasons not to warn a patient.
Physician Comments:

We all need more education in this area.

We need better resources to refer patients to for prescription medication abuse

Thank you for DOPL online.

Need to hire more drug criminal investigators.

Make it easier to report abuse. Review DOPL records of controlled rx.'s filled and
  enforce. Go after them please.

Big problem, especially for young doctors, orthopedics, and providers seeking new
Physician Comments:

One big one; lots of people are interested in making rules, and fixing punitive, even
  criminal punishments onto providers trying to care for patients with chronic
  pain/opioid dependence. I see lots of Medicaid patients. NO chronic pain centers
  accept patients. We're told to refer them on, it is simply not an option available to
  many of us, I wish it were.

Easier access to DOPL records would be helpful. Legal protection as a result of
   reporting suspicious unproven misuse needs to be clarified.

Being able to check DOPL's csdb web site is very helpful, although it still has a 2-4
   week lag time it is helpful to check patients credibility and recent drug use
Next Steps

     Community Coalition Building
            Salt Lake City
            South Salt Lake

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