Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download College of Medicine Reunion Lecture: Physician Prescribing Practices
Document related concepts
no text concepts found
Transcript
Steve Loyd, MD Stephen Loyd, M.D. Associate Professor of Internal Medicine Quillen College of Medicine Johnson City, TN During their practice lifetimes: 8‐12% of physicians will experience a substance related problem: 138,000 will have an alcohol‐related disorder 49,000 will have a drug‐related disorder Substance abuse is the most common reason for disciplinary action by state boards. 8/7/2010 Identify signs and symptoms of acute opiate withdrawal Understand impact of narcotics addiction (strain on healthcare and corrections system) Identify risky prescribing practices of controlled substances Identify drug seeking behavior and screen for chemical dependency Identify strategies to avoid being cited for over prescribing narcotics Look at risk for prescription drug abuse among physicians, residents, pharmacists, nurses How Common : Stratified Randomized National Sample of 1785 PGY IIIs, graduating in 1984: Use within past 30 days ▪ 87% use alcohol, 5% daily ▪ 7% use marijuana, 5% daily ▪ 1.4% use cocaine, not daily ▪ 3.7% use benzodiazepines, not daily Steve Loyd, MD Rates of dependence:10‐14% Alcohol & illicit drug use begins prior to residency Benzodiazepine & opioid use begins during 8/7/2010 Prevalence of dependence: 8‐14% Still means 60 Still means 60‐75,000 affected M.D.s in U.S.!!!! 75,000 affected M.D.s in U.S.!!!! Use & misuse of prescription opioids & benzodiazepines up to 5Xs higher Self‐treatment Self‐prescribed HIGHEST Emergency Medicine Psychiatry Welsh Christopher 2001 LOWEST OB‐GYN Higher use of benzodiazepines & opioids p more parenteral use est es o ogy Anesthesiology Rates similar to general population Higher in emergency room & critical care Especially difficult to monitor Watch for diversion Pathology Radiology Pediatrics Welsh Christopher 2001 Steve Loyd, MD 8/7/2010 85% of cases from colleagues, family, self referral; very few from State Board 601 intakes from 1982‐1990 Estimates of dependence: 10‐18% Less parenteral use @ 50% have used CS w/o script @ 20% on regular basis primarily self‐medication 77% of completers abstinent 5 – 10 years 22% had relapses, most back in treatment All relapsers stopped participating in recovery programs prior to relapse i l 68% of relapses within 2 years of initial treatment 308 cases of Substance Abusing MDs @ 60% of students have used CS w/o script @ 40% on regular basis primarily recreational 1/3 alcohol‐related ¼ psychiatrically‐related 5/12 dementia and other health problems / d i d h h l h bl excludes serious dual diagnosis cases excludes drop outs and deaths favorable outcome means abstinence or one relapse data from self‐report, urine screens, two sources 98% of MDs have favorable outcomes at 2 years 86% of MDs have favorable outcomes at 9 years Prescription Drug Abuse and Addiction and the Role of the Physician Steve Loyd, MD Insomnia Nausea and vomiting Fever Depressed mood Muscle aches Diarrhea Abdominal pain (“Jones”) Yawning Rhinorrhea Sweating (or piloerection or mydriasis) 8/7/2010 The Nation’s Number 1 Health Problem *(Robert Wood Johnson Foundation) Steve Loyd, MD 8/7/2010 Substance abuse is a chronic, relapsing health condition Substance abusers may be in treatment multiple times ‐ p or make repeated attempts p p to quit on their own ‐ before they are successful The improvement rate of people completing substance abuse treatment is comparable to that of people treated for asthma and other chronic, relapsing health conditions Alcohol‐in‐combination 185,000 Cocaine Heroin/Morphine 77,600 Marijuana/Hashish 76,900 Alcohol Direct Deaths = 19,600 Narcotic Direct Deaths= 16,000 As of 1997, excludes deaths from associated diseases such as AIDS, hepatitis, and T.B. Also excludes homicides, suicides, falls and MVA’s 172,000 Steve Loyd, MD Smoking $80 Billion Alcohol Abuse $22.5 Billion Drug Abuse $11.9 Billion 8/7/2010 Steve Loyd, MD 1/2 of arrests for major crimes‐ j including g homicide, theft, assault‐ tested positive for drugs at the time of their arrest Among those convicted of violent crimes, 50% of state and federal prisoners had been drinking or taking drugs at the time of their offense 8/7/2010 # Tennessee is second in the nation in prescriptions for Schedule II (oxycodone) & Schedule III (hydrocodone) narcotics. % 1 Opioids 724 25% 2 Benzodiazepines 491 17% 11% 3 Non-opioid analgesics 317 4 Antidepressants 245 8% 5 Antiinfectives 140 5% 6 Muscle relaxants 132 4% 7 Stimulants and street drugs 121 4% 8 Cardiac (including diuretics) 117 4% 9 Non-benzodiazepine sedatives/antipsychotics 110 4% 10 Antihistamines Total 94 3% 2,491 85% Steve Loyd, MD 80% of adults in select counties in Tennessee are on LONG TERM benzodiazepines. (Studies show about 7% of patients with anxiety benefit from SHORT TERM benzodiazepines.) 8/7/2010 Steve Loyd, MD 8/7/2010 Whiskey Rebellion “To write a prescription is easy, but to come to an understanding with people is hard.” Core personality Patient types Pharmacological knowledge (OxyContin) Professional practice system Steve Loyd, MD DATED ‐ fails to keep current DISABLED ‐ failed judgment due to impairment DUPED ‐ fails to detect “deception” due to f l d d d time constraints DYSFUNCTIONAL ‐ finds it hard to say “no” Definition: Prescribing scheduled drugs in quantities and frequency inappropriate for the patient’s complaint or illness e.g.: Known alcoholic or drug addict l h l d dd Large quantities/frequent intervals Family members For trivial complaints Large quantities to health professionals 8/7/2010 Excessive number and frequency of prescriptions for Schedule II drugs Crescendo pattern Excessive dispensing d Progression to multiple drugs Inadequate records Prescribing for family members Surgery 7% Family Practice/GIM 65% Psychiatry 7% ER 3% Others 19% Steve Loyd, MD 8/7/2010 Feigns physical or psychological problems Pressures the physician for a particular drug or multiple refills of a prescription Presents a dramatic and compelling but vague complaint Allergy to Toradol C=Have you ever tried to Cut down on your drinking? p p y y y y A=Have people Annoyed you by criticism of your drinking? Presents symptoms that contradict clinical observation (chronic pain syndromes) Asks for a specific drug k f f d Has no interest in diagnosis G=Have you ever felt Guilty about your drinking? Rejects all forms of treatment that do not involve narcotics E=Have you ever taken a morning Eye opener to steady your nerves or to get rid of a hangover? Steve Loyd, MD 8/7/2010 Be alert for A/D problems in history (CAGE), physical exam, lab tests Limit new patient prescribing No telephone prescriptions of Schedule II Record keeping by one physician (5 o’clock phone calls) Protect prescription pads Consultation by addiction specialist Check with pharmacist Require all pts to sign a “patient informed consent agreement” Protect prescription pads Require urine drug screens Keep meticulous records Manage the practice with nurses and office managers who recognize the drug seeking h h d k patient Know the pharmacist / Prescription Monitoring System Do not prescribe Schedule II narcotics for family members Require pt to use one pharmacy Steve Loyd, MD DEA Office of Diversion Control http://www.deadiversion.usdoj.gov/ National Association of Drug Diversion g Investigators http://www.naddi.org/ DEA Practitioner Manual http://www.deadiversion.usdoj.gov/pubs/ma nuals/pract/pract_manual012508.pdf 8/7/2010
