Charlene M. Dewey, M.D., M.Ed., FACP
Co-Director, Vanderbilt Center for Professional Health
William H. Swiggart, M.S., L.P.C./MHSP
Co-Director, Vanderbilt Center for Professional Health
Martha E. Brown, M.D.
Assistant Medical Director, PRN
UF Associate Professor of Psychiatry
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All speakers acknowledge that they
developed, teach, and operate CME courses
(fee) for physicians and other health care
providers on proper prescribing of CPDs.
1: Discuss current information regarding controlled
prescription drug abuse in the U.S., including how
physicians continue to overprescribe to their patients
2: Become familiar with the components of screening,
brief intervention and referral to treatment, (SBIRT)
3: Identify specific strategies to avoid risky prescribing to
help physicians avoid trouble with their Boards or the
DEA (including the use of the state prescription drug
monitoring program and CME education)
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Introduction
Proper prescribing
Continuing Medical Education interventions
SBIRT
Small group activity
“To write a prescription is easy, but to come to
an understanding with people is hard.”
~Franz Kafka
A Country Doctor,1919
“It is not what you prescribe, but rather
how well you manage the patient's care,
and document that care in legible form,
that is important.”
~Released by the Minnesota MBE 1990, adapted by both the North Carolina and TN
Boards of Medical Examiners
The problem:
Substance abuse, including controlled prescription
medication, is the nation's number one health
problem affecting millions of individuals.4
Rate of controlled prescription drug (CPD) abuse
has almost doubled from 7.8 million to 15.1 million
in the past decade (1992 to 2003)2
New drug users of pain relievers-2.4 million.
[marijuana (2.1 million) or cocaine (1.0 million)]
Manchikanti L, et al. 2005; Substance Abuse 2001; Bollinger LC 2005.
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Up to 43% of physicians DO NOT ask about controlled
prescription drug abuse when taking a patient's health
history
Only 19% received any medical school training in
identifying prescription drug diversion
Only 40% received training on identifying prescription drug
abuse and addiction5
many are not trained to effectively handle drug-seeking
patients
due to “confrontational phobia”- a term used to describe
physicians’ reluctance to say “no” to a patient, thus making
physicians an “easy target for manipulation.”5
Bollinger et al, 2005
Obtained from a single doctor
(19%)
Given free from a friend or
relative (56%)
Bought from a friend or relative
(9%)
Bought from stranger/dealer
(4%)
Internet (0.1%)
SAMHSA 2006
Definition: Prescribing scheduled drugs in quantities
and frequency inappropriate for the patient’s
complaint or illness.
 Known alcoholic or drug addict
 Large quantities/frequent intervals
 Family members
 For trivial complaints
Why Physicians Misprescribe Controlled Substances
 Family of origin
 Core personality
 Patient types
 Pharmacological knowledge
 Professional practice system
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DATED - fails to keep current
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DISABLED - failed judgment due to impairment
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DUPED - fails to detect deception
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DISHONEST - personal or financial gain
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DISMAYED - Rx as quick fix due to time
constraints
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DYSFUNCTIONAL - finds it hard to say NO
ADDICTION TREATMENT WORKS
100%
80%
70%
30%
20%
10%
50% to 70%
40%
30% to 50%
50%
50% to 70%
60%
40% to 60%
% of Patients who Relapse
90%
0%
Drug
Dependence
Type I Diabetes
Hypertension
Asthma
32%
 Average Age = 51
27%
 Male = 88%
227
21%
 Female = 11%
189
 N = 715
151
10%
5%
74
1%
2%
35
16
6
1940's
1950's
1960's
1970's
1980's
1990's
Medical School Graduation
January 1996 – March 2010
2000's
49%
350
34%
300
250
200
150
9%
100
8%
50
0
Solo
Partnership or
Group
Hospital-Based
January 1996 – March 2010
Other
Total N = 715
62%
62%
441
15%
7%
50
FP IM
Psy
9%
7%
62
Surgery
3%
23
ER
January 1996 – March 2010
3%
108
18
Dentist
Others
N = 715
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Misprescribing can happen easily
Many physicians are not trained to identify
substance abuse, diversion, or correct
protocols for pain management
Medical Boards are becoming more punitive
with physicians who misprescribe
DEA is scrutinizing prescribing practices and
the flow of controlled substances
Education can be helpful and is imperative!
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Provide fact-based education
Treat pain effectively and safely
Reduce contribution to diversion/misuse
Use SBIRT to increase referrals and
interventions/treatments
Recognize warning signs of abuse or misuse
Avoid future misprescribing
Assist with Medical Board requirements
Avoid legal or professional sanctions by SMB or
DEA in future
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61 of 69 physicians who completed the
Prescribing Controlled Drugs Course at CPH
strongly agreed that the course should be
taught to all practicing physicians (3/20112/2012).
The overall average self score on ability to
take a substance abuse history prior to the
course on 69 physicians was 2.8 – compared
to 4.6 after the course.
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Additional education of physicians after
residency is needed
Continuing Medical Education Courses proven
helpful
Prescribing Controlled Drugs
Program for Distressed Physicians
Maintaining Proper Boundaries (Vanderbilt)
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Small group
Identify why/how physicians misprescribe
Family Systems
Personal reflection
Role play of common patient presentations
Syllabus of key lectures and readings
Discuss practice organization
Understand SBIRT and other tools
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20 hour course to meet Board of Medicine
requirements for pain management specialists
in Florida scheduled for June 2012 (University
of Florida)
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Professional Development Series – On-line
modules 2012-13 (Vanderbilt University
Medical Center)
S
Screening – Screening patients at risk for substance
abuse; inquiring about family history of addiction;
using screening tools such as the NIAA 1-question
screening tool for alcohol use, AUDIT, CAGE,
CRAFT for adolescents, etc.
BI
Brief Intervention - Establish rapport with pt.; ask
permission; raise subject; explore pros/cons; explore
discrepancies in goals; assess readiness to change;
explore options for change; negotiate a plan for
change-(motivational interviewing)
RT
Referral to Treatment – For patients responding
positively to the screening tests, refer to AA, drug
addiction clinic, pain clinic, counseling, etc.
 Screening, Brief Intervention and Referral to
Treatment (SBIRT) is a well-studied screening and
intervention procedure to improve patients’ shortterm health outcomes and reduce health care costs.
 The Joint Commission has proposed SBIRT as a
performance measure for accreditation.
Proposed Accreditation Standards Could Compel U.S. Hospitals to Screen Patients for
Addictions (Bob Curley, 9/11/09)
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Individual and family history
“Have you ever used or currently use….[fill in the blank]?”
 tobacco, ETOH, marijuana, street drugs, prescription
drugs or other recreational drugs
Identify & quantify use
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Within your family, has anyone ever used or currently
use…
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Use standard form/tests:
5 A’s
CAGE, AUDIT, DAST, MAST, CRAFT, ASSIST, etc.
Combination: SMaRT
The University of Pittsburg SMaRT©: ASSIST (Alcohol, Smoking and Substance
Involvement Screening Test) Last accessed Jan 10, 2012
http://www.peru.pitt.edu/projects/smart/index.php
35 year-old female with fibromyalgia and low back pain who is
requesting opioids for pain management
Things to watch for:
 Red flags to indicate aberrancy/addiction
 Techniques to elicit relevant history in a patient with pain
 How to deal with an angry, demanding patient
 Technique for screening, referral, and brief intervention
(SBIRT)
Adopted from: Jackson T, Dewey C, Swiggart W, Baron M and Moore D. Guidelines for Proper Opioid Prescription. Vanderbilt
University School of Medicine 2009
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Break into small groups
Discuss question
Prioritize two ideas per group
Two minute report out
Large group discussion
 Statements: Legal issues and consequences for
misprescribing are becoming more prevalent.
The Joint Commission is considering requiring
SBIRT as a quality indicator.
 Question: How might you involve your state to
require physician training in SBIRT, use of the
PDMP for all patients, and training proper
prescribing practices to avoid misprescribing and
consequences of misprescribing?
More states are passing laws that regulate
prescribing:
 Regulations for pain clinics
 Regulations for who can prescribe
 CME hours required in order to prescribe long-term
narcotics
 Laws making diversion for own use a possible felony
 State Prescription Drug Monitoring Programs
 Continue to push for additional education of
our medical students and residents
 Raise awareness of DEA rules and changes
that occur http://www.deadiversion.usdoj.gov
 Implement laws on regular use of State
Prescription Monitoring Program
http://www.pmpalliance.org
 Monitor state laws and regulations that may
be draconian with education of legislators
Most physicians are not bad physicians but lack:
 information
 tools to deal with patients who have substance
abuse or difficult pain issues
 resources
 Small group education can make a difference
 Prevention is first priority
 Reviewed guidelines and regulations
 Described CPD problem
 Discussed SBIRT
 Reviewed CME courses and benefits
 Planned for improvements in each state
 Reviewed consequences and future directions
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The Center for Professional Health,
Vanderbilt University Medical Center,
Nashville, TN. www.mc.vanderbilt.edu/cph
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Prescribing Controlled Drugs: Critical
Issues & Common Pitfalls of
Misprescribing, The University of Florida
at Gainesville, FL.
http://ufcme.info/Misprescribing.html