AppNET Meeting
March 1 2013
Breakout Sessions for:
Prescription Drug Abuse/Misuse
Group 1. MED Exercise
Below are two pill “profiles” that are self-verified accounts from self-identified pill
abusers. For each, please use whatever resources you need, and calculate the
typically ingested daily Morphine Equivalent Dosage (MED). There are three
resources appended to this document that will be useful. Note: Case 1 is a
monthly set of pills, and Case 2 is a daily regimen.
Case No. 1. Per month:
 Ambien 10 mg #30
 SOMA 350 mg #60
 Oxycontin 80 mg #300
 Roxicodone 30 mg #400
 Dilaudid 8 mg #370
 Xanax 2 mg #120
 Mepergan fortis (Demerol) #60 (with a note that says: “try not to use”)
o 1340 pills/month, 44 pills/day
Work together to calculate the MED and place here:
Case No. 2. Per day:
 40-50 Lorcet 10/650’s a day
 4 Xanax 2 mg
 one Valium 10 mg
 one Ativan 2 mg
 one Clonipin 1 mg and
 40-60 Soma 350 mg (Carisoprodol) at set times during the day; plus a
variety of other pills
Work together to calculate the MED and place here:
After your group has calculated the MED, engage in a discussion about training
needs related to MED, the usefulness of this concept in your clinic and any other
topic or information pertaining to volume of morphine equivalents and prescribing
practices.
Suggested additional questions to ask:
1) 120 mg/day MED is the target. Any thoughts about the final disposition of
the MED that are not ingested (assuming the capacity for MED is high).
2) Is there anything about the combination of drugs that is interesting or
important? What do you see in your practice?
3) How does Soma work in these combinations? Acetaminophen?
Group 1 uses the MED calculation framework on pp 16-17 of:
http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
AppNET Meeting
March 1 2013
Breakout Sessions for:
Prescription Drug Abuse/Misuse
Group 2. Communication
Assign small teams from within Group 2 to discuss each of the following two
scenarios. Then prepare two of your colleagues to stand and offer a role play, a
monologue, skit or stand-up comedy routine for each of the scenarios:
1) You need to provide guidance to a parent about protecting their recent
Vicodin prescription in their home, specifying facts about sources for new
initiates to prescription drug misuse, and potential activities or other things
they can do in the home to identify potential diversion issues in the home
and reduce their impact and likelihood.
2) Offer some details/a vignette about communication with a peer prescriber
who is suspected of being, or known to be, very liberal with opioid pain
medication. Predict how the conversation will go. Be sure to address the
following three known contributors to communication breakdown or
success:
a) The individual/actor’s willingness to communicate this information to
their peer. Willingness to communicate is an individual’s personality-based
predisposition to initiate communication about a topic.
b) The individual’s personal reluctance or nervousness level about
communicating this information. This is called communication
apprehension; high apprehension situations predict avoidance of
communication.
c) The individual’s self-perceived communication competence to address
this topic with their peer. This is situation specific and is basically the
same as ‘self-efficacy’, one’s belief in the ability to perform a task in a
specific context. What about their own knowledge level or “topical
competence” and good rules for practice?
Other discussion questions:
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

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What are barriers to communication about professional practices with
your peers? What encourages good, frequent and effective
communication?
What kind of help in identifying potential abuse are you getting from
pharmacies?
What are some other community assets that could be mobilized to
combat substance abuse? Who could mobilize them, or how would
this be done?
What is the proportion of pregnant women in clinic with opioid pain
reliever addiction? Is this a known percentage or perceived? What
motivation do pregnant women have to lie about their use?
AppNET Meeting
March 1 2013
Breakout Sessions for:
Prescription Drug Abuse/Misuse
Group 3. Spotting abuse.
Please discuss with your colleagues your relative comfort with detecting opiate
and other pill abusers in your clinic. Our data show that about 68% of our study
participants agree or strongly agree that they can identify abusers in their
practice. Discuss your own relative comfort with detection.
Next, consider the six screening tools provided with this handout. Comment on
the relative value of each, in your opinion, and the ease of use in your practice.
Please summarize individual experiences and perceptions for the reporter to
offer to the workshop participants.
Group 3 uses the six screening tools found on pp 19-28 of the following guide:
http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
AppNET Meeting
March 1 2013
Breakout Sessions for:
Prescription Drug Abuse/Misuse
Group 4. NEJM letter.
I have provided a two-page letter that appeared in the New England Journal of
Medicine last Fall. In it, Dr. Anna Lembke, provides some thoughts about “Why
Doctors prescribe Opioids to Known Opioid Abusers”.
Please take a few minutes to read this brief piece and discuss it with your
colleagues in the group. Please react to the conclusions and reflect on your own
experience in clinical practice, providing examples to support or challenge her
conclusions. Your group may have additional thoughts on the topic that support
an alternate explanation. Elect a reporter that will offer your conclusions or
thoughts to the larger group.
Screen shot of letter (not for distribution):
AppNET Meeting
March 1 2013
Breakout Sessions for:
Prescription Drug Abuse/Misuse
AppNET Meeting
March 1 2013
Breakout Sessions for:
Prescription Drug Abuse/Misuse
Reference:
Lembke, A (2012). Why Doctors Prescribe Opioids to Known Opioid Abusers. N
Engl J Med, 367;17; 1580-81.