Dr. Anthony C. Tommasello, Associate Professor and Director, University of Maryland School of Pharmacy, Office of Substance Abuse Studies
WHEN:
Wednesday, March 17, 2004, 3:00-4:00 pm EST
SPONSOR:
CSAT
This Web chat is designed to foster discussion of topics raised in the Addiction by Prescription Webcast that was broadcast on March 3, 2004. This program highlights groundbreaking strategies to treat addiction to prescription medications and looks at the new office-based and pharmacological approaches that are helping to make treatment more effective.
To view the Webcast, visit http://www.recoverymonth.gov/2004/multimedia/w.aspx?ID=245.
Chat Transcript
Moderator: The Web chat will begin in 5 minutes.
Welcome to the Road to Recovery: Addiction by Prescription Web chat. Our host today is Dr. Anthony C. Tommasello, associate professor and director, University of Maryland School of Pharmacy, Office of Substance Abuse Studies. This Web chat will foster a discussion about groundbreaking strategies to treat addiction to prescription medications and look at the new, office-based and pharmacological approaches that are helping to make treatment more effective. Please note that the views and opinions expressed by non-CSAT staff members in the Web chats and Webcasts should not be interpreted as official CSAT policy, but, as the views and opinions of the individuals participating in these events.
Now, we are ready for the first question. This question was previously submitted.
Who is best suited for brief interventions?
Dr. Tommasello: I think anybody should have the opportunity to be the recipient of a brief intervention. The question really is how do we know as health professionals who we should select for a brief intervention. The question is how do we screen a population for potential substance abuse problems; and there are several screening questions that we can use. Probably the one most familiar are the CAGE questions. C stands for have you ever had the need to cut down on your alcohol or drug use. A stands for have you ever felt annoyed by criticism of alcohol or drug use. G stands for have you ever felt guilty about alcohol or drug use. E stands for have you ever felt that you needed an eye opener to get you started for the day. If someone answers yes to one of those questions, they are a candidate for a brief intervention.
The other part of the question might be can we tell who can benefit from a brief intervention. I think the answer is that we can't. We do it for everyone and hope for the best.
Andrea: What is the role of the physician versus the pharmacist in preventing prescription drug abuse?
Dr. Tommasello: The physician prescribes and the pharmacist dispenses medications. Pharmacists have a corresponding responsibility in the prescription process. So, physicians should be careful when they prescribe any scheduled drug to ensure the best medication for the patient so the patient is not likely to abuse the substance. And that is a little tricky, so the doctor should be raising all kinds of red flags if patients complain of symptoms such as pain and say the only thing that works for them is Oxycontin 80 mg tablets, for instance. The pharmacist who receives that prescription should be checking that prescription against the patient's prescription profile at the pharmacy. They should be on the lookout for fake prescriptions, and there are a variety of resources to identify fake or altered prescriptions. They should check with the prescribing physician if there are any questions about the authenticity of the prescription. And [they] should refuse to fill prescriptions if they are not satisfied that the prescription is in the best interest of the patient.
ras: What is being done to better screen patients that may require pain medication but who may be at risk for prescription drug abuse?
Dr. Tommasello: AMERSA is a group of varied health professionals. The acronym stands for the Association for Medical Education and Research in Substance Abuse, and the group has published recommendations for faculty development in all the professions to improve substance abuse education for health professionals across the board. The goal of these recommendations is to ensure that all health professionals can screen assess and refer patients for substance abuse and substance abuse treatment. So, we need to instruct and educate health professionals to carry out screening before they prescribe prescription medications that have potential for abuse.
Terry: It seems like more health insurance companies are encouraging mail-order prescriptions these days. What effect does that have on prescription drug abuse? Is it harder to catch the abusers who order via mail?
Dr. Tommasello: I think I have personally looked on the Internet and been surprised that it is relatively easy to order schedule II narcotics. I see a variety of problems with this, and the biggest problem is there is no patient-physician relationship in which a legitimate prescription can be written. I do think this can lead to an increase in diversion of schedule II drugs for purposes other than which they are intended, specifically for abuse.
ras: With all of the press that Oxycontin has gotten over the last 2 years as a drug with high abuse potential, what is being done to try to control the distribution of this drug?
Dr. Tommasello: The drug company that manufactures Oxycontin has done, in my opinion, a good job in informing health professionals about the abuse of their product. And the company has developed good informational packages for physicians and pharmacists that instruct them on the tell-tale characteristics of prescription fraud and patients who might be abusing the prescription process. I think I would go back to the references we talked about: Corresponding responsibility of physician to pharmacist and working together to ensure Oxycontin is available to those who need it and it is not being abused by those who do not need it, those who only want a drug high. The problem with the street abuser of Oxycontin is that he or she may be insufficiently tolerant to the narcotic effect of this high-dose medication and may wind up overdosed by their abuse of Oxycontin.
Andrea: Childproof caps don't keep teens from accessing their parents' medications. What advice would you give to parents to keep their medications out of the hands of teens?
Dr. Tommasello: I think, first of all, it is important to realize the medicine cabinet is one of the places kids get drugs, just as the family bar is a place for teens to get alcohol. So the best advice is to talk with kids about drug use so the expectation is that the teenagers won't be seeking drugs in the first place. If there is concern about teens accessing drugs in the medicine cabinet, then parents should keep the medicine in a more secure place, especially to avoid accidental ingestion by youngsters.
Terry: How are pharmacy students being taught to identify and manage prescription drug abuse?
Dr. Tommasello: My job at the pharmacy school at U of MD is to train and educate students about these very issues. When it comes to prescription drug abuse, I make sure our students are familiar with the tell-tale characteristics of prescription fraud and give them ideas about how to handle questionable prescribing practices by physicians they may run into.
ras: Physicians are concerned that the level of care will suffer if legislation is created that makes it difficult to describe some prescription painkillers. Is this a valid concern?
Dr. Tommasello: I think this is a valid concern. There are concerns in the literature that patients with pain may be undermedicated because doctors feel fear about abuse of the drugs by the patients. I have also been personally involved in cases where physicians, after prescribing to patients for a long time, suddenly become concerned about the patients continued use of the drug and try to abruptly discontinue it.
So we have to strike a balance, and that is not easy to achieve.
ras: What kind of support services are available to pharmacists who are recovering from prescription drug abuse? And is it feasible that they could re-enter their field again once they get their addiction problem under control?
Dr. Tommasello: Across the country, States are developing professional recovery programs that help pharmacists as well as other health professionals receive treatment for their addictions and re-enter the practice of their profession. Again, we have to recognize that a health professional should not be practicing while they are impaired by drug abuse. Therefore, professional recovery programs have to recognize the need to protect the public from impaired professionals as well as helping the professionals into recovery and back into practice. Specifically for pharmacists, there is a national program called the Pharmacists Recovery Network, and, in each State, the point of contact would be the State pharmacy association.
Andrea: Once a pharmacist is in recovery for prescription drug abuse, what level of stigma typically occurs in the workplace?
Dr. Tommasello: Pharmacists in recovery sometimes find it difficult to be employed after treatment. The law protects substance abusers from discrimination. The Americans With Disability Act guarantees that individuals cannot be descriminated against on the basis of their chronic disease, but the law does not remove [discrimination] from people's minds. The idea is that it is risky to employ a recovering health professional, specifically a pharmacist. But the research indicates a pharmacist in treatment and under the monitoring program of their State's pharmacist recovery program is low risk for relapse.
Terry: What new programs have been developed to prevent prescription drug abuse by pharmacists?
Dr. Tommasello: Most pharmacies have surveillance ongoing in their pharmacy departments, and in some cases we see pharmacists being caught ingesting drugs off the shelf by these surveillance programs. In most States, the Board of Pharmacy Policies include sanctions for pharmacists who dispense drugs while under the influence of illegal drugs or alcohol. Therefore, a pharmacist who is practicing while impaired is breaking the law. These pharmacists, if reported to the State Board of Pharmacy, risk losing their licenses. Pharmacy recovery programs in those States can help these pharmacists get into treatment, initiate recovery from their addictions, and eventually return to practice.
ras: What effect do you think the Internet will have on prescription drug abuse over the next 5 to 10 years?
Dr. Tommasello: We have already talked about drug access through the Internet. It seems to be increasing the access to schedule II drugs. We need to figure out as a Nation how to manage this market that is so easily accessible through the Internet.
Andrea: Prescription drugs often are abused by accident, especially by the elderly. What's being done to curb that?
Dr. Tommasello: Nursing homes and assisted living programs are being taught more about elderly abusive medications and are learning techniques to avoid these mishaps from taking place. It sounds from the question that we are not talking about elderly patients abusing drugs to get high, but abusing substances accidentally by not following prescription directions, or because of their increased sensitivity to drug effects.
In the controlled environments of nursing homes and assisted living programs, elderly patients are receiving their medications from trained health professionals, and these health professionals should be reducing the risk of overmedicating these patients simply by observing the patients' response to the drugs.
The bigger problem is the elderly patients living at home and not having someone to monitor their prescription drug use. Pharmacists and nurses should be using different reminder techniques so that patients don't take more than was prescribed, but do take the medication the way it was prescribed.
Andrea: Among health professionals, would you say that there's more prescription drug abuse in the clinical setting or the pharmacies?
Dr. Tommasello: We have some information from research that relates the risk of substance abuse among nurses. Men use more than women; younger professionals use more than older professionals; the more informed they are about psychoactive medications, the more likely they are to use them; and the less control there is, the more likely the nurse is to abuse the medication. On the other hand, there is no evidence that substance use and addiction rates among health professionals are any greater than [the rates among] the general population. What differs is the drugs people select to use. Thus, among pharmacists, the primary drugs of choice are narcotics; whereas, in the general population, the highest addiction rates other than for tobacco are for alcohol. I can say in Maryland our own data suggests we receive more referrals for impaired pharmacists from dispensing sites than from clinical settings.
Moderator: This question was previously submitted.
Why are young kids abusing prescription drugs?
Dr. Tommasello: Young kids are abusing all kinds of drugs. Any medication that changes their feeling state is attractive to someone who is in search of a drug high. Young kids will use what they have access to. It is easy for kids to get drugs in our society-street drugs as well as prescription drugs. When we look at data from self reports by young people in our high school survey, we find that the most frequently abused drug is alcohol and the most frequently abused illegal drug is marijuana. When we ask about prescription drugs in those surveys, the levels remain well below alcohol and marijuana use. But they are rising, and that causes concern among substance abuse prevention professionals.
Terry: What programs exist to bring awareness of the problem of prescription drug abuse among pharmacists?
Dr. Tommasello: One of the best programs available is the Utah Summer School on Alcoholism and Other Drug Dependencies, as far as pharmacists are concerned. Pharmacists from all over the country can join an educational program offered by this summer school that focuses specifically on pharmacists and addiction. In addition, the American Pharmacists Association is undertaking educational campaigns to bring these problems to light among pharmacists, both for their colleagues and for their patients.
Moderator: This question was previously submitted.
What are some of the barriers to increasing the use of brief interventions?
Dr. Tommasello: The biggest barrier is that few health professionals are trained in the art of brief intervention. For this reason, AMERSA is launching a national call to all health professional training programs to ensure all of our graduating health professionals can screen assess and refer individuals who have substance abuse problems. But the issue of brief intervention is different from screening assessment and referral, we have to train professionals specifically on the techniques of brief intervention. However, we cannot do brief interventions until we know how to screen and assess, and so the biggest barrier is the lack of faculty in our health professional schools to teach these subjects.
Andrea: Based on what you've seen during your career, what factors have led to the increase in prescription drug abuse?
Dr. Tommasello: I think one thing is the increase in prescriptions. We are now treating more medical problems than ever without outpatient prescription therapy. Therefore, there are just more prescription drugs in circulation. Now, you couple that with the epidemic of drug abuse in our society and you quickly come to the realization that people who are looking for drug abuse experiences would prefer to use a legitimate prescription medication that has guaranteed potency and purity than a street drug of questionable content.
Terry: I've had surgeries before that required narcotics for pain management during the at-home recovery period. The addictive effects of those meds were not explained to me by anyone. I was able to stop using the medication easily, but definitely understand how it can be addictive. What's the solution to better educating patients?
Dr. Tommasello: This is a challenge to all health professionals. I think we have poorly prepared ourselves to discuss these matters with patients. We have to be honest with pain patients when we talk about treating their pain with narcotic drugs and teach patients how to monitor their own use of prescription narcotic medication. We now have better techniques to help people medically withdraw from narcotic dependence. It is a pharmacological reality that high doses of narcotic prescription therapy taken for any length of time will produce physical dependence. But that is different from addiction, and we can use new medications to help people medically withdraw from their narcotic physical dependence very easily once they have completed their pain management course of therapy.
Moderator: This quesiton was previously submitted
Is the use of brief intervention limited to addiction treatment settings, or can they be administered in non-treatment settings?
Dr. Tommasello: Brief interventions work best in non-addiction treatment settings. If you are in an addiction treatment setting, you will want an intense intervention, not a brief intervention. So, the non-specialist should learn how to do brief interventions that are intended to get people to the experts who can provide the intensive interventions that can lead to recovery.
Moderator: Dr. Tommasello would like to make some concluding remarks.
Dr. Tommasello: I think we have covered a lot of ground. We talked about prescription abuse by teens; we talked about the use of brief interventions; and we talked about health professionals and addiction issues among those individuals. It is very apparent that our society is struggling with these issues and together we have to find a way to address this major public health and patient-centered problem. The challenge of Internet prescribing and access to drugs from remote sources disconnects patients from the physicians and the pharmacists who can give them personal information about their illnesses and about medications used to treat those illnesses. These health professionals are positioned to reduce the complications of prescription drug therapy, and, when we cut them out of the process, we are not doing ourselves a favor.
Join us next month for our next show, Alcohol and Drug Use Screening, Intervention, and Referral: Changing the Nation's Approach to Comprehensive Health Care.
We would like to thank our host, Dr. Anthony C. Tommasello, associate professor and director, University of Maryland School of Pharmacy, Office of Substance Abuse Studies for his participation in this online event. [We also would like to] thank our participants for their questions.
This transcript will be available shortly so that others may benefit from the dialogue. The chat has now officially ended.
