Risk,  Recognize,  Resolve:  Addic2on  in  the  

Pharmacy  Profession    April  2  –  4,  2013  

Omni  Orlando  Resort    

at  ChampionsGate  

Learning  Objec2ves  

•  1.  Iden=fy  risk  factors  for  pharmacy  professionals  that  may  influence  the  development  of  the  disease  of  addic=on.  

•  2.  Iden=fy  the  signs  and  symptoms  of  the  disease  of  addic=on.  

•  3.  Describe  the  resources  available  to  pharmacy  professionals  when  a  colleague  may  need  assistance  with  addic=on  or  substance  abuse  issues.  

•  4.  Describe  the  structure  of  accountability  added  to  the  recovery  person  by  monitoring  with  a  Pharmacist  Recovery  Network.  

Disclosure  Statement  

Brian  Fingerson  has  no  financial  rela=onships  with  proprietary  en==es  that  produce  health  care  goods  and  services.  

Brian  Fingerson,  RPh  •  President,  KYPRN  –  Kentucky  Professionals  Recovery  Network  since  1986  

•  Clients/professions  include:  Accountants,  Pharmacy,  Den=stry,  Physical  Therapy,  Veterinary  Medicine,  Respiratory  Care,  Optometry,  Chiroprac=c,  Social  Work  

•  Work  with  these  professionals  through  their  licensing  Boards  

What  do  you  know?  Self-­‐Assessment  Ques2ons  T  or  F  

•  In  a  diagnosis  of  addic=on  using  DSM  IV  criteria,  one  must  exhibit  any  two  out  of  seven  of  the  criteria  within  the  past  six  months.    

•  Gene=cs  is  the  sole  determining  factor  as  to  whether  someone  becomes  addicted  to  a  substance  or  process.  

•  The  prognosis  for  someone  who  is  addicted  to  a  substance  includes  these  three:  1)  get  sober;  2)  get  locked  up;  or  3)  die.  

•  Alcoholism,  chemical  addic=on,  is  a  disease,  the  very  nature  of  which  renders  the  vic=m  incapable  of  recognizing  the  severity  of  the  symptoms,  the  progression  of  the  disease,  or  of  accep=ng  any  ordinary  offers  of  help.  

And  why  should  we  learn  about  addic2on  in  pharmacy  professionals?  

Crit  Care  Med.  2007  Feb;35(2  Suppl):S106-­‐16  Baldisseri  MR.  

Cri=cal  Care  Medicine,  University  of  Pidsburgh  School  of  Medicine,  Pidsburgh,  Pennsylvania,  USA.    OBJECTIVE:  The  objec1ve  of  the  ar1cle  is  to  present  the  available  data  from  the  literature  on  substance  use  disorders  in  healthcare  professionals.  Prevalence,  risk  factors,  treatment  op1ons,  and  reentry  into  clinical  prac1ce  are  discussed.  

Crit  Care  Med.  2007  Feb;35(2  Suppl):S106-­‐16  Baldisseri  MR.  

•  INTRODUCTION:  Impairment  of  a  healthcare  professional  is  the  inability  or  impending  inability  to  prac5ce  according  to  accepted  standards  as  a  result  of  substance  use,  abuse,  or  dependency  (addic5on).  The  term  substance  use  disorder  can  be  divided  into  substance  abuse  and  dependence  (addic1on).  Substance  abuse  results  in  adverse  social  and  professional  consequences.  Addic5on  manifests  as  physiologic  and  behavioral  symptoms  related  to  a  maladap1ve  paLern  of  substance  use.  

•  MAIN  RESULTS:  It  is  es1mated  that  approximately  10%  to  15%  of  all  healthcare  professionals  will  misuse  drugs  or  alcohol  alcohol  some  1me  during  their  career.  

Why  do  people  take  drugs  “recrea2onally”  in  

the  first  place?  

People  Take  Drugs  To:  

• Feel  good  (sensa2on  seeking)  • Feel  be[er  (self-­‐medica2on)  

A  major  reason  people  take    a  psychoac2ve  drug  is  they  

like  what  it  does  to  their  brains  

Prolonged drug use changes

the brain in fundamental and

long-lasting ways

Addiction is a

brain disease

Reward Pathway

Wow!!!  

Opiates Alcohol Cocaine Amphetamines Marijuana

Frontal  Cortex  

               Young adults may be less likely to develop serious alcohol

and other drug problems if the age of first use is

delayed beyond childhood or adolescence

AA  Grapevine  e-­‐poll  Ques2on:  At  what  age  did  you  have  your  first  drink?    Total  Responded:  7947    

0-­‐11   2308  votes  (29.04  %)  

12-­‐18   5110  votes  (64.3  %)  

19-­‐26   420  votes  (5.29  %)  

27-­‐40   52  votes  (0.65  %)  

41  or  older   57  votes  (0.72  %)  

Addic2on:  One  Defini2on  •  A  primary,  chronic,  neurobiological  disease,  with  gene2c,  psychosocial,  and  environmental  factors  influencing  its  development  and  manifesta2ons.    It  is  characterized  by  behaviors  that  include  one  or  more  of  the  following:  

Addic2on  behaviors:  

•  Impaired  control  over  drug  use  

•  Compulsive  use  

•  Con2nued  use  despite  harm  

•  Craving  

Fr  Vernon  Johnson’s  defini2on  of  addic2on  

•  “”Alcoholism,  chemical  addic2on,  is  a  disease,  the  very  nature  of  which  renders  the  vic2m  incapable  of  recognizing  the  severity  of  the  symptoms,  the  progression  of  the  disease,  or  of  accep2ng  any  ordinary  offers  of  help.”  

DSM  IV:  Diagnosis  of  Addic2on  (3  out  of  7  in  past  12  months)  

1.   Tolerance  2.   Withdrawal  Loss  of  Control:  3.   Used  more  and  longer  than  planned  4.   Unsuccessful  a[empts  to  quit  or  control  use  5.   Excessive  2me  spent  obtaining,  using,  or        

recovering  from  use  6.   Important  ac2vi2es  given  up  7.   Con2nued  use  despite  adverse  consequences  

DSM-­‐V  

Risk  as  a  healthcare  professional?  

 Don’t  know  of  anyone  yet  whose  reason  for  becoming  a  pharmacist  was  drug  access.    But…maybe  so?  

Risk  Factors  • General  Public  =  10%  

• Pharmacists  and  some  other  health  care  professionals  =  HCP  =  12-­‐16%  

So…Why  an  increased  risk  factor?  

•  Access  to  drugs  •  Stress  •  Knowledge  •  Family  history  =  1  parent  20-­‐25%  chance,  2  parents  30-­‐50%  

 And  how  can  this  be,  you  say?  

•  Dean  Dabney  in  JAPhA,  May/June  2001  

•  Vol.  41,  No.  3    •  Use  of  Mind  Altering  or  Poten2ally  Addic2ve  Prescrip2on  Drugs  (PAPD)  

Who  was  asked?  

•  It  was  a  random  sample  of  licensed,  prac2cing  pharmacists  who  were  members  of  APhA  in  the  fall  of  1996.  

   And  what  did  the  study      show?  

•  40%  indicated  using  PAPD  without  1st  obtaining  an  Rx  

•  20%  reported  5  or  more  life2me  episodes  

•  6%  reported  10  or  more  life2me  episodes  

•  6%  iden2fying  as  being  drug  abusers  

•  Drugs  obtained  by  stealing  drugs  from  employers  or  forging  Rx  

DENIAL – not just a river in Egypt* Yes – it has been said before!

• Don’t  • Even  • Know  •  I  • Am  • Lying  

Denial  from  Knots  by  R.D.  Lang  

•  There  must  be  something  the  ma[er  with  him  because  he  would  not  be  ac2ng  as  he  does  unless  there  was.    Therefore  he  is  ac2ng  as  he  is  because  there  is  something  the  ma[er  with  him.  

Denial  con2nued:  

•  He  does  not  think  there  is  anything  the  ma[er  with  him  because  one  of  the  things  that  is  the  ma[er  with  him  is  that  he  does  not  think  that  there  is  anything  the  ma[er  with  him.  

•  Therefore  we  have  to  help  him  realize  that,  the  fact  that  he  does  not  think  there  is  anything  the  ma[er  with  him  is  one  of  the  things  that  is  the  ma[er  with  him.  

HCP  good  at  “cover  up”  and  if  confronted  will  deny  

•  Denial  is  not  just  a  river  in  Egypt  •  Paranoia  and  irritability  •  Depression  •  Use  of  large  quan22es  of  alcohol  –  more  than  normal  or  more  than  others  present  

•  Blackouts  

Blackouts  -­‐  Once  a  person  has  had  one    

Fr  Vernon  Johnson  •  1)  You  can  never  tell  how  much  of  the  chemical  it  will  take  to  put  you  into  the  blackout  again.  

•  2)  You  can  never  tell  how  long  the  blackout  will  last.  

•  3)  There  is  no  connec2on  between  our  value  system  and  what  we  will  do  in  a  blackout.  

Problems  seen:  

•  Slurred  speech  –  frequent  drunkenness  

•  Personal  problems  

•  Paren2ng  problems  •  Sexual  dysfunc2on  or  promiscuity  

•  Insomnia  •  Having  ONLY  friends  who  like  to  party  

Problems  con2nued:  

•  Frequent  promises  to  cut  back  

•  Avoiding  social  func2ons  unless  “altered”  

• Memory  problems  

• Mood  swings  

•  Blaming  of  behavior  on  others  

• Withdrawal  into  isola2on  

Impairment  signs/symptoms  in  the  workplace:  

•  Changes  in  the  manner  in  which  pa2ents  and  colleagues  are  treated  

• Deteriora2on  of  personal  appearance  and  hygiene  

•  Loss  of  interest  in  work,  or….  •  “Super  Pharmacist”  or  Super  whatever  

Workplace  con2nued:  

• Poor  record  keeping  • Problems  with  concentra2on  • Med  errors  or  whatever  • Absenteeism  or  tardiness,  esp.  on  day  following  days  off  

• Pa[ern  of  frequent  job  changes  

Workplace  con2nued:  

• Paranoia  • Frequent  trips  to  the  bathroom  

• Mood  swings  

• Periods  of  unemployment  

Am  I  an  alcoholic?  

•  1.    Have  you  ever  decided  to  stop  drinking  for  a  week  or  so,  but  only  lasted  for  a  couple  of  days?  2  -­‐  Do  you  wish  people  would  mind  their  own  business  about  your  drinking-­‐-­‐  stop  telling  you  what  to  do?  3  -­‐  Have  you  ever  switched  from  one  kind  of  drink  to  another  in  the  hope  that  this  would  keep  you  from  gesng  drunk?  4  -­‐  Have  you  had  to  have  an  eye-­‐opener  upon  awakening  during  the  past  year?  

Am  I  an  alcoholic?  

•  5  -­‐  Do  you  envy  people  who  can  drink  without  gesng  into  trouble?  6  -­‐  Have  you  had  problems  connected  with  drinking  during  the  past  year?  7  -­‐  Has  your  drinking  caused  trouble  at  home?  8  -­‐  Do  you  ever  try  to  get  "extra"  drinks  at  a  party  because  you  do  not  get  enough?  

Am  I  an  alcoholic?  

•  9  -­‐  Do  you  tell  yourself  you  can  stop  drinking  any  2me  you  want  to,  even  though  you  keep  gesng  drunk  when  you  don't  mean  to?  10  -­‐  Have  you  missed  days  of  work  or  school  because  of  drinking?  11  -­‐  Do  you  have  "blackouts"?  12  -­‐  Have  you  ever  felt  that  your  life  would  be  be[er  if  you  did  not  drink?  

CAGE-­‐AID  

• Cut  down  • Annoyed  • Guilty  • Eye  opener  

JAMA 252:1905-1907, 1984 Am J Med 82:231-235, 1987

CAGE-AID: CAGE Questions Adapted to Include Other Drugs

p9  

CAGE-­‐AID  1.  Have  you  felt  you  ought  to  cut  down  on  your  drinking  or  drug  use?  

2.  Have  people  annoyed  you  by  cri=cizing  your  drinking  or  drug  use?    

3.  Have  you  felt  bad  or  guilty  about  your  drinking  or  drug  use?      

4.  Have  you  ever  had  a  drink  or  used  drugs  first  thing  in  the  morning  to  steady  your  nerves,  get  rid  of  a  hangover,  or  get  the  day  started?        Screen  posi5ve  score  =  1+or  2+  

           

CRAFFT  Ques2ons  5.  Have  you  ever  ridden  in  a  CAR  driven  by  someone  

(including  yourself)  who  was  “high”  or  had  been  using  alcohol  or  drugs?  

6.  Do  you  ever  use  alcohol  or  drugs  to  RELAX,  feel  beder  about  yourself,  or  fit  in?  

7.  Do  you  ever  use  alcohol/drugs  while  you  are  by  yourself,  ALONE?  

8.  Do  your  family  or  FRIENDS  ever  tell  you  that  you  should  cut  down  on  your  drinking  or  drug  use?  

9.  Do  you  ever  FORGET  things  you  did  while  you  were  using  alcohol  or  drugs?  

10.  Have  you  goden  into  TROUBLE  while  you  were  using        alcohol  or  drugs?      Screen  posi5ve  score  =  2+  

           

But  I  can’t  be  one!!!!!!!!!!  

If…then  three  courses  of  ac2on:  

• Sober  up  • Get  locked  up  • Get  covered  up  =  PUAD    

Do  they  have  to  reach  this  level?  

It  is  this  serious  folks!  

To  whom  do  I  turn  for  help?    Do  you  call  the  professional’s  licensing  Board?  

  Board  balances  regula2on  with  compassion  

  Is  it  a  bad  person  in  need  of  punishment  or  an  ill  person  in  need  of  care?  

There  is  an  op2on  in  some  states  

  You  could  call  your  state’s  recovery  program  

  I  publish  my  office/home  phone  number  

  The  website  www.usaprn.org  has  a  directory  of  state  programs  

Referral  by:  •  Board  •  Self  •  Colleague  or  employer  

•  Family  

•  Interven2on  •  ***anonymous  

Why  do  they  ask  for  help?  

• Liver  • Lover  • Livelihood  • Law  

Then  what  happens?  

Evalua2on  

•  KYPRN  uses  addic2ons  psychiatrists  and  some2mes  a  residen2al  3-­‐5  day  assessment  

•  Results  of  evalua2ons  will  determine  to  a  large  extent  what  type  of  treatment.    It  may  be  AA/NA,  IOP,  Long-­‐term  residen2al  or  other  or  a  combina2on  

Yes…Rehab  does  work!  

Goals  of  Addic2on  Therapy:  

•  Reduc2on  or  elimina2on  of  denial  •  Increased  self  care  •  Treatment  of  medical  and  psychiatric  problems  

•  Treatment  of  co-­‐morbid  family  

•  Educa2on  to  protect  himself  or  herself  from  substance  abuse  disease  

Contracts  

•  For  a  specific  length  of  2me  –  usually  5  yrs  

•  Shared  with  employer  –  if  per2nent  

• May  limit  number  of  hours  worked  

•  Approved  prac2ce  site  or  type  •  CAPTASA,  U  of  Utah,  SE  PRN  

Other  things  

•  Mee2ng  documenta2on  forms  

•  Medica2on  use  lists  

•  Monthly  self-­‐report  form  

•  Urine  Drug  Screens  

Pharmacist  may  have:  

•  Modifica2on  of  prac2ce  type  •  Prac2ce  monitoring  by  peers/others  

•  Protocols  for  required  mood-­‐altering  drugs  for  a  legi2mate  medical  problem  

•  Consequences  should  she  return  to  substance  use  

Conclusion  

•  Substance  abuse  by  HCP  is  a  condi2on  that  has  become  increasingly  recognized  over  the  past  20+  years.    We’ve  worked  hard  to  develop  treatment  protocols  and  support  programs.  

Treatment  does  work!  

  The  vast  majority  of  Pharmacists  who  successfully  complete  treatment  and  par2cipate  in  a{ercare  monitoring  CAN  and  DO  successfully  return  to  prac2ce.  

  HIRE  THE  RECOVERING  PROFESSIONAL  

“The  alcoholic  is  like  a  tornado  roaring  through  the  lives  of  others.”  page  82  

From  the  book:  “Alcoholics  Anonymous”  

Page  82  also  says:  “Hearts  are  broken.”    Our  goal  is:  Recovery    From  the  book:  “Alcoholics  Anonymous”  

Recovery:  by  Mike  Vye  

Not  this:  

True  or  False  

•  “Alcoholism,  chemical  addic2on,  is  a  disease,  the  very  nature  of  which  renders  the  vic2m  incapable  of  recognizing  the  severity  of  the  symptoms,  the  progression  of  the  disease,  or  of  accep2ng  any  ordinary  offers  of  help.”  

•  TRUE  

True  or  False  

•  In  a  diagnosis  of  addic2on  using  DSM  IV  criteria,  one  must  exhibit  any  2  out  of  7  of  the  criteria  within  the  past  6  months.  

•  FALSE  

True  or  False  

•  Gene2cs  is  the  sole  determining  factor  as  to  whether  someone  becomes  addicted  to  a  substance  or  process.  

•  FALSE  

True  or  False  

•  The  prognosis  for  someone  who  is  addicted  to  a  substance  includes  these  three:  1)  get  sober;  2)  get  locked  up;  or  3)  DIE  

•  TRUE  

Have  you  ever  wondered?  

Ques2ons?  •  Brian  Fingerson,  RPh  •  202  Bellemeade  Road  •  Louisville,  KY  40222-­‐4502  

•  502-­‐749-­‐8385  •  Email  =  kyprn@a[.net      

Thank  you  

Thank you Thank you Thank you