Clinical Track:U.S. and Canadian Prescriber

Attitudes and Education

Presenters:• Jennifer Fan, PharmD, JD, Substance Abuse and Mental

Health Services Administration• Sarah Lewis, MPH, CHES, Centers for Disease Control and

Prevention• Rita Noonan, PhD, Centers for Disease Control and Prevention• Amy Porath-Waller, PhD, Canadian Centre on Substance

Abuse• Paula Robeson, RN, MScN, Canadian Centre on Substance

Abuse

Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, Tennessee Department of Health, and Member, Rx Summit National Advisory Board

Disclosures

• Jennifer Fan, PharmD, JD; Sarah Lewis, MPH, CHES; Rita Noonan, PhD; Amy Porath-Waller, PhD; Paula Robeson, RN, MScN; and John J. Dreyzehner, MD, MPH, FACOEM, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;

Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives

1. Express the critical role for healthcare professionals in responding to Rx drug abuse.

2. Analyze the challenges perceived by healthcare professionals as they play that role.

3. Inform physicians and provider networks of messaging and education tools being designed for them by CDC/SAMHSA.

www.ccsaca • www.cclt.ca

Perceptions among Healthcare Professionals

of Prescription Drug Misuse

Amy J. Porath-Waller, PhDDirector, Research and Policy (interim)

Paula Robeson, RN, MScNTeam Leader, Knowledge Mobilization

Canadian Centre on Substance Abuse

Disclosures and Acknowledgements

• Amy Porath-Waller, PhD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Paula Robeson, RN, MScN, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Funding: Alberta Health

• Ethics approval: Health Research Ethics Board of Alberta, Community Health Committee

The views expressed herein do not necessarily reflect the views of Alberta Health.

Learning Objectives

• Express the critical role for healthcare professionals (HCPs) in responding to prescription drug abuse

• Analyze the challenges perceived by HCPs in that role

About CCSA

• Not-for-profit, arms-length from the federal government

• Created in 1988 by an Act of Parliament with all-party support

• Responsible for, and dedicated to, reducing alcohol- and drug-related harms

• Sets a long-term vision, advances solutions and contributes to international dialogue on these issues

• Primary funding from federal government; also from some provinces and territories, not-for-profit, private sector

• First Pan-Canadian strategy

• 58 recommendations being actioned by seven implementation teams• Prevention• Education• Treatment• Monitoring and Surveillance• Enforcement• Legislation and Regulations• Evaluation and Performance Measurement

• Two years of implementation phase completed

First Do No Harm: Responding to Canada’s Prescription Drug Crisis

Perceptions of Healthcare Professionals

• Dearth of research about HCPs’ roles in prescription drug misuse (PDM) (e.g., identifying, preventing, inadvertently enabling)

– Focus has been on opioids and addiction– Studies generally qualitative in nature with small samples of

physicians

• Important to understand HCPs’ perspectives to:

– Inform development of effective educational and prevention initiatives

– Improve capacity of HCPs to address PDM

Study Objectives

• To investigate perceptions of PDM among HCPs in one Canadian province

• Specific perceptions the study explored include:

– Extent and distribution of PDM

– Clinical characteristics of PDM

– Risk factors for PDM

– Barriers to identifying PDM

– Communication among HCPs about prescriptions

– Strategies for prevention and intervention

Definition of PDM

• Unintentional PDM includes using a prescription incorrectly, either because of misunderstanding instructions or a faulty memory (e.g., taking the wrong dosage)

• Intentional PDM includes using a medication incorrectly for

– Recreational use (e.g., to get high)

– Therapeutic benefits (e.g., to help relieve pain, to improve concentration, to help sleep, to change one’s mood)

The use of a medication for a medical purpose other than as directed or indicated, whether intentionally or

unintentionally, and whether harm results or not.

Methods

• Multidisciplinary expert panel with representation from professional colleges and associations

• Short, anonymous, online survey consisting primarily of closed-ended questions

• Data collected: November 13, 2013 to February 21, 2014

• HCPs were recruited from professional colleges and

associations

• Recruitment strategy included emailed invitations, advertisements in college and association newsletters and websites, and mailed postcards

Participants (n=1,063)

• Nurses (61.1%)

– Mean age: 47.7

– Years in practice: 21.6

– RNs: 93.9%

– NPs: 4.5%

• Physicians (9.3%)

– Mean age: 48.9

– Years in practice: 21.0

– Family medicine: 63.9%

– Emergency medicine: 12.4%

– Psychiatry: 6.2%

• Pharmacists (19.0%)

– Mean age: 40.9

– Years in practice: 16.5

– Community pharmacy: 69.2%

– Hospital pharmacy: 18.9%

• Dentists (10.5%)

– Mean age: 46.6

– Years in practice: 20.6

– General practice: 85.4%

– Orthodontics: 5.2%

Clinical Presentation of PDM

Behaviour indicating a patient is or was misusing prescription drugs• Scale from 1 (not at all) to 7 (definitely)

Behaviour Mean (SD) Group Differences

Altering the delivery of medication (e.g., snorting, injecting)

5.48 (1.39) Pharmacists > dentists*

Prescription forgeries 5.47 (1.40) Pharmacists > nurses**

Double doctoring 5.22 (1.32) Pharmacists > nurses**

Doctor shopping 5.18 (1.31) Pharmacists > nurses***

Family or caregiver expresses worry 4.88 (1.29) None

Use of medication is different than prescribed

4.76 (1.34) None

Request replacement for lost or stolen prescription

4.56 (1.44) Physicians, pharmacists > nurses***

*p <.05. **p < .01. ***p < .001.

Clinical Presentation of PDM (cont’d)Behaviour Mean (SD) Group Differences

Requesting that drug not be billed through routine insurance plan

4.54 (1.66) Pharmacists > nurses,***

dentists** and physicians***

Only requesting the opioid, stimulant or sedative portion of a prescription to be filled

4.40 (1.58) Dentists > nurses*

Pharmacists > nurses***

Coming in early to refill prescription 4.37 (1.59) Physicians > dentists*, nurses**

Pharmacists > dentists, nurses***

Requesting specific drugs 4.27 (1.47) Dentists > nurses*

Frequent visits to prescribers 4.21 (1.84) Dentists > pharmacists**

Nurses > pharmacists*

Change reasons for returning to prescriber 4.20 (1.54) None

Disproportionate pain/disability for presenting problem

4.18 (1.45) Physicians > pharmacists*

Appear intoxicated 4.18 (1.46) Physicians > dentists, nurses**

Pharmacists > nurses*

Lack of improved function 4.16 (1.49) None

*p <.05. **p < .01. ***p < .001.

Other PDM-related Patient Behaviours

• States specifically what should be prescribed

• Provides excuses as to why alternatives would not work

Patients say they are “allergic” to all non-opioid pain relievers.They specifically know the name of and request [a] drug.

• Vague about symptoms and medical history

• Acts aggressively or in an intimidating manner

Aggressive and threatening behaviour in the community when questioned about dosing.Threatening to report the physician to licensing body if pain isn’t treated as requested.

Other PDM-related Patient Behaviours (cont’d)

• Reports maximum amount of pain, but inconsistent symptoms

Rating pain level to be 10/10 as in severe, but vital signs are normal and patient appears to be comfortable (i.e. breathing normally).

• Uses manipulative behaviour

Patients (initially) tend to be very “friendly” or chatty to stay on your good side and keep you distracted.

• Talking too much

Overly talkative about meds.

Patient Risk Factors for PDM

• History of substance abuse

• Recent or active illicit drug use

• Suicidal ideation

• Chronic pain

• Recent or active alcohol use

• Psychiatric disorders

• History of sexual abuse

ChallengesIdentification of PDM in Patients

• Patient tendencies

– Lack of patient honesty

• HCP tendencies

– Lack of communication with the patient and his or her family

– Insufficient time with patients

– Lack of communication with patients’ other HCPs

– Lack of access to chronic pain or addiction specialists

– Reluctance to inquire about PDM with patients

ChallengesInadequate Training and Resources

• Overall, HCPs did not think they were effective in preventing or addressing PDM (M = 3.62, SD = 1.46)

– Nurses’ ratings were lower compared to those of physicians, dentists and pharmacists

– Pharmacists’ ratings were lower than those of physicians

• Only 26% of HCPs felt they had adequate support for preventing or addressing PDM

• On average, HCPs who felt they had adequate support reported it was effective (M = 4.71, SD = 1.16)

ChallengesPrescribing Practices

• Pharmacists indicated that during the past three months they were very likely to have encountered the following prescribing practices:

– Medication was prescribed to a patient that the pharmacist suspected was misusing the prescribed medication

– Medications were prescribed that should not be taken together (e.g., sedatives and opioids)

– Medication was prescribed to a patient who, in the pharmacist’s opinion, probably does not require the medication

– Increases in medication that were made too quickly

ChallengesInterdisciplinary Communication

• Opioids most frequent topic of communication among HCPs, compared to other categories of prescription drugs

• Positive interactions between the groups were generally reported (except interactions between physicians and pharmacists)

• Pharmacists reported that during the past three months they were likely to have encountered a situation where a physician

– Was difficult to reach directly by phone

– Did not promptly return calls

– Was not receptive to concerns

– Did not communicate or was not willing to share the therapeutic plan

Effective PDM-related Strategies

• Better connections with other HCPs (e.g., chronic pain and mental health)

• Improved access to a provincial prescription database

• Clinical guidelines for the management of high-risk patients

• Increased support for the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

• Improved understanding of

– Reporting protocols

– How information is used, tracked and shared

Conclusions

• Similarities and important differences in HCPs’ perceptions

• HCPs did not feel effective in preventing and addressing PDM

• Minority (26%) felt adequately supported to prevent or address PDM

• Communication issues exist between pharmacists and physicians

Implications

• Inform development of a multidisciplinary screening tool

• Provide additional support for HCPs

– Education and training in PDM risk-management and prescribing practices

– Improved access and connections with pain, mental health and addiction specialists

• Consider electronic health record system improvements to help improve communication and collaboration

• Conduct research

– Effectiveness of interventions to improve pharmacist-physician communication

Contact InformationAmy J. Porath-Waller, PhDDirector, Research and Policy Division (interim)

613-235-4048 ext. 252Aporath-waller@ccsa.ca

Paula Robeson, RN, MScNTeam Leader, Knowledge Mobilization

613-235-4048 ext. 267Probeson@ccsa.ca

Canadian Centre on Substance Abuse500–75 Albert StreetOttawa, ON K1P 5E7

@CCSAcanada • @CCLTcanada

Prescription OpioidsU.S. Prescriber Attitudes and Education

Sarah Lewis, MPH, CHES

Rita Noonan, PhD

Jennifer Fan, PharmD, JD

SAMHSA/CDC PresentersCDC National Center for Injury Prevention and Control:

• Sarah Lewis, MPH, CHESHealth Communications Specialist

• Rita Noonan, PhDHealth Systems and Trauma Systems Branch Chief

Substance Abuse and Mental Health Services Administration:

• Jennifer Fan, PharmD, JDPublic Health Advisor

• Sarah Lewis, MPH, CHES, Rita Noonan, PhD, and Jennifer Fan, PharmD, JD, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention and shall not be used for advertising or product endorsement purposes. Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government or the Centers for Disease Control and Prevention.

Session Overview

This session will:

• Discuss the current state of prescription opioid abuse and misuse;

• Review provider and patient attitudes, beliefs, and education surrounding prescription opioids; and

• Provide an introduction to a new education campaign from the SAMHSA and CDC.

Learning Objectives

At the conclusion of the session, participants will be able to:

1. Express the critical role for healthcare professionals in responding to Rx opioid abuse.

2. Analyze the challenges perceived by healthcare professionals as they play that role.

3. Inform physicians and provider networks of messaging and education tools being designed for them by SAMHSA/CDC.

Rates of prescription opioid sales, deaths and substance abuse treatment admissions (1999-2010)

EDUCATION CAMPAIGN

SAMHSA/CDC joint venture campaign to target messaging and educational tools for providers and patients

Research Shaping the Campaign

• Environmental Scan

– Past and Present Campaigns to Reduce Rx Opioid Misuse

– State, Federal, and Non-Profit Organizations

• Prescriber online training modules and webinars

• Web and social media campaigns, largely focused on youth

Prescription Drug Campaigns

Research Shaping the Campaign

• Environmental Scan

– Effective Messaging Strategies

• Use of multiple media channels combined with the distribution of a free or reduced price product

• Health communication interventions presented as social marketing campaigns are more successful

Research Shaping the Campaign

• Focus Groups

– Audiences

• Physicians

• Consumers

• Allied Healthcare

– Locations

• Washington, DC

• Atlanta, GA

Campaign Tools and Resources

• What?– Fact Sheets

– Brochures

• Where?– Campaign website for

providers and consumers

• How?– Partnerships with national and regional agencies

and organizations

Preliminary Results

• Focus groups for each of the 3 target audiences were held in March of 2015, in the DC and Atlanta metro areas.

• Participants were asked to provide feedback on early drafts of campaign materials. – Feedback was incorporated into new drafts and those

materials are currently being finalized.

• Participants also discussed their existing knowledge of prescription opioid misuse along with content areas about which they wished to learn more.

Preliminary Results (cont.)

• Terminology

– “Pain Meds” or “Painkillers”, instead of “Opioids”

• Experience with Alternative Therapies

– Complementary instead of Replacement

– Yoga, Acupuncture, Exercise, Chiropractic

– Issues with time and access

• Current Experience with Rx Opioids

• Receiving Information

Preliminary Results (cont.)

• Content

– More visual appeal

– Fewer words

– Highlighting specific information instead of general overview

• Design

– Less clinical, more eye-catching

• Titles and Taglines

Next Steps

• Finalize material development

• Launch campaign website

• Engage partners for promotional plan

• Implement campaign activities

• Evaluate reach

Clinical Track:U.S. and Canadian Prescriber

Attitudes and Education

Presenters:• Jennifer Fan, PharmD, JD, Substance Abuse and Mental

Health Services Administration• Sarah Lewis, MPH, CHES, Centers for Disease Control and

Prevention• Rita Noonan, PhD, Centers for Disease Control and Prevention• Amy Porath-Waller, PhD, Canadian Centre on Substance

Abuse• Paula Robeson, RN, MScN, Canadian Centre on Substance

Abuse

Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, Tennessee Department of Health, and Member, Rx Summit National Advisory Board