Primary Care: Screening For Risk Of Prescription Drug Abuse

Michael M. Heuninckx

As primary care providers, it is our duty to ensure that the medications we are prescribing to our patients do not do more harm than good. Any goal of pharmaceutical therapy is to aid our patients during their time of medical need. As with anything in medicine, there is always risk involved. No matter how small the risk is, there is always some degree of risk. Primary care providers, when prescribing medication, must always do a risk/benefit analysis to see if the overall benefits of the medication being prescribed outweigh the risks of the medication.

In America today, prescription drug abuse is steadily on the rise. This has led the Drug Enforcement Agency (DEA) to reschedule hydrocodone combination products from a schedule III medication to a schedule II medication("Schedules of controlled," 2014). Becker & Starrels directly correlate a rise in the misuse of prescription medications to the rise in the number of prescriptions being written (2015). Specifically, opioid analgesics for the treatment of chronic pain and stimulants for the treatment of attention deficit hyperactivity disorder (ADHD) (Becker & Starrels, 2015). These medications have seen a drastic increase in the volume of prescriptions being written between the years of 2010 and 2014 (Becker & Starrels, 2015). Patients who were never addicted or abused medications before, now are. Lives are being destroyed and even lost because of prescription drug abuse. This paper will discuss the importance of this topic, a screening tool that can be used to identify patients at risk and strategies to implement the screening tool into practice.

Why Is Identifying The Risk For Prescription Drug Abuse Important?

At times our own biology can be working against us. Our brain is a fascinating and complex organ, but there still is a ton of information that is unknown. We do know our brain is able to detect pleasure, but at times, has the ability to fool us in regulating what is too much of a good thing. Prescription medications such as opioid analgesics, benzodiazepines, sedatives and stimulants have a vital role in managing medical conditions but have the ability fool the pleasure centers in the brains of susceptible individuals (Becker & Starrels, 2015).

Opioid Analgesics

The increase in opioid analgesic medications for treatment of pain has been increasing since the 1990's (Becker & Starrels, 2015). With this increase, there has also been a spike in the morbidity and mortality of this drug class (Becker & Starrels, 2015). In the year 2010, there were over 38,000 deaths in the United States due to drug overdoses (Becker & Starrels, 2015). Of those, 16,650 (43 percent) involved opioid analgesics (Becker & Starrels, 2015). Of the 16,650, 30% of those deaths also involved another drug family of potential abuse, benzodiazepines (Becker & Starrels, 2015).

Stimulants & Sedatives

Stimulants do not have the profound number of deaths as opioid analgesics, but they have gotten some attention for an increase in patient visits to the Emergency Room (ER) (Becker & Starrels, 2015). From the year 2005 to 2010, ER visits have increased by 134%; from 13,379 visits a year in 2005 to 31,244 visits a year in 2010 (Becker & Starrels, 2015). In regards to sedatives, patients run into a problem when the medication is used in combination with opioid analgesics or alcohol (Becker & Starrels, 2015). This combination has a cumulative effect in the body that has proven to be a deadly one.

Evidence-Based Screening Tool

The evidence-based screening tool that can be used to evaluate for risk of prescription drug abuse is called, a single item screening test (Saitz, 2015). When screening, prescribers will ask the single question, "How many times in the past year have you used an illegal drug or a prescription drug for non-medical reasons?" (Saitz, 2015). Patients might be confused with the phrase "non-medical reasons", that can be further clarified with the response, "for instances the experience or feeling it caused" (Saitz, 2015). If the patient's response is anything greater than zero, this would indicate a positive result for the screening (Saitz, 2015). Statistically, a score greater than a zero would be 100 percent sensitive and 74 percent specific for a drug use disorder (Saitz, 2015). Also, a score greater zero would statistically be 93 percent sensitive and 94 percent specific for a past year drug use (Saizt, 2015). Concluding that if primary care providers were to prescribe this patient a potentially habit-forming or historically abused medication, it would not be the best medication choice and other medications should be considered. This screening tool has been proved to yield comparable results to longer questionnaires (Saitz, 2015). Specifically, the screening tool has a similar sensitivity and specificity to the 10 Item Drug Abuse Screening Tool (Saitz, 2015).

Implementation Into Practice

Creative Social History Gathering

When providers are gathering their social history, the provider can replace their usual method of assessing illegal drug use with the screening question. Using the screening question, "How many times in the past year have you used an illegal drug or a prescription drug for non-medical reasons?" will allow for a more thorough assessment (Saitz, 2015). Assessing both potential drug use, and risk for potential prescription drug abuse through a statistically proven screening question.

Timing Of The Screening Question

Work the screening question into a part of the exam when you are not asking the patient a "history list" of yes or no questions. It is easy for the patients to just say no to a list of questions. This question can be a sensitive one for the patient and critical for providers to truthfully know. Thus, working the question into a more relaxed, conversational portion of the exam may lead to a better result and outcome in the end.

Established Patient Episodic Visit

During the established patient episodic visit, there is a high probability that a full history gathering will not take place at this time. One, because this is an established patient episodic visit and the practitioner is already familiar with the patient. Two, unfortunately there are time restraints that practitioners are under to keep the flow of patients throughout the day and obtaining a full history is not realistic. It is imperative though, that the single item screening question is asked every time a prescription of potential abuse is prescribed. An established patients life can be going in a positive direction one minute and disaster can strike the next. The single question screening test can be easily worked into any conversation and requires no extra time to perform by either the patient or the provider. The consequences though can be catastrophic and when the stakes are so high, it would be a shame for something to be missed because the provider felt under a time constraint.

Conclusion

Primary care providers have an enormous amount of responsibility when caring for their patients. With this responsibility, it is imperative that when primary care providers are writing prescriptions, they are cognizant of the risks involved. Not only the side effects of medications but drug classes that have a risk of dependency and abuse. Specifically, medications that fall into the drug classes of opioid analgesics, benzodiazepines, sedatives and stimulates hold a high risk of life-altering consequences (Becker & Starrels, 2015). Primary care providers must first increase their awareness of these pitfalls and educate themselves on techniques to identify the risk of patient abuse. All that it takes is asking the statistically proven single-item screening question, to prevent the poor outcomes detailed in this paper. Incorporation to this screening test into any practitioners daily routine will lead to safer practices of writing prescriptions. It would be a tragedy for a patients life to be lost all because one simple question was not asked, "How many times in the past year have you used and illegal drug or a prescription drug for non-medical reasons?" (Saitz, 2015).

References

Becker, W. & Starrels, J. (2015). Prescription drug misuse: epidemiology, prevention, identification, and management. UpToDate.

Federal Register. (2014). Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II. Retrieved from Federal Register

Schedules of Controlled Substances: Rescheduling of Hydrocodone Combination Products From Schedule III to Schedule II

Saitz, R. (2015). Screening for unhealthy use of alcohol and other drugs. UpToDate.