Primary Care: Screening For Risk Of Prescription Drug Abuse

Primary Care Providers face a challenging task when prescribing medications. Awareness of the pitfalls to medications and proper patient screening for potential abuse is critical for all providers. This article offers providers: a look into why identifying for potential abuse is so important, an evidence based tool for screening and strategies practitioners can use to implement the screening tool into their practice.

Updated:  

  1. In your practice today, do you screen for potential prescription drug abuse?

    • 10
      Yes, I screen all of my patients for the potential of prescription drug abuse.
    • 3
      No, I do not screen my patients for the potential of prescription drug abuse.

7 members have participated

Primary Care: Screening For Risk Of Prescription Drug Abuse

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.

1
Up Vote Up Vote ×
Michael M. Heuninckx

About Michael M. Heuninckx

Nurse Practitioner / Author
11 Articles   43 Posts

Share this post

Share on other sites
Specializes in Nephrology, Cardiology, ER, ICU.

Great article. I screen SOME of my patients but I also rely on our prescription monitoring system PIL - Redirect for info. In IL, this is a computer data base that includes name of the patient, drug (any controlled substance), amt, dates script filled, what insurance they used which includes private pay and the providers name.

This has been invaluable for me. In my area norco 5/325 goes for about $20/pill on the street.

Up Vote Up Vote ×
Specializes in Adult Nurse Practitioner.

This is a serious problem. Although in Florida a NP cannot write prescriptions for controlled substances, it is important to identify patients who are at risk. Thank you for sharing this informative and responsible post!

Up Vote Up Vote ×

You are right on with the fact that something needs to be done with over prescribing especially opiates... But asking the question "How many times in the last year have you used illegal drugs or prescriptions for non medical reasons" you are Not going to get a truthful answer. I agree with you that a pre-screening needs to be done.. but in regards to prescription over-use/dependence you need to out fox the fox...The health care team should look at the pt. history and number of episodes to the ER, that will give you a clue... if you suspect a dependence contact the area pharmacies.. you will be surprised how many times pt. will fill their prescriptions at various pharmacies..(because they will go to the dentist, the specialists ect. ect... ) once they know how to play the system they will play the game. I believe that no one should receive any type of opiate except for post op patients, and even then they should have only a weeks supply... If the patient is well enough to go home, a weeks supply should be sufficient. No one needs opiates for dental pain, back pain, sprained ankle.. etc. etc. A strong anti-inflammatory will keep the pain to a minimum. Thank you for sharing your post, well written... but remember when it comes to drug dependence/addiction you have to out-fox the fox.

Up Vote Up Vote ×
Specializes in Family Nurse Practitioner.

"All that it takes is asking the statistically proven single item screening question, to prevent the poor outcomes detailed in this paper." by Michael M. Heuninckx, BSN, RN

Something worth adding is the provider also needs the stones to say NO or discharge a patient who isn't willing to work within your recommendations. Unfortunately they might become agitated, cry or even threaten which doesn't phase me. It can't. I do drug tox testing when I feel it is indicated. We are not here to be their friend, in these cases we are here to be the responsible, educated professional who is attempting to help them improve their lives or at the very least prevent accidental overdose.

Some of the tip offs include repeatedly mentioning the name of a specific benzodiazepine, opiate, or stimulant during the assessment as the only thing that helps, becoming hostile at the suggestion of other classes of medications to treat ADHD such as strattera, or anxiety such as Buspar and minimizing the benefits of therapy. I address their concerns from the standpoint of current recommendations like stimulants are contraindicated for people with substance abuse history, benzodiazepines contraindicated for geriatrics and no way-no how am I adding percocets to someone on Methadone or Suboxone.

Up Vote Up Vote ×
Specializes in Family Nurse Practitioner.
Great article. I screen SOME of my patients but I also rely on our prescription monitoring system PIL - Redirect for info. In IL, this is a computer data base that includes name of the patient, drug (any controlled substance), amt, dates script filled, what insurance they used which includes private pay and the providers name.

This has been invaluable for me. In my area norco 5/325 goes for about $20/pill on the street.

This database has been so helpful to see the big picture. Every once in a while I'm wrong but most times my gut is right on target and it is shocking to see the multiple ED visits with requests for opiates and benzos. I had one pt who was xrayed 8 times in two months at different EDs where he presented with reported back injury in an effort to get a few opiates. It is not only sad but dangerous.

Up Vote Up Vote ×
Specializes in psych, addictions, hospice, education.

Indiana has a similar program to the one traumaRUs mentioned. Indiana's is named INspect.

Up Vote Up Vote ×
Specializes in ICU.
You are right on with the fact that something needs to be done with over prescribing especially opiates... But asking the question "How many times in the last year have you used illegal drugs or prescriptions for non medical reasons" you are Not going to get a truthful answer. I agree with you that a pre-screening needs to be done.. but in regards to prescription over-use/dependence you need to out fox the fox...The health care team should look at the pt. history and number of episodes to the ER, that will give you a clue... if you suspect a dependence contact the area pharmacies.. you will be surprised how many times pt. will fill their prescriptions at various pharmacies..(because they will go to the dentist, the specialists ect. ect... ) once they know how to play the system they will play the game. I believe that no one should receive any type of opiate except for post op patients, and even then they should have only a weeks supply... If the patient is well enough to go home, a weeks supply should be sufficient. No one needs opiates for dental pain, back pain, sprained ankle.. etc. etc. A strong anti-inflammatory will keep the pain to a minimum. Thank you for sharing your post, well written... but remember when it comes to drug dependence/addiction you have to out-fox the fox.

This subject is a sore one with me. It hits home. Apparently this person has never had chronic, debilitating pain. Or maybe an abscessed tooth? What about a kidney stone? Endometrial pain? Do you not think cancer patients should get opiates? As someone who has had numerous surgeries, I could have probably done without the opiate there before a kidney stone. Or when I was rolling around on the ground screaming my lungs out because endometriosis had invaded pretty much every part of my body except the head, arms, and legs. My ovaries twisted completely around and had fused themselves to my bladder.

The problem is what does a drug addict look like? Also, RN's don't prescribe drugs, the physicians do. So I'm trying to understand this article. It seems to be meant more for a primary care physician than a nurse. As a nurse, it's not your job to decide whether that person is addicted to drugs or not. The role of the RN is to ensure that at that moment and time it is safe to administer the drug to that person.

I take a narcotic on a daily basis. I live in Indiana. I have lots of hoops that I get to jump through for my scripts. I go to a pain management doctor. The physician and I have determined that I have tried absolutely everything to no avail to my pain. The drug regimen that I am currently on is the only thing that keeps my fibro in check. I also make sure I get adequate sleep, I exercise, and I eat fairly healthy. I can't say I don't cheat on my diet every now and then, but for the most part I do well. But this was a decision between my and my physician. It's not for anyone else to judge.

I get treated like a criminal. I must go to the same pharmacy. I have to call if say my normal one runs out and I have to try and find another. Since my medication works on chronic, long term pain, and say I had surgery or dental pain, I have to report to my pain physician if I say get a Norco script filled. I'm subject to random pill counts whenever they see fit. So, I'm kind of screwed if I have class all day and they call. I have drug screens every visit. I have never abused a drug in my entire life. I've never smoked a cigarette, and I have never taken an illegal drug. I have no idea to this day what marijuana smells like. I have only seen it on tv, I have never been around it. I'm 39. I've only ever gotten a few speeding tickets in my life. Never been in trouble with the law. But yet, I have an illness. An illness that I didn't have a say in getting. But I get treated like a criminal for it. I must be a drug seeker right? I know what meds work for me, so I must be a drug seeker. I did NSAIDs in the beginning. I can't take them anymore due to the holes they have eaten in my stomach. But because I say I can't take them, I'm a drug seeker, right?

Needing a medication for pain has become such a stigma. I'm not sure why. There should be so many others that aren't. But if we say we are in pain and need help we are wrong. I don't get that at all.

I understand that people abuse prescription drugs. People will abuse anything they can get their hands on. I recently attended a NA meeting for one of my clinical requirements. It was a real eye opener for me. The mind of an addict is much different than someone else. People with these issues take everything to the extreme, including playing basketball or golf. Shopping a huge one. If it makes this type of person feel good, they are going to take it to the extreme to get that high. Should no one ever play golf again? What about shopping ladies? Hey there are people using shopping to get high!! They are damaging their families by spending all of the family's money. Ban shopping for everyone. Better yet, let's screen everyone. That way we can decide for you if you might be a risk for excessive shopping. Every month they will look at your bank account and decide if you have shopped too much and are a danger to yourself and others. What? You think it's an invasion of privacy to have your bank looked at every month? Why is peeing in a cup in a room where i can't even wash my stinking hands not an invasion of my privacy? Why is what another physician does for me anyone else's business? But hey society has decided I'm a drug addict because I take a legal medication, so my privacy means nothing.

Think the shopping comparison was extreme? It's really not from what I learned. Many of these people who were addicted to drugs also had other addictions. Whether it was shopping, alcohol, golf, work. It's the mindset of that person. So before anyone judges another person for the prescriptions they are taking and want to screen them all, remember that many of us have illnesses that depend on these meds. The other people need to be treated for their addiction issues.

Up Vote Up Vote ×
Specializes in Adult Internal Medicine.

We screen all of our patients maintained on controlled substances as part of our contract in the prescription of those medications. We also review the Gateway database at each refill. We have a strict contract that we will not bend on: single pharmacy, single prescriber, routine monitoring by urine/counts, no early refills, no replacements, psychiatric evaluation. This, in my opinion, is the fairest way to handle the problem. It still creates stigma for those that "need it" (though I hate the phrase because addicts also have a need just a different types) but the problem needs to be addressed.

I've had patients with extensive surgical histories because of their pain addiction: they would let surgeons operate just to get the post-op narcotics.

And a previous poster stated that RNs don't prescribe narcotics physicians do, and just wanted to remind that many RNs (who are APNs) do prescribe these medications.

Sent from my iPhone.

Up Vote Up Vote ×
Specializes in ICU.

I know that a nurse practitioner can prescribe meds. There is one at my pain management clinic. I noticed that the person who wrote this is a BSN RN who does not prescribe.

Up Vote Up Vote ×
Specializes in Emergency Department.
I noticed that the person who wrote this is a BSN RN who does not prescribe.

Sorry for the confusion! Currently I am in graduate school to become a Family Nurse Practitioner. Since I have started my clinical rotations, I have been feeling the pressure and responsibility, that one day I will have when prescribing medications. I was researching techniques that I could incorporate into my practice that were statistically proven and different than the traditional questioners that are currently in practice. Through this research I was able to find the screening tool mentioned above and thought that I would write and article about the topic. It has been phenomenal to read everyones feedback and THANK YOU to everyone who has posted. Your words are not going unread!

Michael M. Heuninckx RN-BSN

Up Vote Up Vote ×

I do some work in Indiana so I get info from the state on a pretty regular basis. Right now there is a county in southeastern Indiana that is having a huge HIV outbreak. Currently 130 cases and climbing every week. The county at the center of the breakout has a population of 25,000.

Indiana HIV outbreak rises to 130 cases

The cases are currently not linked to heroin. It is people shooting up Opana from pain clinics. Given the time it takes for HIV to show up in the system after infection we aren't close to seeing the end of the cases.

I use INSPECT, KASPAR and OARRS (Indiana, Kentucky and Ohio prescription monitoring programs) and I have been totally surprised on occasion by patients I never would have expected to be obtaining multiple prescriptions (Some are probably self abusing others the numbers are so high they have to be diverting).

To the earlier poster who compared shopping and golf to opioid addiction I have some great news. You can rest easier tonight because they aren't in the same stratosphere with regards to risk- no one is dying from excessive shopping and golfing. The same cannot be said for opioid addiction.

Just like I cannot look at someone and know their pain level I cannot look at someone and know their genetic predisposition to addiction or the need to sell pills to others. So I fully support common sense rules like drug testing, pill counts and requirements that limit the number of prescribers and pharmacies. The rules are for public safety because we are in a public health emergency when it comes to the use and abuse of opioids.

Up Vote Up Vote ×
+ Add a Comment