Substance Abuse in WV (Special CME Issue)

Transcription

Delivering on
Our Promise
Fifty years ago, when WVU opened the doors
of the Health Sciences Center, we promised to
serve the healthcare needs of the entire state.
We’ve delivered on that promise.
In every community, WVU alumni are helping people
lead healthier lives. Our medical facilities make worldclass care available to West Virginians close to home.
The WVU School of Medicine is ranked among the Top 10 for rural
health by U.S. News. The American Academy of Family Physicians
ranks WVU in the Top Five for graduating family doctors.
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hsc.wvu.edu
contents
Volume 106, No. 4
Special CME Issue
This document was prepared under a grant from the West Virginia Division of Justice & Community Services. Points of view or
opinions expressed in this document are those of the authors and do not necessarily represent the official position or policies of the
State of West Virginia or the Division of Justice Services.
“This project supported by Grant No.08-P-TRP-01 awarded by the West Virginia Division of Justice & Community Services and the
U.S. Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs, which also
included the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention,
and the Office for Victims of Crime. Points of view or opinions in this document are those of the author and do not represent the official
position of policies of the United States Department of Justice.
Scientific Articles
Also in
this issue…
» Physicians’ Perceptions of Doctor Shopping
» WV Birth Score: Maternal Smoking & Drugs of Abuse
» Bringing All the Players to the Table: The West
»
»
»
»
»
»
»
»
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Virginia Controlled Substance Advisory Board
Prescription Drug Abuse & Addiction: Past, Present
and Future: The Paradigm for an Epidemic
The Face of Hillbilly Heroin and Other Images of
Narcotic Abuse
Preliminary Evaluation of the WV Prescription Drug
Abuse Quitline
Prevalence of Drug Use in Pregnant WV Patients
Spinal Cord Stimulation in Reducing Opioids in
Severe Chronic Pain
Buprenorphine Clinics: An Integrated and
Multidisciplinary Approach to Treating Opioid
Dependence
Understanding the Cultures of Prescription Drug
Abuse, Misuse, Addiction, and Diversion
Approach to Pain Management in Large Outpatient
Clinic Population
Cocaine Abuse Among Patients: A Study at CAMC
6 President’s Message
9 WV Legislature—Bill Signing
54 A Comprehensive Checklist for the Prevention
& Management of the Drug Seeking Patient
84 Opiate Addiction—Commentary
86 Drugs & Alcohol—Commentary
88 F
atal Pharmaceutical Abuse in WV—Bureau for
Public Health News
91 M
eth Addiction—Marshall University JCESOM News
92 E
xcellence in Medicine Gala—West Virginia Medical
Foundation News
96 H
ealthcare Summit Preliminary Program & Registration Form
98 Book
Review—Finding Balance in a Medical Life
100 CMOM Success—Physician Practice Advocate News
102 PPAACA—West Virginia Medical Insurance Agency News
104 Drs. Hendricks, Kelley, Saville, Steele—Obituaries
106 CME Answer & Registration Form
108 Directory of Advertisers
Editor
Managing Editor
Executive Director
F. Thomas Sporck, MD, FACS
Charleston
Angela L. Lanham, Charleston
Evan H. Jenkins, Huntington
Associate Editors
James D. Felsen, MD, MPH, Charleston
Douglas L. Jones, MD, White Sulphur Springs
Steven J. Jubelirer, MD, Charleston
Roberto Kusminsky, MD, MPH, FACS, Charleston
Robert J. Marshall, MD, Huntington
Martha D. Mullett, MD, Morgantown
Louis C. Palmer, MD, Clarksburg
The West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Ave., SE, Charleston, WV 25304, under
the direction of the Publication Committee. The views expressed in the Journal are those of the individual authors and do not necessarily reflect the policies or opinions
of the Journal’s editor, associate editors, the WVSMA and affiliate organizations and their staff.
WVSMA Info: PO Box 4106, Charleston, WV 25364 • 1-800-257-4747 or 304-925-0342
Cover photo courtesy
of Cathy Haglund
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304.720.3300 Option 3
[email protected]
A Continuing Education Program
Title:
Substance Abuse in West Virginia
Sponsors:
est Virginia State Medical Association
W
4307 MacCorkle Ave., SE
PO Box 4106
Charleston, WV 25364
304.925.0342
CAMC Health Education and Research Institute
3110 MacCorkle Ave., SE
304.388.9960
304.388.9966 FAX
Origination Date: July 6, 2010. Credit certification of this program expires July 6, 2012.
Format:
E nduring Material - Journal/Internet delivery of related articles. This special issue is available in print and in pdf format on the WVSMA website: wvsma.com.
Participants are required to complete a post-test instrument for credit completion. Approximate course completion time is 7 hours.
Featured Faculty: Faculty information listed with each article.
Course Materials: Related articles, process evaluation, content post-test.
About the Program and Objectives
The July/August 2010 special issue of the West Virginia Medical Journal provides an update of information for physicians on all aspects of substance abuse in West Virginia. This
program’s broad range of specialty topics provide all physicians with current information on significant advances in select areas of substance abuse treatment, pain management,
pregnancy and substance abuse issues, and the dilemma of doctor shopping. Physicians will be introduced to the WV Controlled Substance Advisory Board, learn more about the
history of abuse, addiction, and the cultures of prescription drug abuse, misuse, addiction, and diversion. An evaluation of the effectiveness of the WV Prescription Drug Abuse
Quitline is included along with recommendations for multidisciplinary approaches to treating opioid dependence and studies of cocaine abuse. Physicians will also find valuable
recommendations and a checklist for the prevention and management of drug seeking patients. At the conclusion of the substance abuse issue, physicians will have an increased
awareness and knowledge of the following:
This program does not meet the educational requirements for end-of-life or pain management credits.
• assess physician’s experiences and attitudes toward doctor shoppers as well
as their knowledge of the WV Board of Pharmacy Controlled Substance
Monitoring Program website and the frequency with which physicians
report to law enforcement.
• understand smoking rates in pregnant women and their exposure to drugs
of abuse.
• introduce physicians to the Controlled Substance Advisory Board; its history,
mission and current initiatives and projects.
• inform physicians of the socioeconomic impact of prescription drug abuse
and addiction.
• comprehend the neurobiology of addiction and explain components in
effectively addressing prescription drug abuse and addiction.
• convey information necessary to suspect, diagnose and assess the compli
cations of intranasal oxycodone abuse.
• inform of the efficacy of spinal cord stimulation and the positive effects
of the therapy towards the reduction of opioid dependence for the
management of chronic pain.
• quantify the rate of substance abuse during pregnancy and describe the
societal consequences of substance abuse during pregnancy.
• learn about the effectiveness of the WV Prescription Drug Abuse Quitline.
• explain what buprenorphine is and how it is used to treat opioid dependence
as well as how physicians can qualify for its use in treatment of patients.
• explain how to integrate buprenorphine into a multidisciplinary treatment
team.
• introduce physicians to new taxonomy categorizing the cultures of
prescription drug abuse, misuse, addiction and diversion.
• learn new approaches for improved opioid screening and adequate pain
control in the face of significant time constraints and patient complexity.
• examine combined modalities and disciplines for pain management.
• determine cocaine usage through urine drug screen (UDS) and its
implications for trauma treatment.
Disclosure
It is the policy of the CAMC Health Education and Research Institute that any faculty (author) who presents a paper for an enduring material designated for AMA Physician’s
Recognition Award (PRA) Category I or II credit, AANA credit or ACPE credit must disclose any financial interest or other relationship (i.e. grants, research support, consultant,
honoraria) that faculty member has with the manufacturer(s) of any commercial product(s) that may be discussed in the educational presentation.
Program Planning Committee Members must also disclose any financial interest or relationship with commercial industry that may influence their participation in this conference.
All authors and faculty have disclosed that no commercial relationships exist.
Professional Continuing Education Credits
This enduring material has been planned and implemented in accordance with the essentials and standards of the Accreditation Council for Continuing Medical Education through
the joint sponsorship of the CAMC Health Education and Research Institute and the West Virginia State Medical Association. The CAMC Health Education and Research Institute is
accredited by the ACCME to provide continuing medical education for physicians.
Physicians
The CAMC Health Education and Research Institute designates this educational activity for a maximum of 7 AMA PRA Category I credit(s) ™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
Cost: $75
CME Certificates
Continuing Medical Education will be certified by the CAMC Health Education and Research Institute, Charleston, WV. Physicians must be registered to obtain CME credits. The
registration and answer sheet, along with the evaluation section of the forms on pages 106-107 must be completed to obtain credits. Copies of these pages may be faxed to (304)
388-9966 or mailed to:
CAMC Health Education and Research Institute | 3110 MacCorkle Ave., SE, Charleston, WV 25304
SUBSTANCE ABUSE IN WV | Vol. 106 President’s Message
Drinking The Pierian Spring
Thoughts on things we ought to know.
A little learning is a dang’rous thing;
Drink deep, or taste not the Pierian spring:
There shallow draughts
intoxicate the brain,
And drinking largely sobers us again.
Fired at first sight with what
the Muse imparts,
In fearless youth we tempt
the heights of Arts,
While from the bounded level of our mind
Short views we take, nor see
the lengths behind;
But more advanced, behold
with strange surprise
New distant scenes of
endless science rise!
From the Essay On Criticism
Alexander Pope
May 1688—May 1744
For West Virginia the escalating
number of prescription drug
related deaths is yet another black
mark to the state and its people.
The following facts illustrate the
significance of substance use disorder
nationally and in West Virginia.
• In the 10 years (1997-2007)
the per capita retail purchases
of Methadone, Hydrocodone
and Oxycodone in the United
West Virginia Medical Journal
States increased 13-fold, 4-fold
and 9-fold respectively.
• Nationally, unintentional
drug poisoning deaths increased
68% during 1999-2004.
• The drug of choice for
adolescents age 12-18 is no longer
Marijuana, but prescription drugs
from family, friends and others.
• 4-6% of individuals 1825 used pain relievers for
non-medical reasons.
• A 2009 report from the West
Virginia Perinatal Partnership
showed that one in five babies born
in the state suffered exposure to
drugs or alcohol while in utero.
• A 2007 Centers for Disease
Control report indicated that the
state experienced a 550 percent
increase in drug overdose mortality
during the years 1999-2004, and
the rate has continued to increase
in subsequent years. This increase
was the largest in the nation.
• According to the U.S. Drug
Enforcement Administration,
West Virginia leads the nation
in methadone-related deaths per
capita, and it has the fastest-growing
rate of methadone overdoses.
Substance abuse is a complex
problem that has societal,
public health, and public safety
ramifications that cross all
socioeconomic and demographic
boundaries. In West Virginia it is
estimated that substance abuse costs
more than $1.8 billion in 2006 and of
that $470 million was in direct costs.
Recent news reports have
highlighted the growing problem
with prescription drug diversion.
This is an epidemic affecting not only
adults but our children and teens.
Although the WVSMA recognizes
the importance of policies that
prevent substance abuse and
prescription drug diversion through
law enforcement mechanisms, we
also recognize that physicians have a
responsibility to provide appropriate
treatment to patients, and policies
should not interfere with their
ability to practice good medicine.
The American Medical Association
reports that there is some evidence
to suggest that prescription drug
monitoring programs, like the
controlled substances database
currently administered by the West
Virginia Board of Pharmacy, reduce
the amount of opioid prescriptions
for pain management. Physicians
and other prescribers of controlled
substances must adequately
balance treating pain against
overprescribing. Under-treatment
of pain is not only detrimental
to patients but can result in civil
liability and professional sanctions.
Through the collective efforts
of knowledgeable members of the
legislature, Senators Evan Jenkins
and Ron Stollings the following bills
were passed addressing the problems
of doctor shopping and drug abuse:
SB 365 - Requiring pharmacies
provide personnel online access the
to controlled substances database.
It was discovered that some of
the largest and busiest pharmacies
in the state had policies which
hampered the pharmacists’ ability
to utilize the best tool in fighting
doctor shopping. Pharmacists did
not have access to the Controlled
Substances Monitoring Database.
This bill requires all prescribers and
dispensers of controlled substances
(it does apply to physicians) to
have “electronic” access to the
database. The Board of Pharmacy
is responsible for developing
rules to implement the law.
The WVSMA will keep
our members apprised of the
developing rules. Additionally
included in this bill is a provision
that clarifies the State Medical
Examiner’s Office may have
access to the database for use in
post-mortem examinations.
SB 81 – Creating WV Official
Prescription Program Act
This bill requires the Board
of Pharmacy to establish a rule
implementing a statewide tamper
resistant prescription paper program.
The paper will be required to be used
for all prescriptions (currently just
Medicaid requires tamper resistant
paper) and the board is responsible
for approving the safety features that
must be included in the paper and
establishing the approved vendors.
Additionally they will
develop a tracking method (i.e.
numbering of prescriptions) to
ensure prescriptions are valid.
SB 362 – Prohibiting providing
false information to obtain
controlled substances prescription.
The bill clarifies the current
law regarding doctor shopping.
It modifies the language to clarify
that “it is unlawful for a patient, in
an attempt to obtain a prescription
for a controlled substance, to
knowingly withhold information
from a practitioner that the patient
has obtained a prescription for
a controlled substance of the
same or similar therapeutic
use in a concurrent time period
from another practitioner.”
It is currently a misdemeanor
to violate this law. The bill raises
the penalty from six to nine
months in jail and raises the
fine from $1,000 to $2,500.
SB 514 – Clarifying
language in Controlled
Substances Monitoring Act
This bill clarifies all dispensers
of schedule II-IV (including
physicians) must report to the
Controlled Substances Monitoring
Database. There was an error
in the current statute that failed
to include the requirement for
reporting the dispensing of schedule
III and IV drugs. This law does
apply to physicians who dispense
such medication in office.
Tucked in the SeptemberOctober 2009 issue is Dr. Alvin
H. Moss’s editorial aptly titled
prescription Opioids and Physician’s
responsibility. His ten sagacious
counsel are important steps to
reverse the tide of this epidemic.
You may request an opioid
risk screening tool or a sample
of a pain management contract
through his e-mail – D. Moss
at [email protected].
This issue of the West Virginia
State Medical Journal is dedicated to
educate the reader and offer solutions
to stem the rising tide of controlled
substance use and abuse disorders.
Recapping the year we started
with a lot of uncertainty—and
with an awkward posture sailed
immediately right through the eye
of the storm—the physician is at
once challenged by legal, political,
and fiscal unrest that will forever
change the delivery of health care.
Health Care Reform, three simple
words that polarized America within
the past two years. First was The
Affordable Health Care for America
Act (passed by the House November
7, 2009) morphed into the Patient
Protection and Affordable Care
Act (passed the Senate December
24, 2009, Merry Christmas!) That in
turn was translated into the Health
Care and Education Reconciliation
Act of 2010 which became the
law of the land March 30, 2010.
I will not continue to attempt to
examine the financial ramifications
of health care reform as wading
through the 906 complicated pages is
not an exercise I wish to under take.
In an effort to gauge how accepted
this is for the medical professionals,
Med Page Today polled its readers—I
asked the following question thus –
Will the new health care
reform law fix the health care
system? The results—
• Less than 10% said yes
• 90% said no, but it’s a first step
• Less than 20% said no,
but it’s all we need to do.
Several (6%) refused to vote
as another option such as:
• No, start all over
• No, it should be repealed
• “Talk about a cure worst than
the disease” were not offered.
A divergent view was offered
in yet another article that
appeared in the June issue of
The Journal of Health Affairs:
TUESDAY, JUNE 8 (HealthDay
News)- The new U.S. health care
reform law was the best option for
providing health insurance to the
largest number of people while
keeping federal government costs
as low as possible, according to
an analysis by the RAND Corp,
a nonprofit policy think tank.
Researchers used a specially
designed computer model to
simulate more than 2,000 different
policy scenarios and found
that the only alternatives to the
new health reform law were all
politically difficult because they
would have included much higher
penalties for noncompliance, lower
government subsides, and less
generous Medicaid expansion.
Continuing the game of “Kicking
the Can”—Senate passes six month
SGR Fix. WASHINGTON—The U.S.
Senate has passed a bill to push back
the 21% cut for physicians who treat
Medicare patients until Nov. 30.
The bill, which also gives doctors
a 2.2% increase in reimbursements,
was approved by voice vote Friday
SUBSTANCE ABUSE IN WV | Vol. 106 afternoon, on the same day that the
Centers for Medicare and Medicaid
Services (CMS) announced it
would begin processing Medicare
claims at the 21% lower rate.
Democratic senators have
been trying for a month to stall
the cut mandated by Medicare’s
sustainable growth rate (SGR)
payment formula by passing a socalled “doc fix” as part of a larger
bill that would extend a number
of expired federal programs.
But that $118 billion package failed
to gain enough votes. Republicans
and some fiscally conservative
Democrats wouldn’t support the
bill because it isn’t paid for, even
though the cost and scope of the
bill have shrunk in recent days.
Recognizing that the tax extenders
bill was stalled, the “doc fix” portion
was removed from the larger bill
and placed in its own measure,
which is fully paid for, according
to a release from Senate Majority
Leader Harry Reid (D-Nev).
Shortly after 7:00 p.m., June
24, 2010, the House passed H.R.
3962, which provides a 2.2 percent
Medicare fee schedule update
for physician services through
November 2010. The bill passed by
a bipartisan vote of 417 to 1. The
2.2 percent update provided by
H.R. 3962 would replace the 21%
Medicare cut currently in effect, and
be applied retroactively to claims for
services provided on or after June 1.
Having just returned from the
American Medical Association House
of Delegates meeting—The House of
the American Medical Association
is still roiling—maybe here in West
Virginia we can start our own poll—
Did the American Medical
Association make a fatal mistake
by supporting health care reform?
A. Yes, it abandoned its
core supporters.
B. No, it made the right decision.
C. Reform decision is just one
of many bad choices.
D. Right decision on reform,
wrong on other issues.
E. The American Medical
Association is totally irrelevant.
Please submit your response and
comments to [email protected]
Pundits are predicting that the
American Medical Association stands
to lose about 7% of its members
this year. In his annual remark, the
Executive Vice President, Michael
D. Maves, reported instead a
decrease in membership by 3%.
Like John Stuart Mill I espouse
participative leadership with the
freedom to discuss differences of
opinion and expression. Anyone
with exposure to a leadership role
has experienced what the first
Viscount Morley of Blackburn acutely
observed, “as being caught in a field
where action is one long second best
and where the choice constantly
lies between two blunders.”
It takes great courage to move and
act and it is with great admiration
that I view Dr. James Rohack’s
action during this difficult time.
I strongly believe that it is our
moral obligation to provide access to
health care for those who can least
afford it. Many of you have strong
sentiments against health care reform
and I certainly respect your position.
Recalling the lessons we learn
from history—In 1773 Ben Franklin
admonished his friend, John
Winthrop at Harvard and wrote the
following—“As between friends
every affront is not worth a duel,
between nations every injury is not
worth a war, so between governed
and government, every encroachment
of rights is not worth a rebellion.”
Many of you question the necessity
and validity of being involved in
organized medicine. These are
turbulent times for the physician
in America as in West Virginia, as
many health care reform provisions
went into effect immediately, though
most are being phased in gradually.
One key provision—a first step
toward eliminating discrimination
against people with pre-existing
conditions—began June 21.
More laws will take effect in
September and this years legislation
won’t be enacted until Jan 1, 2018.
The political climate will certainly
change after November this year.
In his preface in the early edition
of John F. Kennedy’s Profiles in
Courage, R.F. Kennedy wrote the
following, “If there is a lesson from
the lives of the men JFK depicts
in his book, Profiles in Courage, it
is that in this world of ours, none
of us can afford to be lookers on
or the critics on the side lines.
I salute and thank our membership
and ask you to welcome and
continue to support West Virginia
State Medical Association and
the new set of officers under the
aegis of Dr. John H. Schmidt III.
One of the delightful activities we
experience is meeting and speaking
to the student representatives to
the American Medical Association
from West Virginia University and
Marshall University. Brisk, engaging
cererbrated conversation occurred.
The quality of the new patient,
(no loyalty, not motivated, highly
informed, highly mobile). Reluctance
and intimidation by senior physicians
to accept information technology
and electronic medical records;
eschewed ratio of primary care to
specialist of 31% to 66% truly is not
compatible with health care reform,
this further creates a vacuum and
allows ingress of barbarians-at-thegate, insuring new turf battles for
a piece of the action; thus advance
nurse practitioner morphing into
doctor of nurse practitioner.
Future health providers
“feldshers” (foot doctors), and
physician’s assistants with a greater
role. Aging physicians with an
aging population; young doctors
with new culture, (shorter work
hours, more pay, less responsibility)
changing and protecting the political
landscape, i.e., a neoteric governor,
two supreme court justices, U.S.
senator, and U.S. congressman.
Remember the political golden
rule, “He who has the gold rules”,
support and give to West Virginia
State Medical Association PAC.
Finally, for the young doctors
of West Virginia, Conchita and
I wish to share with them the
following scripture written in
the front façade of The Faculty
of Medicine and Surgery of The
University of Santo Tomas quoted
from the aphorism of the ancient
Greek physician Hippocrates:
ARS LONGA
VITA BREVIS
OCCASSIO PRAECEPS
EXPERIMENTUM
PERICULOSUM
JUDICIUM DIFFICILE
The full text is often
rendered in English—
ART IS LONG,
LIFE IS SHORT,
OPPORTUNITY FLEETING,
EXPERIMENT IS DANGEROUS,
JUDGEMENT DIFFICULT
Admonition still appropriate for
the twenty first century physician.
The University of Santo Tomas,
(my school) is the oldest learning
institution in Asia and will celebrate
its 400th year on April 28, 2011. The
Faculty of Medicine and Surgery is
ranked as the only Asian medical
school to be in the top 10 list of
foreign medical institutions by the
U.S. Educational Commission for
Foreign Medical Graduates in 2007.
From Conchita’s Peak—nestled
in the hills of Glen Dale Heights
hemmed by (Pennsylvania) to the
east, as the green dragon, Ohio
on the west as the white tiger
slope and the hills to Wheeling as
the black turtle of the north, we
hasten to send you our good chi.
We will embrace the memory
of this year and thank you for our
grateful joy serving as your president.
Grateful joy as expressed by a
philosopher as a heart that is full,
and a mind purified by gratitude.
It is a steady elation with a current
of “at last” coursing through
it, a tincture of blips, a scent of
accomplishment and fulfillment
and has more staying power than
happiness with nary a chance of
being diminished by circumstances.
On that final day, I will sit
on my favorite ledge to cogitate
on the status of the physician,
always the peer of priests, judges
and scholars. His status may
be lower than a decade ago.
The history of medicine is the
history of humanity, with its brave
aspirations after truth and finality,
its pathetic failures; and perhaps the
physician’s place has risen and fallen
with it; perhaps too pessimistic, Job
spoke of “physicians of no value,”
and perhaps ending with optimism,
Robert Louis Stevenson wrote that
the physician almost as a rule “stood
above the common herd, and was
indeed, the flower of civilization”.
Slowly as the moon glides
over the horizon I leave to
fight another windmill.
Good night Evan!
Good night John Boy!
Carlos C. Jimenez, MD
President
West Virginia State Medical Association
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SUBSTANCE ABUSE IN WV | Vol. 106 What’s Good for Them Is Good for You.
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West Virginia Legislature Works to Address
Prescription Drug Crisis
Prescription drug abuse,
misuse, addiction and diversion
unquestionably is near the top of our
state and nation’s most challenging
health and public safety issues. The
statistics are alarming—nearly 7
million Americans abuse prescription
drugs with an 80% increase between
2000 and 2006. Between 1997 and
2006, the use of the five major
prescription painkillers, the drugs
most commonly abused, increased
by 88%. A recent study indicates
teen abuse of prescription pain
relievers in West Virginia is among
the nation’s highest. Overdose is
now the leading cause of death
for West Virginians under 45. The
State Medical Examiner reported
that seven of the top ten drugs that
contributed to the deaths of West
Virginians were prescription drugs.
For months leading up to the
start of the 2010 Legislative Session,
Senator Ron Stollings, a practicing
physician in Boone County, and I
worked with key stakeholders to
craft legislation to help provide
the tools necessary to tackle this
crisis. Working with a number of
committed legislators willing to
co‑sponsor this pro-active agenda, we
were able to secure passage of four
separate bills that have been signed
into law by Governor Manchin.
SB – 81 Creates the West Virginia
Official Prescription Program Act.
Implements the required use of
tamper resistant prescription paper
and pads by July 1, 2011. This does
not limit or discourage in any way
the use of e-prescribing. Prescription
fraud accounts for 35% of diverted
drugs. The estimated savings in West
Virginia under the new program
exceed $20,000,000 based on a similar
program in New York State.
Governor Manchin signs SB-81, SB-362, SB-365 and SB-514 into law. Each law makes great strides in the efforts
to address the prescription drug crisis in West Virginia.
SB – 362 Prohibits individuals from
providing false information to obtain a
controlled substance prescription. This
new law strengthens and clarifies
the current criminal statute to give
law enforcement and prosecutors
the power to arrest and prosecute
drug seeking individuals who
intentionally deceive physicians in
an effort to obtain a prescription.
SB – 365 Requires access to the
West Virginia Controlled Substances
Monitoring Database by July 1,
2011. This legislation recognizes
the importance and value of
the information available in the
Controlled Substance Database
and the need to promote its use by
authorized individuals including
physicians and pharmacists. The
legislation targets the current practice
of several large retail pharmacy
chains that prohibit internet access in
their stores thus limiting the in-store
pharmacist from being able to access
the state’s on-line database to detect
fraudulent prescription activity.
SB – 514 Corrects an inconsistency
in the West Virginia Code caused by
a previous drafting error that required
pharmacies to report all prescriptions
for Schedule II, III, and IV drugs
dispensed but dispensing prescribers
were only required to report Schedule
II drugs. Dispensing prescribers
will now be required to report to
the Controlled Substance Database,
Schedule III and IV drugs, as is the
current practice of pharmacies.
The Honorable Evan H. Jenkins
Senator, West Virginia State Senate &
Executive Director, West Virginia
State Medical Association
SUBSTANCE ABUSE IN WV | Vol. 106 Scientific Article | Special Issue
Physicians’ Perceptions of Doctor Shopping
in West Virginia
E. Gail Shaffer, MD, MPH
Alvin H. Moss, MD, FACP, FAAHPM
Center for Health Ethics and Law
Robert C. Byrd Health Sciences Center
West Virginia University
Morgantown
Abstract
Prescription drug abuse and diversion
continue to be serious problems in West
Virginia and nationwide. Doctor shopping
(visiting multiple doctors in a short time
frame with the intent to deceive them to
obtain controlled substances) is illegal
and one way that patients gain access to
prescription drugs. We surveyed West
Virginia physicians in emergency
medicine, family medicine, and internal
medicine to determine their experience
with and attitudes toward doctor
shopping, and to assess attitudes toward
proposed legislation to protect physicians
who report doctor shoppers to law
enforcement officials. Of 452 physicians
surveyed, 258 responded (57%).
Emergency medicine physicians had the
highest response rate (61%) and most
frequent encounters (once a week or
more often) with doctor shoppers
compared to family medicine and internal
medicine physicians (88% vs 25% vs
14%, P<.001). Eighty-one percent of
physicians reported using the West
Virginia Board of Pharmacy Controlled
Substances Monitoring Program website,
but only 22 percent presently report
doctor shoppers. If the law protected
them, 85 percent of all physicians
reported they would be likely to report
doctor shoppers.
Introduction
West Virginia leads the nation in
overdose deaths from prescription
drugs. Between 1999-2004, there was
a 550% increase in unintentional
poisoning mortality in West Virginia,
with more than 90% of the deaths
due to prescription drug overdoses.1
In a December 10, 2008 JAMA
article on unintentional drug
overdose fatalities in West Virginia,
opioid analgesics were involved in
93% of deaths and 21% of fatalities
occurred in patients who were doctor
shoppers.2 Doctor shopping is when
patients intend to deceive physicians
to obtain controlled substances
from multiple physicians in a short
time frame. The aforementioned
study recognized doctor shopping
as receiving controlled substances
from 5 or more physicians in a
year,2 but there is not a universally
accepted definition of the term.
A 2004 survey of physicians by
the National Center on Addiction
and Substance Abuse (NCASA)
showed that physicians perceive
doctor shopping to be one of the
main mechanisms of prescription
drug diversion.3 At the time, NCASA
chairman Joseph Califano Jr. noted,
“Our nation is in the throes of an
epidemic of controlled prescription
drug abuse and addiction. While
America has been congratulating
itself in recent years on curbing
increases in alcohol and illicit drug
use… abuse of prescription drugs has
been stealthily, but sharply, rising.”
The West Virginia Board of
Pharmacy (WVBoP) Controlled
Substances Monitoring Program
website was designed to assist
doctors in patient care as well as
decrease diversion. As of November
2008, 32 states had active prescription
monitoring programs.4 Of West
Virginia’s bordering states, all
but Maryland have prescription
drug monitoring programs. West
Virginia’s prescription monitoring
program has been collecting data
since 2002. The US Drug Enforcement
Administration is testing software
to allow inter-state transfer of
prescription drug monitoring data.
The Uniformed Controlled
Substances Act of the Code of West
Virginia (§60A-4-410) states that
“it is unlawful for a patient, in an
Objectives
The objectives of this study were threefold:
1.To assess physicians’ experiences with and attitudes toward doctor shoppers;
2.To determine how frequently West Virginia physicians use the West Virginia Board of Pharmacy Controlled Substance
Monitoring Program website; and
3.To examine how frequently West Virginia physicians report doctor shoppers to law enforcement agencies and how proposed
regulatory changes might affect physicians’ willingness to report doctor shoppers.
10 West Virginia Medical Journal
Special Issue | Scientific Article
attempt to obtain a prescription for a
controlled substance, to knowingly
withhold from a practitioner, that the
patient has obtained a prescription
for a controlled substance of the
same or similar therapeutic use
in a concurrent time period from
another practitioner.” The law
stipulates the act is a misdemeanor
punishable by up to 9 months in jail,
or fined not more than $2,500, or
both fined and confined. However,
the current law does not grant
immunity from prosecution to those
practitioners who report such doctor
shopping to law enforcement.
The purpose of this study was
to assess physicians’ experiences
with and attitudes toward doctor
shoppers and the WVBoP Controlled
website, and to examine how
proposed regulatory changes might
affect physicians’ willingness to
report doctor shoppers to law
enforcement agencies. It is hoped
that the findings from this study
will be useful to policymakers as
they seek to decrease prescription
drug diversion in West Virginia.
the survey was also made available
over the internet, with a web
address and password. The survey
received an exemption concurrence
from the West Virginia University
Institutional Review Board for the
Protection of Human Subjects.
Methods
Figure 1.
Study Population
A list of physicians licensed in
West Virginia in internal medicine,
family medicine, and emergency
medicine was obtained from the
West Virginia Board of Medicine.
Physicians were excluded from
participation if the address listed
was outside of West Virginia or
if they had a subspecialty listed.
After applying these criteria, 428
family medicine physicians, 266
internal medicine physicians, and
110 emergency medicine physicians
remained. Because of the smaller
number of emergency physicians,
all emergency physicians were
surveyed, and 50% of both internal
medicine (n=133) and family
medicine physicians (n=214) were
randomly chosen to be surveyed.
A total of 457 surveys were
mailed; five were returned with
incorrect addresses. The final survey
sample consisted of 452 physicians.
Data Analysis
All analyses were conducted
using SPSS 16.0 (Chicago, IL). The
chi-square test was used to analyze
categorical variables. A P value less
than .05 was considered significant.
Results
Of 452 physicians surveyed,
258 responded (57%). More
emergency medicine physicians
responded than did family
medicine or internal medicine
(61% vs 44% vs 36%, P=0.001).
Frequency of suspected
doctor shopping
Forty percent of responding
physicians reported having a
patient they suspect of doctor
shopping at least once a week
or more (Figure 1). There were
differences between specialties,
with emergency physicians seeing
a higher frequency of doctor
How often doctors report seeing patients who are doctor shopping in their office. (N=253)
Development of Survey Instrument
The survey instrument consisted
of 11 questions regarding physicians’
familiarity with the Board of
Pharmacy Controlled Substances
website, their use of the website, and
their experiences with patients who
doctor shop for controlled substances.
The first mailing of the survey was
conducted in early March 2009, and
a follow-up survey was mailed to
non-responders in late March 2009.
A unique identifier was given to
each survey for the sole purpose
of identifying non-responders.
Physicians responses to the first
mailing were confidential and to the
second mailing anonymous. In an
attempt to increase the response rate,
SUBSTANCE ABUSE IN WV | Vol. 106 11
Scientific Article | Special Issue
Figure 2.
How often doctors report using the West Virginia Board of Pharmacy Controlled
Substances Monitoring Program website. (N=206)
enforcement. Forty-three percent
stated they would be much more
likely to report, 33 percent said they
would be somewhat more likely
to report, 23 percent stated their
reporting practices would not change,
and less than 1 percent reported they
would be much less likely to report.
In total (including those
physicians who currently report
and would continue to report),
85% of physicians responded that
they would be likely to report
doctor shopping if the legislature
granted immunity. There was no
difference by medical specialty.
Additional comments
shoppers than family medicine
or internal medicine physicians
(88% vs 25% vs 14%, p<0.001).
Awareness and usage of
the WVBoP website
Ninety-two percent of responding
physicians (n=238) were aware of
the WVBoP Controlled Substances
Monitoring Program website, and
81 percent of physicians (n=207)
responded that they use the website.
No statistically significant difference
was noted between specialties.
Frequency of website usage was
also assessed. Only 18% of physicians
reported using the website for every
patient for whom they prescribe a
controlled substance (Figure 2).
Reporting doctor shopping
to law enforcement
Thirty-seven percent of
respondents had ever reported
a patient to law enforcement for
doctor shopping, while 22 percent
presently report doctor shoppers.
There was no difference between
specialties for physicians who
currently report doctor shopping.
Reasons that physicians do not
report doctor shoppers to law
enforcement included: uncertainty
about patient being a doctor
shopper (35%), concerns about
Health Insurance Portability and
Accountability Act (HIPAA)
violations (28%), concerns about
confidentiality (26%), too busy (21%),
concerns about physical harm from
patients or associates (11%), not
their responsibility (3%), and other
concerns (31%). Among the other
concerns listed, the most prevalent
were: lack of concern from law
enforcement (n=20), unsure how to
report (n=12), and not aware that
they could/should report (n=12).
Proposed legislative changes
granting immunity for reporting
of doctor shopping
Physicians were asked how their
behavior regarding doctor shoppers
would change if a new law granted
immunity to physicians for reporting
doctor shoppers in good faith to law
Fifty-six percent of physicians
(n=144) wrote in additional
comments about doctor shopping,
the WVBoP website, and the new
proposed law. Several recurring
themes arose. First, many physicians
wrote about the magnitude of
the problem of doctor shopping
and prescription drug abuse in
their communities and practices.
One physician commented:
“I have been practicing for
over 60 years and problems
are by far the worst ever.”
Another wrote:
“I have lost two young (less than
20 years-old) patients to prescription
med overdoses. This has to stop.”
The second most common theme
was the need for information
from bordering states, as well
as a streamlined mechanism
for reporting suspected doctor
shoppers. One physician noted:
“It would be helpful to have
collaboration with border states as
patients often cross the state lines.”
Another physician commented:
“It would be beneficial for
our practice to identify possible
“doctor shoppers” for drug abuse.
Centralized notification center
and resource would be helpful.”
The need for law enforcement
to play an active role was also
mentioned. Lack of follow-up
on previous incidences was
mentioned by several physicians.
One physician commented:
“Unless the law enforcement
makes a priority to follow-up on
my report and actually go ‘get’
that patient, it’s no use to keep
reporting it. I even had patients
that were caught altering my
prescriptions, and the state troopers
did nothing to investigate.”
Other comments pertained to
the use of the Board of Pharmacy
website. Several physicians
noted that the website is not
always up to date, and that it
is difficult to access at times.
Discussion
The results of this study suggest
that doctor shopping is a common
occurrence, especially in the
emergency department, where almost
90 percent of emergency physicians
suspect a patient of doctor shopping
weekly. In addition, we note that
most West Virginia physicians are
aware of the WVBoP Controlled
website, and use it for patients they
suspect of doctor shopping. Only 1 in
5 physicians currently report doctor
shopping to law enforcement. Studies
involving other states’ prescription
monitoring programs have shown
similar awareness and usage of
such resources.5 Of note, 85 percent
responded that they would be more
likely to report if granted immunity
by legislative action. HIPAA and
confidentiality issues were cited
by the majority of physicians who
do not report doctor shopping.
Qualitatively, the survey
demonstrates the need to address
issues with the BoP website’s
accessibility, and underscores
the need for cooperation on this
issue with bordering states. The
need for a streamlined reporting
process was also noted.
Current West Virginia law
explicitly states that doctor shopping
for controlled substances is a crime.
In addition, HIPAA regulations
state that it is a permitted disclosure
for a covered entity (physician) to
report protected health information
on a patient when that patient is
engaged in criminal conduct on the
(physician’s) premises (HIPPA, 42
CFR 164.512(f)(5)). Furthermore,
the state legislature could pass a bill
granting immunity to physicians
who report doctor shoppers to law
enforcement. This bill would be
similar in nature to the one passed in
2008 (Code of West Virginia §17B3-13) that granted physicians the
permission to report protected health
information to the Division of Motor
Vehicles of patients they determine
to be unsafe to operate a motor
vehicle. It is similar in that it would
allow the reporting of confidential
information to a state agency for
the protection of the public health.
Some may question the ethics
of allowing physicians to report
confidential patient information. The
need for physicians to balance patient
confidentiality and the welfare
of the public is well-established.
For example, despite a patient’s
preference for confidentiality
to be maintained, public health
laws require the reporting of
sexually transmitted diseases. The
American Medical Association’s
Principles of Medical Ethics indicate
that physicians have multiple and
potentially competing obligations.8
Principle IV states that “a physician…
shall safeguard patient confidences
and privacy within the constraints
of the law,” and Principle VII
recognizes the responsibility of
physicians “to participate in activities
contributing to the improvement of
the community and the betterment
of public health.” Much like the
epidemic of sexually transmitted
diseases required public health
reporting to curb the problem, it
appears that prescription drug
abuse and diversion which has
reached epidemic proportions in
some West Virginia counties will
require similar action. The scope of
this problem has been documented,
and West Virginia’s death rate per
capita from prescription overdoses,
which leads the nation, substantiates
the need for a new approach.
One limitation of this study is that
not all physicians in West Virginia
were surveyed. However, we chose
to survey those physicians who are
most likely to come into contact
with doctor shoppers- emergency
physicians and primary care
physicians. Also, surveys of this
nature are subject to responder bias.
However, our response rate of 61
percent from emergency physicians
shows a robust sample. The overall
response rate was comparable to
other physician surveys,6 and the
availability of an online survey did
not seem to increase participation,
as demonstrated previously.7
Conclusion
Successfully combating the
problem of prescription drug abuse
and diversion in West Virginia will
require a multifaceted approach. This
survey of over 250 West Virginia
physicians revealed the complexity
of the problem. Physicians
identified difficulties with obtaining
information on doctor shoppers
in border states and the userfriendliness of the WVBoP Controlled
website. They also cited the failure of
law enforcement to respond to their
reports of doctor shoppers and the
need for a central center with an 800
number to which they could report
doctor shoppers. In this study, West
Virginia physicians emphatically
stated that this problem must be
addressed, and with a change in
the law, they report they will do
their part to reduce this problem.
Acknowledgments: The authors
thank Cynthia McMillen for her
assistance in data entry and analysis
and in manuscript preparation.
References
1. Centers for Disease Control and
Prevention. Unintentional poisoning deaths
– United States, 1999-2004. MMWR Morb
Mortal Wkly Rep. 2007;56(5):93-96.
2. Hall AJ, Logan JE, Toblin RL, Kaplan JA,
Kramer JC, Bixler D, et al. Patterns of
abuse among unintentional pharmaceutical
overdose fatalities. JAMA 2008;300(22):
2613-2620.
3. National Center on Addiction and
Substance Abuse. Controlled prescription
drug abuse at epidemic levels. J Pain
Palliat Care Pharm 2006;20(2):61-4.
4. US Department of Justice, Drug
Enforcement Administration Office of
Diversion Control. http://www.deadiversion.
usdoj.gov/faq/rx_monitor.htm#1. Accessed
June 3, 2009.
5. Barrett K, and Watson A. Physicians’
perspectives on a pilot prescription
monitoring program. J Pain Palliat Care
Pharm 2005;19(3):5-13.
6. Kellerman SE and Herold J. Physician
response to surveys: a review of the
literature. Am J Prev Med 2001;20(1):61-7.
7. Recklitis CJ, Campbell EG, Kutner, JS,
Bober SL. Money talks: non-monetary
incentive and Internet administration fail to
increase response rates to a physician
survey. J Clin Epi 2009;62:224-6.
8. American Medical Association. “Principles
of Medical Ethics.” Code of Medical Ethics
of the American Medical Association.
Chicago: American Medical Association,
2008. p. xv.
CME Post-Test
1.In West Virginia which physician specialty most frequently encounters doctor shoppers?
a. emergency medicine
b. family medicine
c. internal medicine
2.What percent of emergency medicine, family medicine, and internal physicians use the West
Virginia Board of Pharmacy Controlled Substances Monitoring Program website?
a. 31%
b. 61%
c. 81%
3.What percent of West Virginia physicians who encounter doctor shoppers report them to law enforcement?
a. 11%
b. 22%
c. 33%
Case Manager for Healthcare Professionals
Harrison County area newly established non-profit organization looking for a qualified
Case Manager, FTE position; working in collaboration with the Medical Director, providing case management, including assessment, referrals, monitoring and other related
program activities. Master’s degree in mental health field & state licensure preferred. At
least 3-5 years experience with direct clinical services with broad exposure to chemical dependency, psychiatric and mental illness. Prior experience in employee assistance program and/or clinical experience with professional populations highly desirable.
Excellent computer skills utilizing Microsoft Office and other programs required. Professional demeanor and excellent communication skills. Personal recovery and office
management experience preferable.
Send Resumes to: 680 Genesis Blvd, Ste 201, Bridgeport, WV 26330
WV Birth Score: Maternal Smoking and Drugs of Abuse
Martha D. Mullett MD, MPH
Christine M. Britton
Collin John MD, MPH
Candice W. Hamilton, MPH
Department of Pediatrics, West Virginia University
Abstract
The WV Birth Score began in 1984
and was revised in 2007. One part of the
form is a score which predicts the top
18% of infants at risk for death in the first
year of life. The other components collect
information regarding the health of
mothers and their infants. Data from the
WV Birth Score between 2001 and 2009
reveal that the average smoking rate
among mothers was 28.5%. The average
maternal tobacco use rate among High
Score infants (53.7%) is significantly
higher than the average rate among
mothers of Low Score infants (23.6%)
(p<.0001). Infants born to women who
smoked during pregnancy in 2007
weighed 250 grams less than infants of
non-smoking women (p<0.0001). A
question on drug exposures during
pregnancy reveals that marijuana is the
most commonly reported drug on the Birth
Score form. Only 5% of the mothers
reported using at least one substance
during their pregnancy. Smoking rates
during pregnancy in WV are among the
highest in the nation and lead to higher
mortality rates in the infant born to
mothers who smoke. Programs to impact
smoking and other maternal health issues
should be a priority in WV.
Introduction
In 1984 Dr. David Myerberg
initiated the implementation of a
scoring system to identify West
Virginia infants who may die of
Sudden Infant Death Syndrome
(SIDS) in the postneonatal time
period (30 days to one year). The
scoring tool was very similar to one
developed by Dr. Robert Carpenter,
used in England, called the Sheffield
Birth Score.1 Dr. Myerberg named the
scoring tool “WV Birth Score” and
it has been used statewide since its
inception in 1984. This scoring tool
identified infants at risk for possibly
preventable death in the first year of
life and a schedule of more frequent
visits to the physician was arranged
for this group. Prior to the inception
of the Birth Score tool, WV had a
relatively high infant mortality rate of
11.1 per 1,000 live births. From 19861989 there was a consistent reduction
of postneonatal mortality, possibly a
result of identifying the most at-risk
infants and linking them to medical
services. In 1992 the American
Academy of Pediatrics published a
position paper on the prevention of
SIDS by placing all infants to sleep
on their backs.2 “Back to Sleep”
resulted in a significant decrease in
total infant mortality in this country.3
The Birth Score continues to
be used to identify infants at risk
for mortality in WV for referral
into services. In 1998, the WV
Legislature passed House Bill 2388
establishing the West Virginia Birth
Score Program and requiring all
WV birthing hospitals or facilities
to ensure that a Birth Score is
determined for all babies born in
WV. A revised Birth Score was
implemented in July 2007. The
revised instrument allows us to
collect other information beyond
the infant “Score” data which is
important for the maternal/newborn
population. We now describe the
methodology for the revised score
and report Birth Score data regarding
drug use during pregnancy and
maternal smoking rates over time.
Methods
In 2005 the Birth Score was
reexamined to ensure that the scoring
variables were still appropriate
in identifying at-risk infants. The
Birth Score database was matched
with birth certificate data from
1994-1998 for all births in the state
of WV. Using SAS (SAS Institute,
Cary, NC) and a stepwise logistic
regression model, variables that
were significantly associated with
mortality during the first year of life
were identified. Specifically, three
variables were highly associated with
death—birth weight < 1500 grams
Objectives
The reader will be able to tell that smoking rates in pregnant women in WV in the last 9 years have not significantly changed.
The reader will know that 5% of pregnant women in WV are exposed to drugs of abuse and that this number is an under estimate
of the real exposure.
The reader will understand that smoking during pregnancy is significantly related to increased mortality in the first year of life and
lower birth weight for the infant.
(VLBW), congenital abnormalities
(chromosomal abnormalities,
congenital heart disease, etc.) and
Apgar score <3 at 5 minutes. Infants
with these factors were removed
from the model, as these were
extreme independent predictors
of infant mortality and other less
significant predictors were left in
the score. The variables remaining
in the score include birth weight,
maternal age, infant sex, feeding
intention, number of previous
pregnancies, maternal education,
and nicotine use during pregnancy.
The revised score was derived
using the remaining items that
significantly predicted infant
mortality and applying weighted
values to each item using the
parameter estimate associated with
the item from the regression analysis.
The revised score was calculated
for a group of infants born in 19992000. After assigning the new score
to each of the infants in this group,
the top 18% were designated as High
Score. The new score was applied
to the test group of infants born in
1999-2000 and it predicted an infant
mortality rate (IMR) of 17.24 deaths
per thousand live births in the High
Score group compared to an IMR
of 1.70 in the Low Score group.
In addition to the changes with
the Birth Score variables, the Birth
Score form was redesigned to
improve the data collection and
data entry process. Also, a section
of the Birth Score form “Questions
for Mother” was inserted to identify
maternal infant health issues (See
Figure 1). Initially, three oral health
questions and one question about
the mother’s use of any substances/
drugs during her pregnancy were
added. The new form design allows
questions to be added to gather
information for an interval of time,
and then changed when sufficient
data have been collected to assess
trends and health behaviors of
the pregnant population in WV.
Statistical analysis was performed
using SAS. Student’s t-test was
Figure 1.
Birth Score Form (07/2007-08/2009)
used to compare birth weights of
infants born to smoking and nonsmoking mothers. Epi Info (CDC
version 3.5.1) was used to compare
the smoking rates between High
Score and Low Score mothers using
an analysis of stratified tables.
Results
Approximately 20,000 infants
are scored in WV annually. In
addition to all WV residents, the
Birth Score is completed for outof-state women who give birth in
a WV birthing facility. The results
described in this paper are limited
to West Virginia resident births.
Tobacco Use
Between 2001 and 2009, the
average smoking rate among mothers
was 28.5%. Figure 2 shows annual
maternal tobacco use rates reported
on the WV Birth Score for that time
period. Figure 3 compares maternal
tobacco use in mothers of High Score
(top 18%) and Low Score infants. The
average maternal tobacco use rate
among High Score infants (53.7%) is
significantly higher than the average
Figure 2.
Reported Maternal Tobacco Use 2001-2009 from WV Birth Score
Figure 3.
Reported Tobacco Use among Mother’s of High Score & Low Score Infants 2001-09
*p <0.0001
rate among mothers of Low Score
infants (23.6%) (p<.0001). As Table 1
illustrates, in 2007, the average birth
weight of infants born to mothers
who smoked was 3039 grams
compared to the average birth weight
of infants born to mothers who did
not smoke of 3289 grams (p<.0001).
Drug Use
Table 2 illustrates the results
among the 45,448 scored births that
had any drug use indicated from July
2007-December 2009. Mothers could
have multiple substances selected for
the single question. Marijuana is the
most commonly reported drug on
the Birth Score form. Only 5% of the
mothers reported using at least one
substance during their pregnancy.
Discussion
West Virginia has one of the
highest rates of smoking during
pregnancy in the US (number 1 in
1999).4 There are many negative
health outcomes for the mother and
the fetus from tobacco exposure.5
One mechanism is maternal smoking
significantly decreases the weight
of the newborn.5 Our data show
that reduced birth weight is the
strongest predictor of mortality in the
first year of life. Infants of smoking
mothers average about 250 grams
(eight ounces) less at birth than do
infants of non smoking mothers.
A second mechanism of the
health effects of maternal smoking
is that it is associated with a higher
mortality rate in the first year of
life after controlling for its effect on
birth weight. This higher mortality
rate is due to SIDS.6 This pattern
is true in WV as smoking was one
of the variables remaining in the
regression analysis. The reason
for this association is unknown
but recent research suggests that
lower serotonin levels in the brain
of SIDS deaths may be contributed
to by maternal smoking during
pregnancy.7-8 Although several
smoking and pregnancy initiatives
have been implemented, Birth
Score data show that the problem
is still present and must be a public
health priority in West Virginia.
The High Score infants are born to
mothers with a higher smoking rate.
This is expected since smoking affects
the birth weight and independently
adds to mortality. Many of the
other components leading to a
high score are socioeconomic in
nature and not directly modifiable
during this pregnancy. Only breast
feeding, education, and smoking
cessation are modifiable during
pregnancy. Maternal age, gravida,
and education level need to be
addressed during the interpregnancy
interval by family planning services
in order to potentially impact
mortality in the first year of life.
A recent study by the WV State
Health Department and several
birthing hospitals, using umbilical
cord samples analyzed for drugs,
found that 19% of fetuses in WV are
exposed.9 This is far higher than our
sample of 5%. It is unlikely that the
true exposure rate of fetuses
Helping professionals. Helping our babies.
The West Virginia Perinatal Outreach Education project
offers continuing education for doctors, nurses, social
workers, and other health care providers to screen,
identify, and refer for treatment - substance abusing
mothers and their newborns.
A program of West Virginia Community Voices, Inc.
Funded by the Claude Worthington Benedum Foundation
and the WV Rural Health Education Partnership.
Presentation topics covered:
• Substance Abuse Among Pregnant
WV Women
• WV Cord Tissue Study
• Antepartum Screening Guidelines
• Guidelines for Uniform Testing
and Referral for Drug/Alcohol
Treatment During Pregnancy
• Short and Long Term Effects of
Substance Abuse on Newborn
• A Toolkit For Identification and
Neonatal Abstinence Syndrome
Uniform Assessment Tool
for Identification of Addicted
Neonates
• Resources for Treatment
To view the Learning Opportunities
Calendar for WV, please visit:
http://www.wvperinatal.org/calendar
To schedule a training,
please contact:
Shauna Popson, EdD, RN CLS;
at 304-473-8223,
or email:
[email protected]
Table 1: Birth weight of Infants to
Smoking and Non-Smoking Mothers
in 2007
Smoking
3039 Grams
Non-Smoking
3289 Grams
*p <0.0001
Table 2: Reported Maternal Drug
Use on WV Birth Score
Reported Maternal Drug Use among 45,448
scored births during 07/2007-12/2009
Alcohol
Cocaine
Marijuana
Methadone
Heroin
Methamphetamine
444
223
1272
366
50
63
in WV is 19% as the hospitals for the
cord study were not randomly
selected. The hospitals included in
the study contained the tertiary
perinatal centers where obviously
addicted mothers are referred for
delivery. The drug question on the
Birth Score captures both information
that is self-reported by the mother,
and information from drug screens
reported by health care professionals
(physicians, social workers, nurses).
Self-reported drug use during
pregnancy is unreliable, as mothers
may not reveal their drug history
because they fear repercussions.
The Birth Score is a risk
identification tool to refer infants
to medical/social support systems
such as Right From The Start, Birth
To Three, and HealthCheck. Also,
the Birth Score allows us to gather
additional information on health
topics relevant to pregnant women.
Oral health data were collected
from approximately 40,000 mothers
on the Birth Score for two years.
Mothers were asked questions
about periodontal disease. These
data revealed oral health issues
among pregnant women in WV.
According to the Birth Score data
obtained from July 2007- August
2009, 15% of pregnant women
had never had their teeth cleaned
during the previous five years. Gum
disease is a known factor for serious
long term health issues.10 Many
women in WV are at risk for these
problems due to lack of dental care.
New questions replaced the oral
health questions on the Birth Score
in September 2009. The questions are
designed to evaluate self-perceived
health, stress, and diabetes in
pregnancy and the associations with
infant outcomes (e.g. prematurity).
Thereby, in addition to identifying
high risk infants, the data collected
on the Birth Score may be used to
identify maternal health issues in
WV and in turn develop measures
to improve infant health.
Acknowledgements: The West
Virginia Birth Score Program is
funded under an agreement with
the West Virginia Department of
Health and Human Resources,
Bureau for Public Health, Office of
Maternal, Child and Family Health.
References
1. Carpenter RG, Gardner A, Jepson M, et al.
Prevention of unexpected infant death:
evaluation of seven years of birth scoring
and increased visiting of high risk infants to
prevent unexpected infant deaths in
Sheffield. Lancet. 1983; i: 723-727.
2. AAP task Force on Infant Positioning and
SIDS. Positioning and SIDS. Pediatrics
1992; 89:1120-1126.
3. American Academy of Pediatrics, Task
Force on Infant Sleep Position and Sudden
Infant Death Syndrome. Changing
concepts of sudden infant death syndrome:
implications for infant sleeping environment
and sleep position. Pediatrics 2000;
105:650-656.
Prevention. Trends in Smoking Before,
During, and After Pregnancy- Pregnancy
Risk Assessment Monitoring System
(PRAMS), United States, 31 Sites, 20002005. Surveillance Summaries, May 29,
2009. MMWR 2009; 58 (No. SS-4).
5. Reeves S, Bernstein I. Effects of maternal
tobacco-smoke exposure on fetal growth
and neonatal size. Expert Rev Obstet
Gynecol. 2008 Nov 1;3(6):719-730.
6. Duncan JR, Garland M, Myers MM, Fifer
WP, Yang M, Kinney HC, Stark RI.
Prenatal nicotine-exposure alters fetal
autonomic activity and medullary
neurotransmitter receptors: implications for
sudden infant death syndrome. J Appl
Physiol. 2009 Nov;107(5):1579-90. Epub
2009 Sep 3.
7. Kinney HC, Richerson GB, Dymecki SM,
Darnall RA, Nattie EE. The brainstem and
serotonin in the sudden infant death
syndrome. Annu Rev Pathol. 2009;4:517-50.
8. JDuncan JR, Paterson DS, Hoffman JM,
Mokler DJ, Borenstein NS, Belliveau RA,
Krous HF, Haas EA, Stanley C, Nattie EE,
Trachtenberg FL, Kinney HC . Brainstem
serotonergic deficiency in sudden infant
death syndrome. JAMA. 2010 Feb
3;303(5):430-7.
9. Charleston Gazette. Dec 13, 2009.
10. Krejci, C, Bissada, N. Women’s health
issues and their relationship to
periodontitis. JADA, Vol. 133, March 2002.
CME Post-Test
4. T
he most common substance of abuse taken during
pregnancy in WV is:
a. marijuana
b. vitamin pills
c. heroin
d. French fries
he Birth Score is completed following deliveries in
5. T
WV and is:
a. optional
b. mandatory by law
c. completed only on infants that expire
moking during pregnancy is significantly associated
6. S
with:
a. large for dates infants
b. higher infant mortality in the first year
c. infants who have CNS abnormalities
Bringing All The Players to the Table: The West Virginia
Controlled Substance Advisory Board
Karen L. Hannah
Epidemiologist
West Virginia Medical Institute
Michael O’Neil, PharmD
Associate Professor
The University of Charleston
School of Pharmacy
Abstract
Abuse and diversion of controlled
substances are well-known problems in
West Virginia and nationally. The costs to
our society in both dollars and human
capital are substantial. These problems
touch groups as diverse as law
enforcement, medical professionals,
government leaders, addiction specialists,
pain specialists, social workers, educators
and regulatory boards, among others. The
issues these groups face are varied and
often unique to each profession, often
resulting in a lack of communication and
collaboration. This problem has been
compounded by the fact that each group
often makes decisions based on
independent data related to substance
abuse and diversion, which historically
have not been shared due to privacy and
other concerns. The West Virginia
Controlled Substance Advisory Board was
created to address these and other issues
involved in drug diversion and substance
abuse in West Virginia.
History of the CSAB
In April 2007 the University
of Charleston created the Center
of Excellence for the Study and
Prevention of Drug Diversion and
Substance Abuse, with the mission to
provide up-to-date information and
services for educating, preventing
and understanding drug diversion
and substance abuse in all areas
and populations within the state.
It quickly became apparent that
the huge scope of this issue would
also require the involvement of law
enforcement, health professionals,
state regulatory boards, pain
specialists, addiction specialists,
psychiatrists, and legislators, and
would necessitate a statewide task
force. A September 2007 meeting
with representatives of the WVU
Ethics Committee, the State Pain
Initiative and the WV Partnership
to Promote Community WellBeing led to the recognition of the
need for a more comprehensive
entity – a West Virginia Controlled
Substance Advisory Board.
In the fall of 2007, a small group
representing what would become the
core of the CSAB met with leaders
of the West Virginia Legislature,
the West Virginia State Police, the
American Cancer Society, the West
Virginia Partnership to Promote
Community Well-Being, the
Secretary of State’s office, and other
groups around the state. All parties
supported the development, makeup
and organization of the CSAB.
However, the ability to initially
fund activities such as data mining,
education, administrative support,
and possible legal fees was limited.
The first CSAB meeting was held
at the UC School of Pharmacy in
December 2007. Twenty-eight of the
30 invitees attended, representing the
State Medical Association, behavioral
health agencies, state and local law
enforcement organizations, the
federal Drug Enforcement Agency,
the state Medical Examiner’s office,
both houses of the West Virginia
legislature, pain specialists, endof-life specialists, family practice
physicians, and the state boards
of medicine, nursing, pharmacy,
dentistry, osteopathic medicine
and veterinary medicine. Attendees
agreed that the broad spectrum
of interests represented would
be key to optimizing efforts in
prescription drug abuse prevention
and education in all communities
(government, health professionals,
educators and law enforcement).
At this initial meeting there was
a consensus agreement that a major
priority for the CSAB should be
gathering, collating, analyzing and
reporting of data that are often not
shared in West Virginia. Currently,
most data regarding substance
abuse, illegal prescribing, drug
diversion and other related issues
are only seen by isolated individuals.
When combined with other data
sources (within the bounds of state
and federal privacy laws), this
information could ultimately guide
efforts by law enforcement, medical
boards, educators and practitioners.
At this initial meeting the
importance of direct communication
Objectives
The objective of this article, “Bringing All the Players to the Table: The West Virginia Controlled Substance Advisory Board,” is to
introduce the reader to the CSAB, explain its history and mission, and describe its current initiatives and projects. The article also
describes how the CSAB brings together representatives of various disciplines in West Virginia in order to provide a consistent
framework around the areas of education, treatment, prevention and intervention of drug diversion and substance abuse of
prescription drugs as part of the Governor’s plan for a “drug free state.”
about this issue, especially between
law enforcement and health
professionals, was clearly illustrated.
By face-to-face communication,
unsubstantiated and unfounded
perceptions – such as a belief that law
enforcement aggressively monitors
practitioners, especially pain
specialists and end-of-life specialists
– were resolved immediately. This
meeting also made clear that health
care professionals, prosecutors,
law enforcement officials as well
as society as a whole are often
deficient in understanding addiction
as a disease, and that efforts aimed
at prevention and treatment of
substance abuse and addiction could
significantly minimize deaths, crimes
and worsening of other diseases.
At this initial meeting, the
workgroup established the
mission of the CSAB: to provide a
comprehensive approach from law
enforcement, medical practitioners,
medical boards, legislators,
health affairs specialists, support
groups, and epidemiologists to
help direct the state in the areas of
education, treatment, prevention
and intervention of drug diversion
and substance abuse of prescription
drugs as part of the Governor’s
plan for a “drug free state.”
able to provide funding as well as
administrative support for the CSAB.
Ownership and Funding for
the CSAB
The CSAB currently supports
several initiatives and projects
involving legislative, education, and
data issues that are recommended to
other subgroups and then brought
to the Partnership for a vote.
Current legislative initiatives of
the CSAB include recommendations
for drug diversion laws, monitoring
guidelines for controlled substances,
recommendations for scheduling
of controlled substances, support
for law enforcement regulations,
creation of pain initiative guidelines,
and support of related legislation.
Current education initiatives of
the CSAB include several dealing
with addiction/substance abuse
treatment, pain management, drug
diversion and prevention in diverse
venues, including medical schools,
veterinary schools, pharmacy schools,
nursing schools and dental schools.
The CSAB, through the Partnership,
has given over 80 presentations or
in-services for national, regional,
The next step was developing
ownership, financial support, and
housing for the CSAB. In April 2008,
The West Virginia Partnership to
Promote Community Well-Being
voted to adopt the CSAB as a work
group of the Partnership. The WV
Partnership is an alliance of existing
agencies from all three branches
of state government, community
representatives, and experts. The
Partnership was created in May 2004
to serve as the Governor-appointed
substance abuse, prevention, and
intervention planning body. The
Partnership’s purpose is to develop
a well-coordinated, comprehensive
statewide approach to WV’s
substance abuse problems, including
prescription drugs, illicit drugs and
alcohol. The WV CSAB’s mission
fit perfectly into this structure.
Additionally, the Partnership was
Current Initiatives
Figure 1.
Current Structure of the Partnership and the CSAB
Figure 2.
2010 legislation successfully passed with the support and/or recommendation of the
CSAB.
along with community specialists,
physicians, and pharmacy doctoral
students will provide the educational
component of this project. Success
of the project will be evaluated
by a patient survey assessment.
A third project is the development
of best practices for disposal of
prescription drugs for the state. This
will include a plan for a prescription
“take-back” process for drug disposal
as well as guidelines for public
education on medicine cabinet
cleanout and the appropriate disposal
of “left-over” or unused medication.
Conclusion
state, county, and local audiences. We
have created a 30 hour dental review
course for the WV Board of Dental
Examiners on pain management and
prescribing that is being considered
for national distribution, as well as an
eight hour law enforcement training
course for law enforcement officers
at all levels on how to identify and
deal with prescription drug abuse,
diversion and addiction. We are
also planning to conduct continuing
education programs for physicians
and other professionals, which will
include guidelines on waste disposal,
tools to minimize drug diversion,
and education on how to maintain
optimal medical board compliance
for prescribing controlled substances.
Current data initiatives of the
CSAB include tracking DEA/
ARCOS (Automation of Reports
and Consolidated Orders System)
statistics and trends, various state
controlled substance monitoring
reports, drug task force statistics
and trends, recovery network
statistics, hospital discharge data,
WV Poison Center data and Medical
Examiner data. The goal of this
effort is integration of multiple
databases into one system so that
data is collated, integrated, and
disseminated in a way that allows
for optimization of state and local
funds used for prevention, detection,
education, and prosecution of
prescription drug diversion and
alcohol / substance abuse.
Current Projects of the CSAB
The CSAB is currently comparing
data from the West Virginia
Board of Pharmacy’s Controlled
Substance Monitoring Program
database with data from the West
Virginia Poison Control Center to
evaluate methadone prescribing
trends and deaths over the past
five years. Data from these two
databases will be combined
with other state data to develop
recommendations concerning
methadone education, prescribing,
utilization and potential legislation.
Another project the CSAB is
currently studying is a pilot project
for prescription drug education
in areas of high opiate abuse. We
have secured $22,800 of funding
for a 5-county pilot project from
the PPAF (Purdue Pharma Asset
Forfeiture fund), and will conduct
the project in Mingo, Wayne, Lincoln,
Cabell, and Logan counties. This
project will cover drug disposal and
sharing of prescription medications.
Dr. Michael O’Neil, Pharm.D.,
The West Virginia Controlled
Substance Advisory Board was
created to fill a void in the approach
to substance abuse and diversion in
West Virginia. The CSAB strives to
bring together professionals in all
disciplines involved with the issue
of controlled substance abuse and
diversion, including law enforcement,
education, health care, licensing
boards, social services, epidemiology,
and government, in order to discuss
the issues involved and to promote
appreciation and awareness of each
discipline’s unique perspective on
this issue. The CSAB also provides
education for law enforcement,
medical professionals, and the
public on issues related to controlled
substance abuse and diversion.
Finally, the CSAB is developing
an integrated data collection
system which includes collection,
integration and dissemination of
data to allow optimization of state
and local funds used for prevention,
detection, education, and prosecution
of prescription drug diversion and
substance abuse. Each of these
functions is essential in order for
West Virginia to deal effectively with
the issues involved in controlled
substance abuse and diversion.
CME Post-Test
7.
What is the purpose of the CSAB?
a. To bring together professionals in various professions who are concerned
with controlled substance abuse/diversion in West Virginia.
b. To provide education for law enforcement, medical professionals, and the public
on issues related to controlled substance abuse and diversion.
c. To develop an integrated data collection system to deal effectively with
the issues involved in substance abuse and diversion.
d. All of the above.
8.
Under which agency is the CSAB housed?
a. The West Virginia Partnership to Promote Community Well-Being
b. The West Virginia State Police
c. The federal Drug Enforcement Agency
9.The CSAB does not support or recommend legislation regarding controlled substances.
a. True
b. False
Providing Mental Health and Substance
Abuse services to health care providers
and their patients for over 30 years.
Randall A. Clifford, MA
Licensed Professional Counselor
Licensed Certified Social Worker
Certified Employee Assistance Professional
4501 MacCorkle Ave, SW, Suite 204
South Charleston, WV 25309
Phone: 304.768.1401
Fax: 304.768.1402
E-mail: [email protected]
Participating in over 35 Health Insurance programs, and in over 33
Employee Assistance Programs.
Prescription Drug Abuse & Addiction: Past, Present and
Future:The Paradigm for an Epidemic
P. Bradley Hall, MD, DABAM, AAMRO
Denzil Hawkinberry, II, MD, DABA
Pam Moyers-Scott, PAC, MPAS, DFAAPA
“Substance abuse affects
a broader segment of West
Virginia’s citizens and their
state and local governments
than any other single issue
confronting us today”.1
Governor Joe Manchin III
Abstract
Prescription drug abuse has reached
epidemic proportions in the United States
and West Virginia is not immune. It is
estimated that in 2009, the number of
adolescents and adults with a substance
abuse and/or dependence problem has
reached 23.2 million in the US. There has
been an alarming rate of increased sales
of methadone, hydrocodone and
oxycodone. This article addresses the
scope of the problem of prescription drug
abuse in West Virginia and the impact by
and on the addicted individual. Addiction
is a chronic relapsing neuropsychiatric
illness manifested by compulsive drug
seeking and use. It has created a
substantive socioeconomic burden on our
state. Prescription drug abuse and
addiction increase medical expenses,
drug related crime and unemployment.
There are misconceptions regarding the
etiology and treatment of addiction based
on past clinical experience. The view of
addiction as volitional misconduct alone
has been disproven scientifically. A more
current understanding of neurobiological
alterations caused by this disease, current
treatment strategies and future directions
will be presented. This article provides an
understanding of prescription drug abuse
and addiction’s contribution and impact on
society’s health and social policy.
Addressing the problem of prescription
drug abuse requires an understanding of
the disease of addiction, thus enhancing
the effectiveness in diminishing the
associated health and social costs. It is
the article’s intent to illuminate the
mutually symbiotic relationship of
prescription drug abuse and the disease
of addiction and subsequently provide
recommendations toward the resolution of
this most important issue.
The Past…outmoded
Addiction has historically been
considered a disease of “weak will or
moral turpitude”. However, advances
in brain imaging technology and
the ability to accurately measure
neurotransmitters over the past
two decades has significantly
improved our understanding of the
neurobiology of addiction. Complex
animal and human studies have
led to evidence based science that
recognizes “addiction as a disease”.
This is a dramatic change from the
long-standing misperception that the
addicted patient is afflicted with the
illness due to a lack of willpower.
In 1997, National Institute on Drug
Abuse (NIDA) published “Addiction
is a Brain Disease and It Matters”, by
Dr. Alan Leshner, the then current
director. This publication served a
pivotal role in the introduction of
the disease model of addiction based
on emerging new research.2 In 2007,
Dr. Nora Volkow, as the current
NIDA Director, presented “The
Neurobiology of Free Will” at the
American Psychiatric Association’s
annual conference further enhancing
the medical research community’s
understanding of the drive of active
addiction overriding individual
personal needs. Consequently, the
public is becoming better informed
that the epidemic of addiction
is the result of a disease. Public
information of this disease is
being disseminated by the media
via educational programs and
publications such as the 1998 PBS
special Moyers on Addiction: Close
to Home, the 2005 special issue of
the journal Nature3 on addiction,
the 2007 HBO special, Addiction:
Why Can’t They Just Stop? and
Time Magazine’s 2007 cover story,
“How We Get Addicted”.4 Viewing
addiction as a chronic medical
illness makes the long-standing
stigmatization no longer acceptable.
The Present…an epidemic
The estimate of lifetime
prevalence of a substance use
disorder, in the general population,
is approximately 10%.5,6 According
to the US Department of Health
and Human Services in 2009, 23.2
Objectives
As a result of reading this article, the physician will better:
1.
Be able to explain the socioeconomic impact of prescription drug abuse and addiction
2.
Comprehend the neurobiology of addiction as result of prescription drug abuse
3.
Be able to explain important components in effectively addressing prescription drug abuse and addiction in the future.
million Americans age 12 or older
experienced a substance use or
abuse problem where treatment
would have been indicated. Only
10% of these individuals received
the indicated treatment at a specialty
facility.7 Estimates from the 2008
National Household Drug Use and
Health Survey (NHDUHS) revealed
the predominant reason for not
receiving substance abuse treatment
among persons age 12 or older
who needed but did not receive
treatment for the period 2005-2008
combined was “no health coverage
and could not afford the cost
(37.4%)”. According to the Substance
Abuse and Mental Health Services
Administration (SAMHSA), the
need for substance abuse treatment
among Americans older than age
50 is likely to double by 2020.8
The National Institute on Drug
Abuse (NIDA) estimated the cost
of drug abuse in the United States
to be 246 billion dollars in 1992.3
Current estimates of the financial
burden to society due to substance
abuse exceeds half a trillion dollars
annually.9 The West Virginia
partnership to promote community
well-being estimates “In 2006,
the total cost to West Virginia for
substance abuse was 1.86 billion with
470 million related to direct costs
to the consequences of substance
abuse”.1 The intangible personal
costs to society are immeasurable.
Prescription drug use and abuse
have significantly increased in the
United States and West Virginia. In
the 10 years (1997 – 2007) the per
capita retail purchases of methadone,
hydrocodone and oxycodone in the
United States increased 13-fold, 4 fold
and 9-fold, respectively. Nationally,
4.8% of individuals 18-25 use pain
relievers for non-medical reasons and
5.2 million age 12 years and older
have used prescription medications
non-medically in the past year
during 2002-2005.10 Prescription
drug abuse and addiction are
epidemic in the United States with
West Virginia leading the way.
From 1999 to 2004, deaths as result
of unintentional drug poisoning
increased 68% nationwide. West
Virginia experienced the Nation’s
largest increase in unintentional drug
poisoning mortality rates (550%).
In 2006, those overdose deaths in
West Virginia were associated with
non-medical use and diversion of
pharmaceuticals, primarily opioid
analgesics. Diversion was highest
among the 18-24 year age group with
the decedents lacking prescription
documentation for one or more
contributing pharmaceuticals 91% of
the time. Although opioid analgesics
were the most prevalent drug class,
79.3% of decedents had multiple
substances contributing to their fatal
overdose. Opioid analgesics were
involved in 93% of deaths with only
44.4% ever having been prescribed
these drugs. Psychotherapeutic
drugs were involved in 49% of
deaths with Benzodiazepines
being most commonly involved
(78.5%). Alcohol was a significant
contributing factor in the vast
majority of fatal prescription drug
overdoses. Prescription opioid
analgesics played a dominant role in
deaths with a secondary contribution
from psychotherapeutics. Virtually
all of the individuals experiencing
prescription drug related deaths
showed signs of drug abuse. Risk
factors included being male, lower
education, living in impoverished
counties of the state and having a
positive family history. Many users
are naïve to the potentiative and
synergistic effects contributing to
the lethality of combining these
drugs. This lack of understanding
and/or concomitant usage of
alcohol provides some accounting
for the escalation of unintentional
pharmaceutical overdose fatalities.
This, potentially, partly explains
why methadone was found to
be responsible for more singledrug deaths and was involved
more than any other drug.10
In a society which has gotten
very comfortable with “a pill for
everything” philosophy there
is another issue in addition to
unintentional drug overdoses to
be considered. Prescription drug
abuse is affecting our children and
therefore our future. The drug
of choice for adolescents age 1218 is no longer marijuana, but
prescription drugs. These are easily
obtained from medicine cabinets
within the home, from friends and
family with the majority reporting
that the friend or relative received
the drug from a single clinician.11
The problem of adolescent
substance abuse and addiction
with associated co-morbidities is
widespread. Adolescent addiction is
a developmental disorder with peak
onset between ages 15 and 21. The
onset of addiction prior to age 15
statistically increases disease severity
and duration.12,13 Many adolescents
are potentially self medicating coexisting psychiatric disorders such
as depression, a well known major
comorbid factor in the development
of marijuana dependence.12 Other
contributing factors include; genetic
predisposition, childhood trauma,
disruptive or addictive child
rearing environments, poor school
performance and substance abusing
friends. It is well known traumatized
adolescents have greater difficulty
learning addiction recovery skills.14
A deeper understanding is needed
in the relationship of addiction as
a disease and prescription drug
abuse in adolescents and adults.
The Chronic Medical Illness
Model of Addiction
Addiction is a chronic medical
illness; therefore, the comparisons of
diagnosis, treatment and outcomes
are similar to that of other chronic
illnesses such as, type II diabetes
mellitus, asthma and hypertension.
There are accepted diagnostic
criteria available in the DSM IV
that provides a reliable, valid and
refined differentiation of use, abuse
and dependence disorders.15 The
utilization of short screens similar
to the CAGE16 questionnaire, the
AUDIT,17 and the MAST18 applied
during a medical evaluation
followed with the application of
standardized diagnostic criterion
has been proven reliable.19,20 These
well-known multiple question
screening tools vary in degrees of
usability in the primary care setting
and in their ability to identify more
severe unhealthy drinking (i.e.,
dependence). A single-question
screen: “How many times in the
past year have you had X or more
drinks in a day?” (where X was
4 drinks for women and 5 drinks
for men); was 82% sensitive and
79% specific for unhealthy alcohol
consumption. A positive result is
>1 occasion for both males and
females. This screen is a useful tool
in the busy primary care setting,21
similar to using a finger-stick glucose
measurement in diabetes screening.
It has been shown that screening
followed with brief interventions
by physicians can affect the
motivational change among patients
and positively impact the long-term
health outcomes. Studies specific
to substance abuse and addiction
have shown abstinence increased
and HIV seroconversion decreased
in opiate dependent individuals
when provided motivational
counseling from a health educator.22
The presence of cocaine in the
urine of pregnant mothers getting
some treatment for addiction and
counseling in the context of their
prenatal visits has been shown
to be significantly decreased at
delivery compared to addicted
pregnant mothers who received
routine prenatal care only.23
The treatment of addiction
requires both long-term management
and acute interventions. Similarly,
asthma and diabetes are managed
chronically with the utilization of
maintenance measures and acutely
with more immediate treatment.
This principle should also be applied
in the management of the addicted
patient where relapse occurs at
a rate of 40-60% in the first year
following treatment.24,25 Treatment
effectiveness is dependent upon
compliance with the treatment
recommendations. According to
McLellan, et al, there is a significant
degree of non-compliance with
medication and behavioral treatment
recommendations which contributes
to relapse rates of 30-50% and 5070% of adult patients with diabetes
and asthma respectively.19 Noncompliance leading to relapse is
known to occur in both addictive
and non-addictive illnesses and
should be managed rather than
viewed as treatment failure.
Nature and Nurture
Evidence shows a significant
genetic contribution to the risk
of addiction comparable to other
chronic illnesses. A multitude of twin
studies have shown significantly
higher rates of dependence
among twins than non-twin
siblings. There is a higher rate of
dependence among monozygotic
than dizygotic twins.26,27 Twin
studies of hypertension, diabetes
and asthma show a significant
component of heritability.28,29,30
As with other chronic illnesses
a genetic predisposition and the
environmental trigger must often
co-exist before disease occurs. For
example, exposure to asbestos in a
patient with a genetic predisposition
to lung cancer is more likely to result
in the development of carcinoma of
the lung than the exposed patient
without this genetic predisposition.31
The voluntary initiation of drug
use does not distinguish drug
dependence from other medical
illnesses. Many other diseases
are affected by voluntary choice
especially when taking into account
genetic, environmental and cultural
factors. Excessive salt intake, for
example, can contribute to the
development of hypertension
when combined with the genetic
predisposition for salt sensitivity,
cultural stress and exogenous obesity.
The initiation of alcohol use can
be extremely pleasurable to some
individuals (or not). The pleasant
sensation induced by a casual drink
at the end of the day is familiar and
safe for many people. However,
this recreational usage progresses
to tolerance and dependence for
some individuals. Studies have
shown sons of alcohol dependent
fathers have a higher degree of
tolerance to alcohol and are less
likely to experience hangovers than
sons of non-alcoholic dependent
fathers.32 Conversely, the “flushing”
response to alcohol in the inherited
presence of aldehyde dehydrogenase
genotype (associated with alcohol
metabolism) leads to an unpleasant
initial reaction to voluntary alcohol
use resulting in very few alcoholics
being found with this genotype.33
Environmental and other
influences such as comorbid mental
illness, low-self-esteem, poor social
skills, poor coping mechanisms,
exposure to physical or sexual
abuse, poor parental influences,
poor school performance, peers
who abuse substances, male gender,
and poverty7,19 can lead individuals
to seek pleasure by reactivating
the dopaminergic system (see
Neurobiology). In patients without
the genetic predisposition for
addiction, it is less likely that this
disease will be established even in
the presence of at risk behaviors.
The overall addiction vulnerability
is related to genetic influences,
environmental conditions, other
complex personality traits, stress
responses and comorbid issues
including self-medication of
undiagnosed psychiatric illness,
codependency, family of origin
issues, poor coping skills, etc.
The Neurobiology
Chronic exposure to an addictive
drug can “hi-jack” the neural
circuits of the susceptible brain
causing enhanced “plasticity” in the
neural circuits related to reward,
motivation, and learned behavior.
This circuit is contained in the
ventral tegmental area connecting
the limbic cortex through the midbrain to the nucleus accumbens.
Although by different mechanisms,
alcohol, opiates, cocaine and nicotine
activate the dopaminergic system,
resulting in the euphoria associated
with drug use. Administration of
an addictive substance increases
synaptic dopamine levels in
the brain creating euphoria and
enhanced sense of well-being.34,35,36
This occurs predominantly by the
neurons of the ventral tegmental
area (VTA) releasing dopamine
into the nucleus accumbens and the
prefrontal cortex.4,35,36,37 Volitional
behaviors become habits and then
compulsions through pavlovian
learning. The brain adapts replacing
appropriate reward for survival
activities like quenching thirst,
satisfying hunger, sleeping and sex
with the drive for activation of the
dopaminergic system. Repeated
activation eventually leads to chronic
changes in the neuroregulatory
mechanism.34,35,36 This neuro-adaptive
transformation occurs at a higher
rate if the initial’s substance exposure
occurred during adolescence when
there is a greater degree of synaptic
plasticity.37 Other neuroendocrine
substances and structures involved
include, but not limited to, serotonin,
norepinephrine, N-methyl-Daspartate receptors, opioid peptide
receptors, γ-Aminobutyric acid
(GABA) systems, dynorphin,
acetylcholine, corticotrophin
releasing factor, adrenocorticotropic
hormone, and corticosterone.34,36,37
For a free brochure on our nationally recognized addiction
professionals alcohol and drug treatment program visit us
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Pharmacotherapy
Increased understanding of the
pathophysiology of addiction has
led to medications useful in the
treatment of addiction.38 Nicotine,
bupropion and varenicline are good
examples of pharmacologic agents
utilized in the treatment of cigarette
smoking. Opioid dependence has
been successfully treated with the
partial agonist buprenorphine,39
and methadone is known to reduce
opiate use, the spread of infectious
diseases and crime.38 The opioid
antagonist naltrexone competitively
blocks the actions of heroin resulting
in neither dysphoria or euphoria in
abstinent patients.40,41 The GABA
agonist acamprosate has been
shown to decrease craving and
relapse to alcohol use.42 Disulfiram
is well-known to be useful in the
prevention of relapse in individuals
The FarleyCenter
AT WILLIAMSBURG PLACE
with alcohol dependence.43 These
agents are infrequently prescribed,
despite being indicated and proven
effective. With the knowledge now
available, this is comparable to
withholding an antihypertensive
agent from a hypertensive
patient. Medications coupled with
adjunctive lifestyle modifications
can be of therapeutic benefit.
Relapse
Healthcare professionals
perceive relapse rates of diabetics,
hypertensives and asthmatics as
acceptable and even expected in
many cases. Yet, the relapse to drug
or alcohol use following discharge is
often considered “treatment failure”.
It is essential to realize that a relapse
in a patient suffering from addiction
is no different than an exacerbation
of other chronic medical illnesses.
The immediate and profound
desire for the re-administration
of an addictive drug is common.
The re-initiation of use following
a period of abstinence, despite
potential negative consequences, is
counterintuitive. The awareness of
potentially negative consequences
is not necessarily protective or
preventative. This is due to possibly
permanent pathophysiologic changes
in the reward circuitry which
occur with chronic administration
of addictive substances. Physical
signs of withdrawal are short
lived. Motivational and cognitive
impairments may resolve over a
period of months, but the tolerance
to drugs may never return to normal.
Neurobiological changes in the
brain, impulse dysregulation and
alterations of decision making all
impact executive function. People,
places or things previously associated
with drug/alcohol use can induce
conditioned physiologic reactions
resulting in profound “craving”
for the drug/alcohol. Cravings
in the absence of good recovery
skills and unresolved co-morbid
issues can result in relapse. These
physiologic responses have been well
documented using positron emission
tomography (PET) examinations
of the limbic and control brain
regions further confirming that
addiction is a disease with definable,
reproducible, anatomical and
biochemical brain alterations.44
Discussion
Although there are other
important aspects to the supply
and demand continuum related
to prescription drug abuse and
addiction not addressed in this
article, it was the authors’ intent
to focus on the interrelationship of
prescription drug abuse related to
addiction. The disease of addiction
is a major driving force to the
prescription drug abuse problem we
are facing in West Virginia today. It
is obvious that addiction is a disease
and shares many common features
with other chronic illnesses resulting
in as many health problems as there
are social problems. The evidence
showing neurobiological and
neuroplastic alterations in the brain’s
“circuitry” provide confirmation
that prescription drug abuse related
to addiction is an incurable, chronic
medical illness. The stigma of
the drug addict as “weak or bad
people” unwilling to live a more
socially acceptable moral life is being
replaced with a better understanding
of the addicted individual as a “sick
person”, who may or may not be,
trying to get well. The public is no
longer naïve because many of us
have a loved and respected friend
or family member who suffers from
the disease of addiction. There is no
better antidote to the stigmatization
than the personal experience of
knowing one or more individuals
in successful long-term recovery.
Even if addiction is the result
of voluntary behavior initially, the
brain chemistry in the addicted
individual is different from the nonaddicted brain and must be treated
as if he or she is in a different brain
state (much like the schizophrenic,
diabetic in ketoacidosis, cirrhotic
with hepatic encephalopathy and
Alzheimer’s patient). We need
to continue narrowing the gap
between the scientific knowledge
and the public perception about
prescription drug abuse and
addiction in order to enhance our
ability to address this problem.
Federal studies show that the
best drug treatment programs pay
for themselves over time, especially
when utilizing strong motivation to
facilitate the treatment process. A
combination of sanctions or rewards
from personal, professional and/or
legal relationships can increase the
utilization of treatment and retention
rates, as well as, the success of
interventions.14,45 A good example
is law enforcement’s “drug court
diversion” to treatment initiatives.
11,45
Evidence shows treatment
response benefits of reduced drug
use improved personal health and
reduced social pathology, but not a
cure for addiction. A comprehensive
study conducted in 2000 of the cost
benefit of drug treatment services
estimated that for every $1 spent on
treatment, $7 are saved in the form
of reduced medical expenses, costs of
crime and the increased employment
earnings.46,47 Every man, woman,
and child in America pays nearly
$1,000 annually to cover the costs of
unnecessary health care, extra law
enforcement, motor vehicle crashes,
crime, and lost productivity due to
substance abuse.48 The management
of addictive disease and cooccurring disorders in a continuing
care model of treatment must
include consideration of; a chronic
disease requiring long-term follow
up, integration of healthcare, the
possibility of dual diagnosis, the level
of detoxification, relapse prevention,
pharmacotherapy, psychosocial
recovery, educational needs and
other factors based on the American
Society of Addiction Medicine
Placement Criteria.49 If effective
education and prevention programs
were implemented nationwide,
substance abuse initiation would
decline for 1.5 million youth and
be delayed on average for 2 years,
which reduces subsequent problems
later in life. In 2003, it is estimated
that 10.2% fewer youth would have
used marijuana, 30.2% fewer would
have used cocaine and 8% fewer
would have smoked regularly. With
an average cost of effective school
based programs in 2002 at $220
per pupil (only 20% of American
youth were exposed to effective
prevention programs in 2005),
these programs could have saved
an estimated $18 per $1 invested
if implemented nationwide.50
The education and treatment of
addiction needs to continue the
shift from acute treatment alone
(detoxification, stabilization and
discharge) to the model applied
to other chronic illnesses.
Healthcare providers have
an important role in education
regarding; addiction treatment
and prescription drug abuse, the
risk of drug interactions, overdose
and the proper prescribing and
administration of addictive
medications. The American Society
of Addiction Medicine and others
are actively addressing these and
many other important aspects in the
research and treatment of addiction
as a disease. Addiction medicine is
now a mainstream medical society
recognized by the American Medical
Association and has established
an American Board of Addiction
Medicine.11 Irrespective of the
underlying science of addiction, the
massive health and social problems
that drug addiction brings is not
just epidemic in West Virginia,
but across the nation, maybe even
should be more appropriately
referred to as pandemic. The interest
and safety of the public are best
served when regulatory agencies
and experts develop a process
allowing for early intervention,
evaluation, treatment and followup of the addicted patient.51
Conclusion
The current and future impact
of prescription drug abuse and
addiction on society is being
evaluated. A new paradigm,
which would include health care
reform legislation encompassing
parity of insurance coverage for
mental health and substance use
disorders, is imminent. Funding of
evidence based addiction research,
treatment and education of the
healthcare community and the
public is greatly needed. Addiction
screening, brief interventions,
diagnosis, medication management
and referrals when indicated should
be a mandatory component of all
medical school, residency, and
non-physician healthcare providers
training program curricula. This
should also be part of continuing
educational programs to ensure
the skill set and resources are
available in the institution of these
services. They would then be more
routinely incorporated into clinical
practice with associated future
benefit to patients and society.
It is important that practitioners
adapt to the advances made in
the care and monitoring strategies
as they are in the treatment
of other chronic illnesses.
As stated by the Governor of West
Virginia, we need to “Implement a
long-term approach that will sustain
a meaningful and effective system
addressing the entire substance
abuse continuum: Prevention,
Early Intervention, Treatment, and
Recovery”.1 The formation of the
Governor’s Prescription Drug Abuse
Advisory Board exemplifies such an
effort. It is the authors’ belief that
this combined effort and education
Drug or Alcohol Problem? Mental Illness?
If you have a drug or alcohol problem, or are suffering from a mental illness you can get
help by contacting the West Virginia Medical Professionals Health Program. Information
about a practitioner’s participation in the program is confidential. Practitioners entering the
program as self-referrals without a complaint filed against them are not reported to their
licensing board.
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of our children (prior to exposure),
the healthcare profession as a whole
during and subsequent to training
and the public is the key to resolving
the issue of prescription drug abuse
and addiction. Clinicians have a
critical role, not only in preventing
the diversion of prescription drugs,
but also in the treatment of addiction
acutely and the long-term as with
any other chronic medical illness
affecting our society. Collaboration
of legislators, legal authorities, the
clinicians and healthcare community,
including organized medicine, and
the public will provide the ability
to stop living in the problem and
begin to live in the solution. As
representatives of the healthcare
profession and the public, we ask…
what are we going to do about it?
References
1. Manchin III J. The governor’s
comprehensive strategic plan to address
substance abuse in West Virginia. The
West Virginia Prevention Resource Center.
2009 (November) Available at: http://www.
prevnet.org/wvpartnership/docs/Plan.pdf.
(Accessed: March 20, 2010.)
2. Leshner, A.I. (1997). Addiction is a Brain
Disease, and it Matters. Science, 1997;278
(5335): 45-47.
3. I-han C, Narasimhan K (eds). Neurobiology
of Addiction. Nature Neuroscience.
2005;8(11):all.
4. White, W.L. In search of the neurobiology
of addiction recovery: a brief commentary
on science and stigma. 2007(August):all.
Available at: http://wsam.org/files/White_
neurobiology_2007.pdf. (Accessed April 4,
2010).
5. McLellan, AT, Skipper, GS, Campbell, M,
DuPont, RL, Five Year Outcomes in a
Cohort Studies of Physicians Treated for
Substance Use Disorders in the United
States. BMJ. 2008;337(November):a2038,
doi: 10.1136/bmj.a2038.
6. American Society of Addiction Medicine.
(2003). In Principles of Addiction Medicine,
3rd Edition. Chevy Chase MD: ASAM.
Section 1, Chapter 2, The Epidemiology of
Addictive Disorders, page 20.
7. National Institute on Drug Abuse. NIDA
InfoFacts: Treatment Approaches for Drug
Addiction. Washington D.C.: U.S.
Department of Health and Human
Services. 2009 (September): all
8. Substance Abuse and Mental Health
Services. Report on illicit drug use among
older adults 2006-2008. ASMA News.
2010;25(1):14.
InfoFacst: Treatment Approaches for Drug
Addiction. Washington D.C.: U.S.
Services. 2008 (June): all
Kraner JC, et al. Patterns of abuse among
unintentional pharmaceutical overdose
fatalities. JAMA. 2008;300(22):2613-2620.
11. Hall, P.B. M.D. “A Lessor Evil for Drug
Addicts”, Editorial Response to the Toronto
Sun. May 2009.
12. Gurley, R.J., Aranow, R., Katz, M. “Medical
Marijuana: A Comprehensive Review”.
Journal of Psychoactive Drugs. 1998;30(2),
137-148.
13. National Institute Drug Abuse. Principles of
drug addiction: a research based guide.
2nd ed. Washington, DC: US Department
of Health and Human Services. NIH
Publication No. 08-4180. 2008 (revised
2009):all.
14. Rothman, B, O’Gorman P. Working with
traumatized and addicted adolescents”.
Counselor, 2008;9(6):24-29.
15. American Psychiatric Association.
Substance-related disorders. In: American
Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, 4th
ed (text revision). Washington, D.C.:
American Psychiatric Association.
1994;191-295.
16. Buchsbaum DG, Buchanan RG, Center
RM, Schnoll SH, Lawton MJ. Screening for
alcohol abuse using CAGE scores and
likelihood ratios. Ann Intern Med.
1991;115:774-7.
17. Saudners JB, Assland OG, Babor TF,
Fuente Jr, Grant M. Development of the
Alcohol Use Disorders Identification Test
(AUDIT): WHO collaborative project on
early detection of persons with harmful
alcohol consumption-II. Addiction.
1993;88:791-804.
18. Selzer ML. The Michigan alcoholism
screening test: the quest for a new
diagnostic instrument. Am J Psychiatry.
1971;127:1653-8.
19. McLellan, A. Thomas PhD, et al. “Drug
Dependence, a Chronic Medical Illness –
Implications for Treatment, Insurance, and
Outcomes Evaluation”, JAMA. 2000;(284
(13):1689-1695.
20. Buchsbaum DG, Buchanan RG, Lawton
MJ, Elswick RK Jr., Schnoll SH. A program
of screening and prompting improves shortterm physician counseling of dependent
and nondependent harmful drinkers. Arch
Intern Med. 1993; 153:1573-7.
21. Smith PC, Schmidt SM, AllensworthDavies D, et al. Primary care validation of
a single-question alcohol screening test.
Journal of Internal Medicine, 2009;
24(7):783-788
The complete Bibliography can be
accessed at www.wvmphp.org.
CME Post-Test
10. W
hat is the estimated number of individuals over
the age of 12 years who have a substance abuse
and/or addiction problem in the United States?
a. 1 million
b. 5 million
c. 10 million
d. 23.2 million
e. 50 million
11. W
hat is currently considered to be the “drug of
choice” in adolescents in the United States?
a. Marijuana
b. Cocaine
c. Gamma-hydroxybutyrate (GHB)
d. Inhalants
e. Prescription drugs
hich one of the following neurotransmitter
12. W
is most involved in euphoria, reward,
motivation, abuse, and addiction?
a. Dopamine
b. Norepinephrine
c. Serotonin
d. γ-Aminobutyric acid (GABA)
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D. Richard Lough, MD
Michael R. Goins, MD
P. Todd Nichols, MD
G. Stephen Dawson, MD
F. Thomas Sporck, MD, FACS
The Face of Hillbilly Heroin and Other Images of
Narcotic Abuse
Rachel Lagos, DO
Radiology Resident, West Virginia University Hospitals
Michael Hogan, MD
Associate Professor of Radiology, West Virginia
University School of Medicine
Karthikram Raghuram, MD
Associate Professor of Radiology, West Virginia
University School of Medicine
Abstract
The nationally recognized popularity
of recreational intranasal oxycodone
abuse among rural Appalachians is
apparent to West Virginian healthcare
providers. Three recent cases of narcoticinduced injury at WVU Ruby Memorial
Hospital demonstrate the facial bone
necrosis associated with “hillbilly heroin”
abuse as well as other imaging features
of narcotic-induced intracranial ischemia.
This paper shows how diagnostic imaging
may facilitate clinical evaluation of
patients with narcotic abuse.
Introduction
The West Virginia Prescription
Drug Abuse Quitline reports that
fatal drug overdoses increasingly
occur in rural areas. West Virginians
own the greatest increase, a 550%
increase in fatal drug overdoses. 1
Suspecting, recognizing and treating
narcotic abuse, including prescription
narcotic abuse, is a growing priority
among local health care providers.
The US Department of Health and
Human Services compiles a national
survey on drug use and health.2 The
statistical data portray the “typical”
drug abuser. Most illicit drug users
are sixteen to twenty-five years-olds
with a multi-ethnic background and
a full-time job. Men and women
have similar rates of nonmedical
use of pain relievers, stimulants and
methamphetamine. Diagnostic crosssectional images acquired at West
Virginia University Ruby Memorial
Hospital illustrate their problems.
The Face of Hillbilly Heroin
The first report on “hillbilly
heroin” written by Greg Stone
in 2001 credits a pharmaceutical
representative for this epigram
connoting the regional popularity
of “a potentially lethal” and “highly
abused painkiller”, oxycodone.3 The
heroin-quality high of this synthetic
opiate prescription painkiller earns
notoriety locally and throughout
the United States as an addiction
often affecting impoverished
rural Appalachians.4,5,6 Regional
predilection for this addiction is
due in large part to its availability
through Medicaid prescription
coverage. Recent narcotic indictments
report that a single 80-milligram
oxycodone tablet can sell for $120
on the street.”7 Although the
Schedule II controlled substance is
manufactured as a sustained-release
formula, intranasal use of a crushed
oxycodone tablet foils the sustainedrelease mechanism and affords more
intense and instantaneous opiate
effects. These include a lessened
sensation of pain, dreamy euphoria,
pinpoint pupils and respiratory
depression. A patient with chronic
recreational oxycodone abuse may
present with nasal congestion.
A twenty-three-year-old man with
a history of intranasal oxycodone
Images A and B.
Bony defects of the nasal septum and hard palate from intranasal oxycodone.
Objectives
The following article conveys the information necessary to suspect, diagnose and assess the complications of
intranasal oxycodone abuse. There is discussion of three recent cases of narcotic-induced cranial and brain injuries. Crosssectional neuroimaging demonstrates the severity of physical injury in these cases. In addition, the article summarizes
radiological findings of narcotic-induced physical injury to multiple organ systems.
abuse presents to his primary care
provider with sinusitis. Unenhanced
computed tomography of the sinuses
demonstrates a bony defect of the
anteroinferior nasal septum with
prominent mucosal soft tissues and
nasal secretions in this region (image
A). In addition, there is thinning and
necrosis of the hard palate (image B).
Destructive midfacial lesions
subsequent to narcotic abuse are
documented as early as a 1912
case of cocaine-induced hard
palate perforation. The local
vasoconstrictive effect of inhaled
cocaine compounds the mucosal
irritation from the powdered
substances used to cut the cocaine.8
Such irritants include talc, lactulose,
mannitol, plaster of paris, borax
and amphetamines. Resultant nasal
mucosal ischemia and inflammation
may progress to ulceration and
mucosal necrosis within three weeks
of repetitive abuse. With prolonged
cocaine inhalation, osteocartilaginous
necrosis may extend to the turbinates,
paranasal sinuses and hard palate.
Nasal septal perforations are the most
common complication of intranasal
cocaine abuse, occurring in 5% of
recreational cocaine abusers. Nasal
septal perforation, lateral nasal wall
destruction and hard palate necrosis
may all occur. The presence of any
two of these findings constitutes the
diagnosis of CIMDL, cocaine-induced
midline destructive lesion.9,10 Similar
changes are more recently described
in cases of oxycodone inhalation.11,12
Narcotic-induced palatal necrosis
presents similar to angiocentric nasaltype natural killer/T-cell lymphoma,
Wegener’s granulomatosis
and infectious diseases. When
histopathology, flow cytometry,
T-cell rearrangement, gram stain
and culture studies are negative,
narcotic-induced osteocartilaginous
necrosis may be confirmed by
biopsy demonstrating the presence
of polarizable foreign material. An
elevated classical antineutrophil
cytoplasmic antibody (c-ANCA),
although 90% specific for an
inflammatory systemic vasculitis,
may also be present in the setting
of intranasal narcotic abuse.10
Cocaine-induced Cerebral
Ischemia
An eighteen-year-old
unresponsive man is brought to
the emergency department. An
emergent head CT scan excludes an
acute intracranial injury; however,
subsequent magnetic resonance
imaging reveals brain parenchyma
abnormalities. Abnormal signal
intensity occurs within the cranial
vertex white matter on the T2weighted (image C) and FLAIR series
(image D). Associated abnormal
restriction of diffusion is present in
the same area on diffusion-weighted
imaging (image E) and apparent
diffusion coefficient imaging (image
F). There is sparing of the subcortical
U-fibers. Differential considerations
for such image findings include
inhalation injury, toxic injury and
metabolic injury, including an
inborn error of metabolism. In this
patient with a history of cocaine
intoxication, these findings most
likely represent brain injury from
cocaine-induced vasoconstriction
and respiratory depression.
Brain Necrosis from
Recreational Narcotics
A thirty-five year-old man with
a history of psychotropic abuse
is transported to the emergency
department following a sudden loss
of consciousness. Although emergent
imaging shows no acute intracranial
process, chronic brain necrosis is
present. Magnetic resonance imaging
demonstrates abnormal foci within
the medial globi pallidi. These foci
exhibit T2-weighted (image G) and
FLAIR hyperintensity (image H) as
well as T1-weighted hypointensity
(image I). Such bilateral focal areas of
chronic necrosis in the globi pallidi
are likely due to recreational drug
use, such as ecstasy or heroin.
Additional Narcotic-induced
Neuroimaging Findings
Sympathomimetic drugs,
including cocaine and amphetamines,
are commonly associated with
Images C, D, E and F.
Ischemic brain injury from cocaine-induced ischemia.
Images G, H and I.
Chronic brain necrosis from recreational ecstasy and heroin.
intracranial hemorrhage, possibly
due to transient hypertension or
arteritis-like vascular change. Up to
fifty percent of drug abusers who
sustain an intracranial hemorrhage
have an underlying structural cause
such as an aneurysm or arteriovenous
malformation. Symptoms may
develop within seconds to hours
following drug administration.
Because of this phenomenon, the
authors of the Fundamentals of
Diagnostic Radiology facetiously
refer to sympathomimetic drug
abuse as a “stress test for brain
vascular anomalies”. This text
documents a 21-year-old male
who collapses immediately after
snorting a line of cocaine. His
noncontrast head CT shows cocaineinduced rupture of an anterior
communicating artery aneurysm
with subsequent subarachnoid and
intraventricular hemorrhage.13
Narcotic-induced vascular lesions
produce distinctive intracranial image
patterns. Heroin and amphetamines
cause patchy inflammation within
intracranial arterial walls, which
can result in large or small-vessel
stroke extending through multiple
vascular territories. This is an atypical
pattern for non-vasculitic strokes.
Mycotic aneurysms can occur
subsequent to intravenous drug
abuse or trauma. On crosssectional and angiographic
imaging, these aneurysms are
characteristically found along
distal vascular branches.13
Hematogenous spread of infection
may result in osteomyelitis of the
vertebral bodies with subsequent
spinal epidural abscesses. Such
abscesses comprise up to 18% of the
central nervous system complications
from intravenous drug abuse.
Progression of vertebral osteomyelitis
may result in vertebral body collapse
with subsequent cord compression.
In addition, meningitis and cerebral
abscess are sometimes attributed
to intravenous drug abuse.14
Imaging the Multi-systemic
Effects of Narcotic Abuse
Intravenous drug abuse manifests
numerous physical and radiological
findings that depend on the
particular narcotic, its impurities,
the site of administration and the
method of administration. Diagnostic
imaging recommendations progress
from radiographic to cross-sectional
examinations, with possible
indication for additional fluoroscopy,
angiography or interventional
procedures. Local and systemic
complications of narcotic drug abuse
can occur within multiple organ
systems as summarized below.14
Skeletal complications include
septic arthritis and osteomyelitis.
The latter may occur through
direct contamination such as a
pubic bone “groin hit” or clavicular
“pocket shot”. Pleuropulmonary
complications include pneumothorax,
hemothorax, pyothorax and septic
pulmonary emboli. Gastrointestinal
complications include severe colonic
ileus, colonic pseudoobstruction,
necrotizing enterocolitis and liver
abscess. Genitourinary complications
include amyloidosis, renal mycotic
aneurysms, and in the heroin abuser,
focal segmental glomerulosclerosis.15
Soft tissue complications include
hematoma, abscess, foreign body,
cellulitis and lymphadenopathy.
Cardiovascular complications
include endocarditis, embolization
of injected substances inadvertently
into an artery, intravenous
migration of a needle to the heart
or lungs, venous thrombosis,
arterial occlusion, arteriovenous
fistula or arterial pseudoaneurysm.
A pseudoaneurysm may
progress to rupture with
exsanguination and limb loss.14
Inhalers of crack cocaine,
marijuana and nitrous oxide
utilize the Valsalva maneuver.
By obstructing expiration,
this maneuver may result in a
spontaneous pneumomediastinum
or pneumothorax. Diffuse alveolar
damage histologically identical
to early adult respiratory distress
syndrome (ARDS) is another
common pulmonary manifestation
of crack cocaine and heroin abuse.
The lungs demonstrate an acute onset
of interstitial or air-space opacities.
These opacities are indistinguishable
from pulmonary edema, although
the heart size is typically normal in
the non-pulmonary edema, narcoticinduced ARDS. Characteristically,
the edema rapidly resolves.9,13
Conclusion
West Virginia health care
providers must increasingly
recognize and treat patients with
narcotic abuse. These patients
may present urgently with loss of
conscious and acute intracranial
injury. They may also present with
more indolent or allosystemic
sequelae. While certain radiologic
findings suggest narcotic abuse,
a single positive diagnostic study
should not assuage further clinical
evaluation for comorbid narcoticinduced physical injury. Narcotic
abuse predisposes to many healthcare
issues, some of which may be
permanent and life-altering. Doctors
need to be aware of how narcotics
alter multiple organ functions, how
patients with narcotic abuse may
present clinically, and how to best
utilize diagnostic imaging for further
evaluation of suspected narcoticinduced injury. Specific imaging
findings contribute to the diagnosis
of narcotic abuse, define the extent
of physical injury, and facilitate the
most appropriate treatment planning.
References
1. Spickler D. PDA Facts. In: Witmyer B. ed.
West Virginia Prescription Drug Abuse
Quitline. Vol. 1, 2010. www.wvrxabuse.org
2. US DHHR Substance Abuse and Mental
Health Services Administration. Results
from the 2008 National Survey on Drug
Use and Health: National Findings. 2009.
www.oas.samhsa.gov/nsduh
3. Stone G. This painkiller can kill. In: The
Sunday Gazette Mail. March 25, 2001.
4. Borger J. Hillbilly heroin: the painkiller
abuse wrecking lives in West Virginia. In:
The Guardian. June 25, 2001.
5. Mehren E. Hooks of ‘hillbilly heroin.’” In:
Los Angeles Times. 4 October 2001.
6. Johnson GC. Make No Mistake About It--This is war! In: Time Magazine Quote of
the Day. 5 October 2007.
7. Jordan G. Law enforcement targets out-ofstate prescriptions. In: Bluefield Daily
Telegraph. September 17, 2009.
8. Weisleder R, Wittenberg J, Harisinghani M,
Chen JW, Jones SE. Primer of Diagnostic
Imaging. 4th ed. Mosby Elsevier;
Philadelphia, PA. 2007:806.
9. Di Cosola M, Turco M, Acero J, NavarroVila C and Cortelazzi R . Cocaine-related
syndrome and palatal reconstruction:
report of a series of cases. In: International
Journal of Oral & Maxillofacial Surgery.
2007;36:721-727.
10. Seyer BA, Grist W and Muller S.
Aggressive destructive midfacial lesion
from cocaine abuse. In: Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology
and Endodontics. 2002;92(4):465-470.
11. Greene D. Total necrosis of the intranasal
structures and soft palate as a result of
nasal inhalation of crushed OxyContin. In:
Ear Nose and Throat Journal.
2005;84(8):512,514,516.
12. Birchenough SA, Borowitz K and Lin KY.
Complete soft palate necrosis and
velopharyngeal insufficiency resulting from
intranasal inhalation of prescription
narcotics and cocaine. In: Journal of
Craniofacial Surgery. 2007;18( 6):14821485.
13. Brant WE and Helms CA. Fundamentals of
Diagnostic Radiology. Lippincott Williams
& Wilkins. 3rd Ed. 2007;1:100,105,110.
14. Dahnert W. Radiology Review Manual.
Lippincott Williams and Wilkin.
Philadelphia, PA. 2003:633-634.
15. Hagan IG, Burney K. Radiology of
Recreational Drug Abuse. In:
RadioGraphics. 2007;27(4):917-949.
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CME Post-Test
13.Substance abuse can cause injury to which of the following organ systems?
a. Pleuropulmonary
b. Skeleton
c. Central Nervous System
d. All of the above
14.Depending on the method of narcotic administration and the particular narcotic used,
both local and systemic physical injuries may occur to multiple organ systems.
True or False?
15.Intranasal narcotic use may result in bone erosion, brain ischemia and brain necrosis.
True or False?
Preliminary Evaluation of the WV Prescription
Drug Abuse Quitline
Keith J. Zullig, MSPH, PhD
Associate Professor, Department of Community
Medicine, West Virginia University, Morgantown, WV
Laura Lander, LICSW
Clinical Therapist, Department of Behavioral Medicine
and Psychiatry, West Virginia University
Rebecca J. White, MPH
Graduate Research Assistant, Department of
Community Medicine, West Virginia University
Carl Sullivan, MD, FACP
Professor, Vice Chair, and Director
Addictions Program, Department of Behavioral Medicine
and Psychiatry, West Virginia University
Clara Shockley, MSW
Garrett County Health Department, Oakland, Maryland
Lili Dong, MS
Health Data Analyst, Department of Community
Medicine, West Virginia University
Robert P. Pack, PhD, MPH
Associate Dean for Academic Affairs and Associate
Professor, Department of Community Health, College of
Public Health, East Tennessee State University,
Johnson City, Tennessee
Tara Surber Fedis, MEd
Program Manager & Lead Counselor, West Virginia
Prescription Drug Abuse Quitline, West Virginia
University
Acknowledgement: This work
was supported by Civil Action
No. 01-C-238 from the West
Virginia state Education Fund.
Abstract
Purpose: To evaluate the
effectiveness of the West Virginia
Prescription Drug Abuse Quitline
(WVPDAQ). Methods: Descriptive data
and inferential analyses are provided for
the period of operations from 9/11/2008
to 3/1/2010. Chi-square tests for
Independence compared differences
between callers completing at least one
follow-up survey against callers
completing only the baseline intake
survey were observed. A Wilcoxon signed
rank sum test tested differences between
the scores of intake callers and follow-up
callers at the one-week (n=177) and onemonth (n=89) intervals. Results: A total of
1,056 calls were received, including 670
intakes, 177 1st follow-ups, 89 2nd followups, and 36 3rd follow ups, and 84 caller
satisfaction surveys. Chi-square analyses
determined that callers who only
completed the intake survey tended to
have initiated drug use at a younger age
(<39 years of age, χ2= 7.63, p=.02).
Longitudinal findings indicated significant
self-reported declines in daily drug use
(p<.0001), increased intentions to quit in
the next 30 days (p<.0001), and declines
in requesting a referral for treatment
(p<.0001) at the one-month follow-up.
Finally, approximately 19% (n=17) of
callers reported obtaining a counseling/
treatment appointment as a result of
calling the WVPDAQ at the one-month
follow up. Conclusions: Preliminary
results suggest the WVPDAQ has
established itself as a meaningful
resource to combat prescription drug
abuse in West Virginia. Sustainable
funding and greater integration of the
WVPDAQ into existing and developing
treatment infrastructure could provide
more affordable options for the state of
West Virginia and its citizens.
Introduction
In 2008, 33.9 million retail
prescription drugs were filled in
West Virginia.1 West Virginians
filled an average of 18.7 prescriptions
per capita in 2008 whereas the
United States average was only 12
prescriptions per capita.1 Both fatal
and non-fatal prescription drug
overdoses represent increasing
problems in West Virginia as well.
From 1999- 2004, there was a 550%
increase in drug overdose deaths
in West Virginia, representing the
highest increase in any state in the
nation.2 Not coincidently, drug
overdose represents the leading
cause of death for West Virginia
adults under the age of 45,3 with
prescription drugs involved in the
majority of drug overdose deaths.4
In addition in 2005, West Virginia
was one of only six states in which
opioid analgesics represented
over 7% of drug caseloads.5 It was
also reported that 11% of drug
caseloads were for opioid analgesics,
ranking the state second only after
Kentucky (20%) for the highest
percentage of opioid analgesics.5
Unlike illicit drug abuse,
prescription drug abuse tends to
be more prevalent in rural areas
compared to urban areas.6 Much
of West Virginia is rural. In 2000,
46% of West Virginia’s 1.8 million
residents were living in rural areas7
with 45 of the state’s 55 (82%)
counties considered rural.8 The rural
nature of West Virginia may be one
Objectives
The objective of this study was to evaluate the effectiveness of the West Virginia Prescription Drug Abuse Quitline. A Wilcoxon
signed rank sum test was performed to test differences between the scores of intake callers and follow-up callers at the one-week
and one-month intervals. Significant self-reported declines in daily drug use (p<.0001), increased intentions to quit in the next 30
days (p<.0001), and declines in requesting a referral for treatment (p<.0001) at the one-month follow-up. In addition, approximately
19% (n=17) of callers reported obtaining a counseling/treatment appointment as a result of calling the WVPDAQ at the one-month
follow up were observed. Preliminary results suggest the WVPDAQ has established itself as a meaningful resource to combat
prescription drug abuse in West Virginia.
contributing factor to the increase of
prescription drug abuse in the state.
Prescription drug abuse rates
have also been found to be
positively correlated with poverty
and unemployment rates.9 A study
conducted in Kentucky showed
that prescription opioid drug rates
increased as unemployment and
poverty rates increased.9 Poverty
rates are high in West Virginia.
From the most recent Census data,
the per capita income in West
Virginia was $16,500 whereas
the national per capita income
was $21,500.10 The percentage of
individuals living below the poverty
line in West Virginia was 17% in
2007 as compared to the national
percentage of only 13%.10 Poverty
rates also differ within the state
of West Virginia, with rural areas
having a higher poverty rate (19.8%)
than urban areas (15%) as of 2007,7
Hence, the rural nature and high
poverty rates in West Virginia may
contribute to daily life stressors that
can exacerbate issues of drug use or
abuse. The topography of the state
also presents challenges regarding
transportation, treatment access, and
child care for individuals seeking
assistance with prescription drug
abuse. Hence, there is a potential
connection between rural location,
poverty, and prescription drug abuse.
The West Virginia Prescription
Drug Abuse Quitline (WVPDAQ)
was created as one response to the
developing prescription drug abuse
crisis in the state. With the mission
of service, outreach, and research,
the WVPDAQ is a telephone quitline
that provides information, support,
and assistance with treatment referral
regarding prescription drug abuse.
Telephone educators also enter caller
demographics and drug use patterns
into a database designed for the
purposes of research and evaluation.
This article briefly outlines
WVPDAQ functions, describes
caller characteristics, and provides
preliminary evaluation findings.
Methods
The WVPDAQ (1-866-WV-QUITT)
began operations in September 2008
and aims to educate prescription
drug abusers and their families
about recovery from drug abuse and
treatment services in their areas.
The WVPDAQ is not a counseling
service. Telephone staff educators
give information about referrals to
treatment centers, provide education
about 12-Step programs such as
Alcoholics Anonymous and Narcotics
Anonymous meetings, and mail
self-help and other educational
materials upon request. In addition,
with the callers’ permission,
proactive follow-up calls are made
by the educators at 1 week, 4 weeks,
and 3 months from the time of the
initial call. Multiple proactive calls
are viewed as best practice in the
telephone tobacco quitline literature
where significantly higher quit
rates are observed among those
receiving call-back education.11,12
Callers may also be directed to the
WVPDAQ website, www.wvrxabuse.
org, for educational materials and
information. Hours of operation are
8 a.m. until 10 p.m. on weekdays and
from 10 a.m. to 10 p.m. on weekends
and services are provided to both
prescription drug users and nonusers (proxy callers), or those who
call on behalf of another. Afterhours
callers have the option of leaving
a message for the following shift.
Evidence based practice for
brief intervention (SAMHSA/
CSAT Treatment Improvement
Protocols) is utilized to guide our
phone intervention. During each
telephone call, the FRAMES model
is employed. FRAMES stands for
Feedback, Responsibility, Advice,
Menu, Empathetic, and Self-efficacy.
Feedback is given to the caller
about personal risk or impairment.
Responsibility for change is placed
on the caller. Advice on how to
change is suggested by the educator,
which includes staying away from
drug related people, places and
things. A menu of treatment options
and self help resources is offered
to every caller with specific phone
numbers and locations. An overall
empathetic style is used by the
educator throughout the intervention.
And lastly, educators attempt to
instill self-efficacy in each caller
by building on apparent strengths
and existing personal resources. In
addition, phone educators are trained
in Motivational Interviewing.13
Using motivational interviewing, the
educator creates an environment that
is supportive of change by expressing
empathy and encouragement as
well as helping callers explore
discrepancies between their current
behaviors of using drugs and the life
style they would like to achieve.
Instrumentation
Survey questions from the
WVPDAQ were adopted and
modified for prescription drug abuse
from established tobacco quitline
questions.14 These ‘best practice’
minimal dataset questions were
initially developed by the 14-member
North American Quitline Consortium
composed of quitline researchers,
service providers, evaluators,
and funding organizations across
North America over a two-year
period starting in 2002.14
The minimal dataset questions
and associated documents can be
located at http://www.naquitline.
org/?page=technical and include
15 baseline questions requested
from all callers during their first
intake call and an additional eight
questions during all subsequent
follow-up calls. For example, all
intake callers are requested to
report their awareness of WVPDAQ
promotions, previous (if any) calls
to the quitline, if the caller is a proxy
caller or user, geographic location
of the caller, caller demographics,
and prescription drug use behaviors.
Additionally, callers are requested
to also report their satisfaction with
their WVPDAQ experience, and
changes in prescription drug use
behavior (including quit attempts).
Among tobacco users, three
primary factors are known to predict
success (dependence, readiness
to quit, and the use of quit aids).14
Thus, the WVPDAQ also requests
this information from callers during
the intake and during each followup session. Although the WVPDAQ
requests callers to report on their
readiness to quit, this request is not
bound within the Transtheoretical
Model’s stages of change, owing to
the equivocal evidence in the stages
of change in predicting quit success
in the tobacco literature.15,16,17
Data Analysis
Data reported in this paper
include data collected by the
WVPDAQ from September 11, 2008
to March 1, 2010. Analyses include
descriptive summaries of caller
demographics and satisfaction with
WVPDAQ services, followed by
inferential analyses to preliminarily
evaluate WVPADQ success. All
analyses were conducted with SAS
version 9.1. Owing to the relatively
small sample size among callers
completing both the 1st (n=177)
and 2nd follow up surveys (n=89),
which violated the assumption of
normality, a Wilcoxon signed rank
sum test for two dependent samples
was performed to test differences
between the scores of intake callers
and the follow-up callers. The null
hypothesis stated that there would
be no difference between intake
and follow-up survey scores. These
analyses were executed in two
steps. First, those that completed
both the intake and 1st (one week)
follow-up surveys were compared.
Second, those that completed both
the intake and 2nd (one month)
follow-up surveys was compared.
A p-value less than 0.05 was
considered as statistically significant.
For these analyses, some recoding
was necessary to modify several
question response options from
ordinal to nominal responses. For
example, for the question “Do
you feel that you are addicted to
prescription medications?” the
response options of (1) ‘yes’, (2) ‘no’,
(3) ‘refused’, and (4) ‘other’ needed
to be altered to (1) changed (e.g.,
responses that changed from ‘yes’
to ‘no’, ‘yes’ to ‘refused’, etc. across
the surveys) and (2) no change (i.e.
responses that remained consistent).
Results
Description of the Sample
To date, the WVPDAQ has
received a total of 1,056 calls. These
calls included 670 intakes, 177
1st follow-ups, 89 2nd follow-ups,
36 3rd follow ups, and 84 caller
satisfaction surveys. Table 1 provides
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Table 1: Description of the Sample*
Questionnaire Item
n (%)
Caller type
Calling for Self
Caller for Other (Health Professional, Friend/Family Member)
Gender
Male
Female
Ethnicity
White
Other
422 (63.0)
248 (37.0)
186 (47.6)
205 (52.4)
364 (95.0)
19 (5.0)
Education
Less than Grade 12
High School Degree or GED
Some College
College Degree or greater
76 (20.3)
168 (44.9)
81 (21.7)
49 (13.1)
Health Insurance
Yes
No
198 (52.0)
183 (48.0)
Health insurance type
Medicaid/Medicare
Private
Veteran
Self-pay/Do Not Have
109 (28.8)
89 (23.5)
3 (0.9)
177 (46.8)
How did you learn about the Quitline?
Media
Referral
Other advertising (billboards, flyers, brochures, phone directory)
136 (19.9)
136 (19.9)
356 (54.1)
Use of Prescription Drugs Non-Medically
Everyday
Some days (Less than 7 per week)
Not at all
315 (76.6)
55 (13.4)
41 (10.0)
How soon after waking do you take your prescription drugs?
30 minutes or less
More than 30 minutes
320 (88.6)
41 (11.4)
Age of 1st use
Less than 20 yrs.
20 to 39
30 to 49
50 or more yrs
95 (24.5)
229 (59.2)
45 (11.6)
18 (4.7)
Intentions to quit, next 30 days
Yes
No
Don’t know
317 (81.3)
15 (3.8)
58 (14.9)
*Numbers and percentages may not add to 100%, owing to missing data
demographic and behavioral
descriptive data for all WVPDAQ
callers. This information was
obtained from the responses to
the WVPDAQ intake survey and
the percentages shown have been
computed by excluding callers who
did not answer a particular question.
Although not tabled, 76% (n=494)
of callers reported abusing opioids
(most commonly Oxycodone and
Hydrocodone). Callers reported
obtaining prescription drugs most
commonly by buying drugs from
the street (77%, n=283) or from
a friend or family member (50%,
n=185). Notably, only 11% (n=41)
reported obtaining their drugs by
doctor shopping. Not surprisingly,
because of the addictive nature of
opiates, 46% (n=266) of callers stated
they take prescription drugs to feel
normal and another 24% (n=135) for
chronic pain relief. Still, 11% (n=109)
of callers reported taking prescription
drugs to achieve a “high”.
Satisfaction with WVPDAQ Services
In September 2009, the WVPDAQ
implemented a caller satisfaction
survey. The caller satisfaction survey
is a brief, five question survey that
asks callers about their opinions
and satisfaction with the WVPDAQ
services. When callers were asked
“How satisfied were you with
the services you received today?”
100% (n=84) of callers reported
being somewhat to very satisfied
with the services they received
with 83% (n=70) reporting they
were very satisfied. When asked,
“How quickly were you able to
speak to an educator?” 98% (n=82)
of callers reported that they were
able to speak to an educator right
away. Finally when asked, “Would
you recommend the Quitline to
others who have a problem with
prescription drug abuse?” 94%
(n=79) of callers said that they
would definitely or probably
recommend the Quitline to others.
Drop-out Analyses
After removing proxy (non-user)
callers (n=248, 37%) from surveys,
a chi-square test for independence
was employed to determine if any
group differences existed between
WVPDAQ callers who completed at
least one follow-up survey against
callers who only completed the intake
survey at the baseline (intake survey
data). Analyses were conducted
among caller demographics
and behavioral characteristics.
Demographic variables included: a)
males and females, b) education level
Table 2: Wilcoxon Signed Rank Sum test for Intake and First (One Week) Follow-up Surveys (n=177)*
%
(Intake)
%
1st Follow-up)
Use prescription drugs non-medically?
Every day
Some days
Not at all
74.7
16.7
8.6
46.3
17.3
34.6
-28.4
0.6
+25.9
<.0001
Have a pattern to your drug use?
Yes
No
27.5
72.5
23.8
75.0
-3.8
+2.5
<.0001
Feel addicted to prescription drugs?
Yes
No
95.1
1.2
98.8
1.2
+3.7
0.0
0.06
How soon do you take your first pill after waking up?
Within 30 min. of waking
92.4
84.8
-7.6
0.09
How do you take your prescription drugs?
By mouth
Snorting
Intravenously
40.3
47.8
9.0
49.3
43.3
6.0
+9.0
-4.5
-3.0
0.002
Intend to quit in the next 30 days?
Yes
No
Do not know
80.5
0.0
19.5
84.2
2.4
13.4
+3.7
+2.4
-6.1
<.0001
What will encourage your quit attempts to be successful?
Self-help materials
Referral or treatment for detoxification
Community support group
3.1
24.5
2.1
7.1
13.3
12.2
+4.0
-11.2
+10.0
<.0001
Get drugs by doctor shopping?#
13.8
7.5
-6.3
0.16
Buy drugs from streets?#
83.8
82.5
-1.3
0.20
Buy drugs from family members/friends?#
47.5
51.3
+3.8
0.72
Steal drugs from family members/friends?#
11.3
1.3
-10.0
0.02
Given drugs by family member/friend?#
31.3
21.3
-10.0
0.07
Get /buy drugs by some other means?#
10.0
11.2
+1.2
0.70
Would like a referral to a treatment center?
Yes
No
75.5
7.1
27.1
62.6
-48.4
+55.5
<.0001
Questionnaire Item
Difference*
P value
* Differences computed only for those completing both surveys; # % reporting occasional or greater frequency
(less than a high school education/
GED or high school graduate/and
some college or greater), c) health
insurance status (yes/no), and d)
type of insurance (public/private/
self-pay). Behavioral characteristics
included: a) frequency of use
(everyday use/some days/no use);
b) a series of drug procurement
strategies (yes/no), which included
doctor shopping, the street, buying
from a family member or friend,
stealing from a family member or
friend, drugs given by a family
member or friend, or by some
other means; c) pattern of use (no
pattern/pattern); d) taking drugs
after waking ( < 30 minutes/ > 30
minutes); e) method of drug use
(orally/snorting/intravenously); f)
intention to quit in the next 30 days
(yes/no); g) age of initiation ( < 19/
20-39/ > 40); h) length of abuse ( <
1 year/ 1+ years); and i) desire for
treatment referral (yes/no/not sure).
These analyses determined that
callers who only completed the intake
survey tended to have initiated their
prescription drug use at a younger
age ( <39 years of age, n=195) when
compared to callers who completed
at least one follow-up survey (n=157,
χ2= 7.63, p=.02). No significant
differences existed between the
groups on any of the other variables.
Longitudinal Analyses
Results for callers who completed
both the intake and 1st (one week)
follow-up surveys can be found
in Table 2. As shown, findings are
generally in the expected direction.
Specifically, the percentage of callers
who reported no use of prescription
drugs increased 25.9% while daily
use declined 28.4% from the Intake
call to the 1st follow up call (p<.0001).
Similarly, the percentage of callers
who reported intentions to quit in
the next 30 days increased 3.7%
(p<.0001) from the Intake call to the
1st follow up call. In addition, the
percentage of callers who reported
that self-help materials, referral for
treatment, or a community support
group would encourage quit attempts
changed +4.0%, -11.2%, and +10.0%,
respectively. The percentage of callers
who reported taking their drugs in
a safer manner also increased with a
9% increase in taking drugs by mouth
and corresponding decreases by
snorting (-4.5%) or intravenously (3.0%) (p=.002). A 10% (p=.02) decline
in callers who reported stealing drugs
from family members or friends was
also observed from the Intake call
to the 1st follow up. Interestingly,
the percentage of callers who
reported they would like a referral
to a treatment center decreased by
48.4% (p<.0001) and callers beliefs
that they had a pattern to their drug
use decreased 3.8% (p<.0001) from
the Intake call to the 1st follow up.
A subset of callers from the 1st
(one week) follow up, results for
callers who completed both the
intake and 2nd (one month) follow
up are detailed in Table 3. With the
exception of method of drug use (orally/
snorting/intravenously) and stealing
drugs from family members or friends, all
previous significant trends noted in
Table 2 continued. Furthermore, the
percentage increases (or decreases)
became even more pronounced. For
example, the percentage of callers
who reported no use of prescription
drugs increased an additional 16%
(from 34.6% at the first follow up)
to 50.6% from the Intake call to the
2nd follow up call (p<.0001). The
combined findings preliminarily
suggest that the interventions
carried out by the phone educators
are having a beneficial effect on
callers who are utilizing long
term service recommendations.
Although not tabled, WVPDAQ
also tracks the desire of callers to
receive subsequent follow up calls.
For example, 79% (n=303) of callers
at the Intake call requested a oneweek follow up. However, at the
1st follow up (one week) call, 87%
(n=146) of callers requested a 2nd (one
month) follow up call. This increased
to 93% (n=75) at the 2nd follow up
call for callers requesting a 3rd (three
month) follow up call. In contrast
to outpatient treatment setting
completion rates of 47%,18 these
numbers are encouragingly high.
More importantly, approximately
12% (n=21) of first follow up callers
reported obtaining a counseling or
calling the WVPDAQ. If those who
intend to obtain an appointment (but
have not yet) are added to this total
(n=15), the percentage increases to
20.3%. At the second follow up call,
approximately 19% (n=17) of callers
reported obtaining a counseling or
calling the WVPDAQ. If those who
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Table 3: Wilcoxon Signed Rank Sum test for Intake and Second (One Month) Follow-up Surveys (n=89)*
%
(Intake)
%
1st Follow-up)
Use prescription drugs non-medically?
Every day
Some days
Not at all
80.7
13.3
6.0
31.3
18.1
50.6
-49.4
-4.8
+44.6
<.0001
Have a pattern to your drug use?
Yes
No
43.3
56.7
23.3
76.7
-20.0
+20.0
<.0001
100.0
0.0
93.3
0.0
-6.7
0.0
0.50
How soon do you take your first pill after waking up?
Within 30 min. of waking
86.2
72.4
-13.8
0.23
How do you take your prescription drugs?
By mouth
Snorting
Intravenously
34.8
46.2
15.4
50.0
34.6
15.4
+15.4
-11.5
0.0
0.06
Intend to quit in the next 30 days?
Yes
No
Do not know
82.8
3.4
13.8
82.8
0.0
17.2
0.0
-3.4
+3.4
0.004
What will encourage your quit attempts to be successful?
Self-help materials
Referral or treatment for detoxification
Community support group
8.3
20.0
1.7
8.3
8.3
11.7
+4.0
-11.2
+10.0
<.0001
Get drugs by doctor shopping?#
16.7
16.6
-0.1
0.62
Buy drugs from streets?#
83.3
83.4
+0.1
0.84
Buy drugs from family members/friends?#
56.7
43.3
-13.4
0.28
Steal drugs from family members/friends?#
20.0
10.0
-10.0
0.25
Given drugs by family member/friend?#
43.3
30.0
-13.3
0.18
Get /buy drugs by some other means?#
10.0
3.3
-6.7
0.50
Would like a referral to a treatment center?
Yes
No
75.6
7.7
17.9
78.2
-57.7
+70.5
<.0001
Questionnaire Item
Feel addicted to prescription drugs?
Yes
No
Difference*
P value
* Differences computed only for those completing both surveys; # % reporting occasional or greater frequency
intend to obtain an appointment
(but have not yet) are added to
this total (n=11), the percentage
increases to 31.5%. These findings
demonstrate the effectiveness of
the WVPDAQ educators as well as
the importance of the WVPDAQ
as a resource for callers.
Discussion
Preliminary findings suggest that
the WVPDAQ is effective in assisting
callers with prescription drug abuse
problems in taking meaningful
steps toward recovery. Significant
changes were observed in the three
primary factors known to predict
success (dependence, readiness
to quit, and the use of quit aids)
and approximately 19% of callers
reported enrolling in treatment as
a result of using WVPDAQ service
recommendations at the one-month
follow-up. In addition, satisfaction
with services provided appears to be
quite good, as indicated by the selfreported caller satisfaction survey.
Furthermore, the high percentage of
callers who requested follow-up calls
(from 79% at the Intake survey and
increasing to 93% at the 2nd followup) demonstrates the effectiveness
of the WVPDAQ interventions
carried out by the educators and
the value and importance of the
WVPDAQ to callers in helping them
implement changes in their lives.
The trend of callers reporting
a significant decline in requesting
a referral for treatment across the
surveys deserves further comment.
Given the challenges in accessing
treatment in West Virginia and
the short duration of time between
the initial Intake and 1st follow
up call, although speculative, it is
possible that those who requested a
referral for treatment at the Intake
were still in the process of trying
to access treatment options after
one week, and thus did not make
a request for additional referral.
For example, some may have been
placed on waiting lists, or in the case
of detoxification treatment, were
told to call back daily to check on
bed availability. Qualitative data
logs kept by staff confirm this is the
case, at least for some. However,
others may have had a negative
experience trying to engage in the
treatment process, which may have
resulted in feelings of stigmatization.
Tests of sample independence
suggest that callers who initiated
their drug use at a younger age are
less likely to utilize WVPDAQ long
term service recommendations. While
it is unclear why this phenomena
exists, one speculation may be that
these callers are further progressed in
their addiction, and may have made
multiple attempts to quit their drug
use and called the WVPDAQ looking
for a “magic fix.” On a percentage
basis, 52% of younger callers reported
having no insurance compared to
25% of older callers, which may
also suggest a socioeconomic
factor behind this discrepancy.
Although the WVPDAQ is
relatively new and more longterm follow-up data is needed to
verify these preliminary findings,
the methodology employed by the
WVPDAQ is based on the successful
tobacco quitline models. Tobacco
telephone quitline effectiveness is
well known.11,19, 20, 21, 22 For example,
tobacco quitline counseling has been
reported as being 1.5 times more
effective than self-help materials
alone or brief interventions.22 These
findings suggest that the WVPDAQ
will also demonstrate similar success,
given time, for West Virginians.
On the other hand, the WVPDAQ
faces challenges dissimilar from
its tobacco quitline peers. First,
the stigma faced by prescription
drug users and/or abusers is
multifaceted. Unlike tobacco
users, prescription drugs are often
obtained illegally from family or
friends, stolen, or purchased from
the street and because the use of
drugs is strongly moralized, those
violating moral norms are subject
to marginalization.23 The lower call
volume to the WVPDAQ relative to
its tobacco quitline counterparts may
partially reflect this stigmatization
where callers are often hesitant
to reveal their identity despite
assurances of complete confidentiality
for the fear of ‘getting caught’.
Second, the stigma facing those
who seek treatment, particularly
when accompanied by a mental
illness, is well-documented.24,25 This
factor may also contribute to the
approximately 63% increase in callers
who report that they do not wish to
have a referral to treatment by the
one-month follow-up survey. These
factors limit the potential reach of the
WVPDAQ, which is disappointing
when the annual mean reach for
successful tobacco quitlines is only
1% of smokers in the United States.26
Third, even if this stigmatization
can be overcome, prescription drug
abuse treatment is limited in the
state of West Virginia. In a state
with a population of 1.8 million
people, 88,000 West Virginians
reported non medical pain reliever
use (opioid abuse/dependence) in
2005-2006.27 However, in 2006, only
1,249 were admitted to treatment
for opiate abuse or dependence.28
West Virginia has only 10 residential
treatment centers which provide
fewer than 300 beds. There are eight
halfway houses, eight methadone
clinics and approximately nine
additional centers which offer statewide outpatient treatment. Many of
the more rural counties have little
to no substance abuse treatment.
There are only 13 Community
Behavioral Health programs in the
state and they have long waiting
lists for treatment appointments.
Furthermore, of the substance abuse
treatment available in WV, 79%
is private for profit, which means
they do not accept Medicaid.29
Limitations
Although many WVPDAQ
survey questions were modified
from established and standardized
sources from the tobacco quitline
literature,14 additional questions still
needed to be developed specifically
for prescription drug abuse. For
example, questions regarding drug
procurement strategies (e.g., doctor
shopping, from friends or family
members, etc.) were developed
specifically for the WVPDAQ and
have not undergone psychometric
evaluation. Conversely, WVPDAQ
services are not intended to impact a
caller’s drug procurement methods,
as this is seen as realm for law
enforcement. Thus, the significant
decline among callers who report
stealing their drugs from friends or
family members from the intake to
the first follow-up survey may be a
spurious finding. Second, although
study results are encouraging,
the relatively small sample size
for the follow-up surveys should
not be interpreted as anything but
preliminary in nature. Larger samples
and longer follow-up periods will be
required to confirm these findings.
Third, a 60% attrition rate was
observed in this preliminary study.
While this may seem high, when
contrasted to outpatient treatment
completion rates of 47%,18 a 40%
retention rate is encouragingly
high. Moreover, chi-square tests
of Independence revealed only
one significant difference between
callers who completed the 1st and
2nd follow-ups to those that did
not, also reducing concerns related
to attrition. Finally, all data are
self-reported from callers and
subject to all limitations associated
with self-reported survey data.
Conclusion
Although data presented here are
preliminary in nature, WVPDAQ
has established itself as a meaningful
resource to combat the prescription
drug abuse epidemic in West Virginia
at a fraction of the cost allocated
to tobacco quitline services. In
2006, mean annual tobacco quitline
service budgets were $887,603.26 To
date, the WVPDAQ has expended
approximately $612,000 of its overall
$1,000,000 initial three-year operating
budget. When costs for research and
start-up efforts are subtracted, total
expenditures drop to $239,040 (at
approximately $13,280 per month
over 18 months) for a cost of about
$226 per caller compared to the
average of $220 for an initial intake
evaluation at an outpatient addiction
treatment center. Seeing that the
cost difference is nearly identical
presently, with an increase in the
utilization of services, WVPDAQ
costs will be driven downward in
contrast to outpatient treatment with
the added convenience of accessibility
of the WVPDAQ (particularly for
those without health insurance) while
still retaining robust confidentiality.
However, given internal data
linking promotions to increased
call volume and corroborated
by tobacco quitline literature,30
sustainable funding and greater
integration of the WVPDAQ into
existing and developing treatment
infrastructure could provide even
more affordable options for the state
of West Virginia and its citizens.
References
1. State Health Facts. West Virginia
prescription drugs. State Health Facts Web
site. 2008. Available at: http://www.
statehealthfacts.org/profileind.
jsp?cat=5&sub=66&rgn=50.
Accessed August 24, 2009.
Prevention [CDC]. Unintentional poisoning
deaths United States, 1999-2004.
Morbidity and Mortality Weekly Report
(MMWR). 2007;56(5):93-96.
3. Tuckwiller T, Finn S. Painkillers: Overdose
now leading cause of death for West
Virginians under 45. Charleston Sunday
Gazette-Mail Web site. 2007. Available at:
http://wvgazette.com/News/
PrescriptionforanEpidemic/
200711040017?page=1&builcahe
Accessed May 20, 2009.
Kraner JC, Bixler D, Crosby AE, Paulozzi
LJ. Patterns of abuse among unintentional
pharmaceuticaloverdose fatalities. JAMA.
2008;300(22):2613-2620.
5. Strom KJ, Wong L, Sannerud C, Weimer
BJ, Ancheta J, Rachal V. NFLIS Special
Report: Controlled Substance Prescription
Drugs, 2001-2005. Washington, DC: U.S.
Drug Enforcement Administration. 2006.
Available at http://www.deadiversion.usdoj.
gov/nflis/2006rx_drugs_report.pdf.
Accessed March 3, 2010.
6. Havens JR, Oser CB, Leukefeld CG,
Webster JM, Martin SS, O’Connell DJ,
Surratt HL, Inciardi JA. Differences in
prevalence of prescription opiate misuse
among rural and urban probationers. Am J
Drug Alcohol Ab. 2007;33:309-317.
7. Economic Research Service-United States
Department of Agriculture (ERS-USDA).
Data sets: West Virginia. USDA Web site.
2009. Available at: http://www.ers.usda.
gov/StateFacts/WV.htm. Accessed
September 24, 2009.
8. National Association of Counties. West
Virginia counties. National Association of
Counties Web site. 2002. Available at:
http://www.naco.org/RuralTemplate.
cfm?Section=RAC_County_
Data&Template=/cffil srac/rac_res.cfm.
Accessed June 3, 2009.
9. Spiller H, Lorenz DJ, Bailey EJ, Dart RC.
Epidemiological trends in abuse and
misuse of prescription opioids. J Addict
Dis. 2009;28(2):130-136.
Please contact the authors for a complete list
of references.
CME Post-Test
16.Three key indicators predictive of quitting that the Quitline has impacted among callers
who have utilized long-term service recommendation are the percentage of callers who have
reported 1) a significant decline in daily drug use, 2) increased readiness to quit in the next 30
True or False
days, 3) and an increased use of quit aids to encourage quit attempts.
17.What percentage of callers have made a treatment or counseling appointment as
a direct result of the Quitline intervention at the second follow-up call?
a. 19%
b. 6%
c. 37%
d. 50%
18.Proactive, long term follow up calls are one of the most important
aspects of the Quitline intervention.
True or False.
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Prevalence of Drug Use in Pregnant West Virginia Patients
Robert Nerhood, MD
absence of cocaine, methamphetamine
and buprenorphine. Voluntary reporting
on birth certificates and other maternal
questionnaires underestimated the
prevalence by 2-3 fold.
Conclusion: One in five infants born
in West Virginia has a significant drug
exposure that is not captured by
conventional reporting instruments. It is
hard to estimate the societal and financial
cost since so many infants are exposed.
David Chaffin, MD
Introduction
Michael L. Stitely, MD
Department of Obstetrics and Gynecology, West
Virginia University School of Medicine
Byron Calhoun, MD
Department of Obstetrics and Gynecology, West
Virginia University – Charleston Division
Stefan Maxwell, MD
Department of Neonatology, Charleston Area
Medical Center
Department of Obstetrics and Gynecology, Joan C.
Edwards School of Medicine at Marshall University
Department of Obstetrics and Gynecology, Joan C.
Edwards School of Medicine at Marshall University
Support provided by the West
Virginia Department of Health and
Human Resources, Bureau for Public
Health, Office of Maternal, Child and
Family Health with federal Maternal
and Child Health Block Grant funds.
Abstract
Introduction: Substance abuse in
pregnancy is of serious concern to society
as well as health care providers caring for
pregnant women and their infants.
Various studies have suggested a
prevalence of 10 -20%. This study used
anonymous sampling of umbilical cord
tissue to estimate the prevalence of
substance abuse in West Virginia.
Methods: For the period of August
2009, as many umbilical cord samples as
possible were collected at 8 regionally
diverse hospitals in West Virginia. The
cord tissue samples were then assayed
for amphetamines, cocaine, opiates,
marijuana, benzodiazapines, methadone,
buprenorphine and alcohol.
Results: 146 of 759 collected (19.2%)
were positive for drugs or alcohol. The
regional diversity in drug and alcohol
consumption was striking, as was the
Substance abuse in pregnancy
is known to have deleterious
effects on neonates. These effects
differ with respect to the substance
ingested and can include neonatal
abstinence syndrome (NAS),
low birth weight, intrauterine
fetal demise, and structural
abnormalities such as gastroschisis.
The substance abuse rates have
been estimated to be between 2.819%1,2,3 These reported rates vary
based upon the population screened
and the method of screening used.
The lowest number reported in the
study by Ebrahim and Gfroerer
utilized a population survey of
the entire United States1 while the
highest rates reported (19%) by Azadi
and Dildy utilized urine toxicology
testing.3 Chasnoff et al developed a
screening tool that estimated that 15%
of the population studied continued
to use substances of abuse after
becoming aware of the pregnancy.2
Recent work published by
Montgomery et al compared
the performance of meconium
samples versus the testing of
umbilical cord tissue.4 This study
showed concordance of the testing
methods that correlated at or above
90% for all substances analyzed.
Follow-up work included a study
in which umbilical cord samples
were collected and tested if high
risk criteria for substance abuse
were identified. Out of this cohort,
157 of 498 (32%) cords tested
positive for substances of abuse.5
The number of newborns treated
for neonatal abstinence syndrome
(NAS) has increased dramatically
in West Virginia. In data collected
from the Cabell Huntington
Hospital in Huntington, WV, the
number of neonates treated for
NAS increased from 25 in 2003 to
70 in 2007.6 The cost difference in
the care of an otherwise healthy
neonate with NAS compared to a
normal full-term healthy neonate
was estimated to be $3,934 in the
Cabell-Huntington cohort. Because
of the added costs associated with
the increased risk of prematurity, the
average cost of all infants with NAS
was $36,000 compared to $2,000 for
a normal neonate.6 Obviously any
significant reduction in the number
of neonates being treated for NAS
can save significant amounts of
money for the healthcare system.
In order to formulate public
policy and to ensure that the proper
maternal and neonatal medical
services are available in West Virginia
to prevent and to care for pregnancies
complicated by substance abuse, an
accurate determination of the rate of
substance abuse during pregnancy
as well as the substances involved
Objectives
After completing this program, the reader will be able to quantify the rate of substance abuse during pregnancy in West Virginia and
describe the maternal, fetal, neonatal and societal consequences of substance abuse during pregnancy.
Table 1. Umbilical cord drug profile.
Table 2. Distribution of sample collection by hospital.
Table 3. Prevalence and distribution of drug use in umbilical cords.
Table 4. Polypharmacy in pregnant drug users.
distribution and collection of
1000 samples in one month.
Delivery staff in each hospital
was instructed to collect a 6 to 9
inch segment of umbilical cord from
as many deliveries as possible for
the month of August (2009). Each
sample was stripped of intravascular
blood, rinsed in sterile saline,
put in a separate sterile plastic
specimen container and frozen for
subsequent shipment to United
States Drug Testing Laboratories
(USDTL, Des Plaines, IL).
Eight drugs were selected for
testing (Table 1). Commercially
available enzyme linked
immunoabsorbent (ELISA)
kits, with confirmatory testing
by gas chromatography/mass
spectometry were used for 6 of the
drugs. Buprenorphine was tested
using liquid chromatography/
mass spectrometry (LCMSMS).
Phosphatidylethanol (a metabolite of
ethanol) testing was based on high
pressure liquid chromatography/
mass spectrometry (HPLCMS).
Self reporting was assessed
determining the prevalence of
drug and alcohol use reported on
birth certificate data as well as a
nursing assessment tool used in
West Virginia called the WV Birth
Score as provided by the Office of
Maternal Child and Family Health
of the State of West Virginia.
Results
is required. The objective of our
study was to accurately determine
the rate of substance abuse affecting
pregnancy in West Virginia.
Materials and Methods
This study was conceived as an
anonymous (no patient information
collected) survey of normally
discarded tissue (umbilical cord).
As such, consent was waived and
the study was approved by the
institutional review boards at each
of the eight participating hospitals.
Hospitals were recruited with the
goal having broad geographic
Seven hundred fifty nine (759)
samples were collected in one
month and analyzed in batch form
by USDTL. The participation by
hospital is shown in Table 2. There
were 142 (19.2%) cord specimens
positive for drugs and/or alcohol
(Table 3). Polypharmacy was
common (Table 4), especially
among those patients using
benzodiazapines and methadone.
There was also significant regional
variation in drug and alcohol use
(Table 5). Self reporting prevalence
rates of drug and alcohol rates
are compared to actual umbilical
cord prevalence in Table 6.
Discussion
This anonymous sampling of
umbilical cords involving 8 medical
centers in West Virginia identified
an overall prevalence of drug and
alcohol use of almost 1 in 5 deliveries.
There was a 10-19% prevalence of
substance and 1-15% incidence of
alcohol use in patients delivering
during August 2009 with marked
underreporting with standard
data collection tools. There was a
wide geographic variability in the
prevalence of individual drugs
and alcohol with one hospital
reporting a 1 in 4 rate of drug and
alcohol use! The lack of significant
cocaine and methamphetamine
use was surprising. Buprenorphine
diversion has also been noted
elsewhere but was not a significant
contributor to the drug problem
among these pregnancies.
Some limitations of this study
should be noted. The hospitals
were not selected at random. Rather
they were selected to optimize
the possibility of obtaining a large
enough sample size (approximately
1000 deliveries) to be relevant and
where possible to geographically
cover the state of West Virginia.
It includes the three tertiary care
centers located in the state which
could result in an overestimation of
the prevalence as some out of state
referrals may be included. However,
the prevalence of drug exposure
at these hospitals was comparable
to the other hospitals in the study.
Due to the anonymous nature of the
sampling, it is impossible to analyze
reasons for the wide geographic
variations. While factors such as
poverty, unemployment, and location
of drug rehabilitation centers may
play a role, definitive answers await
a more comprehensive exploration of
the problem. Finally, while there are
Table 5. Regional variation in drug and alcohol use.
Table 6. Comparison of self-reporting tools and umbilical cord screening.
some well known cross-reactivities
on the ELISA screening tests used,
each positive sample was confirmed
using gas chromatography/mass
spectroscopy which virtually
rules out false positive results.
As noted earlier in the paper,
the cost of drug addicted infants
averages $36,000 per infant
compared to $2,000 for non-affected
infants6, with multiple fetal effects
contributing to this cost (Table 7).
These findings sparked interest
in possible detoxification or
rehabilitation for patients who are
using either illegal or non-prescribed
substances or alcohol. The literature
previously described the avoidance of
detoxification during the second and
third trimesters of pregnancy due to
concerns about harms to the fetus.7,8
Recent literature, however, does
not substantiate these claims.9,10,11
Luty studied 101 opiate dependent
women who underwent a 21 day
opiate withdrawal with no adverse
effects found.11 Opioid dependence,
including methadone maintenance,
has been linked to fetal death, growth
restriction, pre-term birth, meconium
aspiration, and neonatal abstinence
syndrome.7,12 Neonatal abstinence
syndrome may be present in 60-90%
of neonates exposed in-utero with
up to 70% of affected neonates with
central nervous system irritability
that may progress to seizures.13 Up
to 50% may experience respiratory
issues, feeding problems, and failure
Table 7. Prenatal and neonatal effects of drugs of abuse.
to thrive.14 These issues are present as
well in those infants whose mothers’
are on methadone maintenance.15
However, with methadone the onset
of neonatal abstinence syndrome
may be delayed for several weeks.15
Some authors recommend 5-8 days
of maternal hospitalization while
their neonates’ undergo observation
for neonatal abstinence syndrome.16
However, most insurance plans will
not reimburse for the prolonged
uncomplicated maternal stay.
The incidence of opioid relapse
in pregnant opioid abusing women
is very high with 41-96% relapsing.
This mirrors the relapse rate of the
general population at 1 month of
65-80%.17,18 Over 90% of patients
will relapse at 6 months after
medication-assisted withdrawal.19
Buprenorphine (SubutexTM) appears
to have no difference in outcomes
with regard to treatment of opiate
addicted women. The same
neonatal abstinence syndrome and
neonatal effects are present.20
Treatment of amphetamine abuse
with fluoxetine and imipramine
may be useful but is not a panacea
for treatment. A recent review
by the Cochrane Collaboration in
2001 (reissued in 2009) noted that
medications are of limited use in
treatment of amphetamine abuse.21
They note that there are very limited
trials at this time to be able to
suggest what is the best way to treat
amphetamine abuse. Benzodiazepine
dependence and detoxification
must be done gradually to reduce
symptoms. Little has been written
about benzodiazepine detoxification
in pregnancy. Alcohol rehabilitation
has had little written and until
recently (as found in our paper)
no ability to verify chronic use of
alcohol due to its volatile nature and
inability to test for its presence.
Co-morbidities with multiple
psychiatric issues in the patients
with substance abuse issues must
be considered. Many patients with
substance dependence have affective
disorders including: depression,
mania, schizoaffective disorders,
schizophrenia, borderline personality,
and bipolar disorders. Therefore,
many authors recently note that
detoxification must be linked with a
combination of behavioral therapy
with contingency management
therapy.16,22,23 Behavioral therapy
consists of the use of addictions
counselors and counseling to assist
substance and alcohol abusers to
remain drug and alcohol free. A
pilot program at Charleston Area
Medical Center (CAMC) uses this
approach with both individual
and group therapy. Contingency
management therapies are a type
of psychosocial intervention where
the clients receive rewards in the
form of vouchers or prizes if they
demonstrate changed behaviors.
There seems to be data to support its
use in cocaine and opioid abuse.24,25
Due to the large number of
patients affected in the State of West
Virginia by both substance abuse
and alcohol abuse, we suggest a
programmatic approach with the
use of both inpatient and outpatient
therapy be used. Detoxification seems
a reasonable approach with treatment
of the psychological co‑morbidities
associated with substance use.
Multidisciplinary clinics would
appear the ideal solution with the
combination of medical, psychiatric,
counseling, and social support
necessary to return healthy mothers
with healthy drug-free neonates.
References
1. Ebrahim SH, Gfroerer J. Pregnancyrelated substance use in the United States
during 1996-1998. Obstet Gynecol.
2003;101(2):374-9.
2. Chasnoff IJ, McGourty RF, Bailey GW,
Hutchins E, Lightfoot SO, Pawson LL,
Fahey C, May B, Brodie P, McCulley L,
Campbell J. The 4P’s Plus screen for
substance use in pregnancy: clinical
application and outcomes. J Perinatol.
2005;25(6):368-74.
3. Azadi A, Dildy GA 3rd. Universal screening
for substance abuse at the time of
parturition. Am J Obstet Gynecol.
2008;198(5):e30-2. Epub 2008 Feb 14.
4. Montgomery D, Plate C, Alder SC, Jones
M, Jones J, Christensen RD. Testing for
fetal exposure to illicit drugs using
umbilical cord tissue vs meconium. J
Perinatol. 2006;26(1):11-4.
5. Montgomery DP, Plate CA, Jones M,
Jones J, Rios R, Lambert DK, Schumtz N,
Wiedmeier SE, Burnett J, Ail S, Brandel D,
Maichuck G, Durham CA, Henry E,
Christensen RD. Using umbilical cord
tissue to detect fetal exposure to illicit
drugs: a multicentered study in Utah and
New Jersey. J Perinatol. 2008;28(11):7503. Epub 2008 Jul 3.
6. Baxter FR, Nerhood R, Chaffin D.
Characterization of babies discharged from
Cabell Huntington Hospital during the
calendar year 2005 with the diagnoses of
neonatal abstinence syndrome. WV Med J.
2009;105(2):16-21.
7. Rementeria JL, Nunag NN. Narcotic
withdrawal in pregnancy. Am J Obstet
Gynecol 1973;116:1152-1156.
8. Finnegan JP. Treatment issues for opioid
dependent women during the perinatal
period. J Psychoactive Drugs
1991;23:191-202
9. Jarvis MAE, Schnoll SH. Methadone
maintenance and withdrawal in pregnant
opioid addicts. In CN Chiang & LP
Finnegan (eds). Medication development
for the treatment of pregnant addicts and
their infants. (pp 58-77). Washington, D.C.:
US Department of Health and Human
Services (NIDA Monograph 149).
10. Dashe JS, Jackson GL, Olscher DA,
Zane EH, Wendel GD. Opioid
detoxification in pregnancy. Obstet
Gynecol 1998;92:854-58.
11. Luty J, Nikolaou V, Bearn J. Is opiate
detoxification unsafe in pregnancy? J of
Substance Abuse Treatment
2003;24:363-367.
12. Hoegerman G, Schnoll SH. Methadone
maintenance and withdrawal in pregnant
opioid addicts. Clinical Perinat
1991;18:51-76.
13. Briggs GG, Freeman RK, Yaffee SJ. Drugs
in pregnancy and lactation. Williams and
Wilkins, Baltimore, MD, 1994, pp 557-558,
14. Cooper JR, Altman F, Brown BS,
Czechowicz D. (Eds) (1983). Research on
the treatment of narcotic addiction: State of
the art. (NIDA Research Monograph 831201). Rockville, MD: US Department of
Health and Human Services.
15. Andres RL, Jones KL. Social and illicit drug
use in pregnancy. In RK Creasy & R Resnick
(eds). Maternal-Fetal Medicine (pp 191-192),
1994, Philadelphia, PA: Saunders.
16. Winklbaur B, Kopf N, Ebner N, Jung E,
Thau K, Fischer G. Treating pregnant
women dependent on opioids is not the
same as treating pregnancy and opioid
dependence: a knowledge synthesis for
better treatment for women and neonates.
Addiction 2008;103:1429-1440.
17. Chutuape MA, Jasinski DR, Fingerhood
MI, Stitzer ML. One, three, and six month
outcomes following brief inpatient opioid
detoxification. Am J Drug Alcohol Abuse
2001;27:19-44.
Please contact the authors for a complete list
of references.
for preemies
The fight goes on for
more than 500,000 babies
born too soon each year.
They need your help.
What will you do to
give premature babies
a fighting chance?
marchofdimes.com/fightforpreemies
© March of Dimes Foundation, 2009
March of Dimes West Virginia
(304) 720-2229
3508 Staunton Ave. SE
CME Post-Test
19.Which of the following substances is
associated with fetal growth abnormalities
when ingested during pregnancy?
a. Cocaine
b. Marijuana
c. Amphetamines
d. Opiates
e. all the above
20.In the study population, the detection of
alcohol ingestion was similar at all eight of
the participating hospitals.
True or False?
21.According to the study results, the most
frequently abused substance (excluding
tobacco) during pregnancy in West Virginia is:
a. Benzodiazepines
b. Methadone/opiates
c. Alcohol
d. Cannabinoids/marijuana
e. Methamphetamine
Substance
abuse hurts
If you have a patient who
suffers from substance
abuse or chemical
dependency, partner with
a psychologist now to help
your patient cope.
Look for deteriorations in:
- physical health
- personal and family
relationships
- workplace safety or
productivity
- financial stability
Partner with a licensed psychologist who can help individuals and families deal with job
loss, emotional stress, abusive behavior, and marriage and family problems associated
with substance and chemical dependency. Psychological treatment is often covered by
medical insurance.
The West Virginia Psychological Association is dedicated to positive health outcomes
for West Virginia citizens. Visit wvpsychology.org today for more information.
West Virginia Psychological Association
PO Box 58058 • Charleston, WV 25358
Phone: 304.984.0308 • Email: [email protected]
www.wvpsychology.org
A Comprehensive Checklist for Prevention &
O
ffice and emergency room management of the drug seeking patient
places a significant burden on the healthcare system. Identification,
detection, deterrence and treatment of these patients may be
complicated. Below is a checklist that may be used to facilitate detection
management of prescription drug seekers and drug addicts not in
recovery.
Preventative Measures
1
equest driver’s license or insurance cards of new patients. Insist on a delivery address where the patient actually
R
lives. Patients traveling significant distances should be queried regarding why they chose your office, referral
sources and known patients. Drug seekers frequently travel great distances from within and outside the state.
2
einforce “No Sharing” of medications with family or friends. Sharing medication is quickly becoming the leading
R
source of prescription drug abuse and misuse.
3
se a substance abuse / addiction questionnaire (e.g. NIDA-Modified ASSIST1) when considering chronic
U
controlled substance treatment. Document performance of an opioid risk screening questionnaire at least quarterly.
4
Observe patient records for multiple reports of prescription drug theft or repeated prescription losses.
5
hen patients present with family or friends, try to isolate the patient to assess their true needs. Frequently
W
patients are coerced to request prescriptions by friends or family members.
6
onsider tapering medications that patients have been prescribed for greater than 6-8 weeks (e.g. opioids or
C
benzodiazepines). Physiologic withdrawal often leads to further medication abuse, misuse and prescription
requests.
7
et appropriate goals for pain management. Patients or practitioners with the perception that pain will be
S
completely eliminated with treatment may lead to perceived failure of therapy and prescription misuse.
8
erform the Opioid Risk Tool analysis (ORT) prior to initiating chronic pain therapy. This 30 second assessment of
P
family abuse history, self abuse history, age, sex abuse history and psychiatric history readily helps direct
treatment.2
9
aintain a list of alternative medications for the management of pain, anxiety, and insomnia for patients that are
M
addicts or alcoholics in recovery. Prevent your patient’s risk of relapse.
10
bserve patient records for multiple requests of early refills for controlled substances, muscle relaxants,
O
antipsychotics, gabapentin and tramadol. Frequently, medications other than controlled substances are abused.
11
or patients requiring chronic therapy with a substance of abuse, initiate a contract that includes pill counts,
F
random drug testing, and a single, patient designated pharmacy.
12
ften patients that request an increase in dosage early in treatment may not be at therapeutic goal. They may
O
be perceived as drug seekers. This is known as pseudo-addiction and may lead to under treatment of patients.
13
Always perform thorough background checks on new medical and office staff.
14
stablish a single lock up site to store tamper proof prescription pads. Never leave prescription pads in patient
E
rooms.
15
Maintain thorough records of prescribed medications including drug, date, dose, duration, disease and refills.
& Management of the Drug Seeking Patient
Identifying Prescription Drug Seekers
16
ou or designated office personnel should perform a prescription monitoring report on new and chronic patients
Y
receiving controlled substances. The report alone does NOT prove a crime has been committed and should be
used to further questioning or an investigation of prescription drug abuse or diversion.
17
equest reports using your DEA number quarterly from WV Board of Pharmacy to identify unknown patients or
R
prescription fraud.
18
Enforce pill counts and random urine drug screens. Often times these activities are in contracts but not performed.
19
Acting immediately on” hear-say” reports from office staff, patients and patient relatives may jeopardize your practice.
20
If patients report illnesses that are treated with a controlled substance AND a non-controlled substance such as an
antibiotic. Follow-up with the pharmacy to see if the non-controlled substance was filled. Frequently doctor
shoppers only fill the controlled substances.
Treatment Considerations and Reporting Strategies
21
Communicate with other practitioners (physicians, dentists, etc) when mutual patients are doctor shopping.
22
rovide at least a 30 day notice prior to discharging a patient from your practice for contract violations or criminal
P
activities with at least 2 notifications one being certified mail.
23
24
Agree to treat patients under the contingency they must comply with a medication management contract (e.g. Pain).
Consider referrals to medical or surgical specialists to optimize therapeutic options.
25
aintain a list of local and regional detox centers, substance abuse treatment facilities, and Alcoholic Anonymous
M
/ Narcotics Anonymous meetings. Refer to these centers when substance abuse or addiction is detected.
26
practitioner who is NOT part of an addiction treatment program may administer controlled substances to an
A
addicted individual to relieve acute withdrawal symptoms while arrangements are made for treatment referrals. Not
more than 1 day’s supply can be prescribed at one time and the treatment MUST be limited to not more than 3 days.3
27
28
29
Report criminal behavior occurring on your premises. HIPAA provides a waiver to report criminal activity. 4
Report criminal behavior to the WV State Police Drug Diversion Unit (304) 766-5560.
Practitioners
lenient towards doctor shoppers will inadvertently attract more doctor shoppers. Support prosecution
to send the message this behavior is not tolerated in your practice.
References
1.Passik SD, Kirsh KL, Casper D. Addiction related assessment tools and pain management: instruments for screening, treatment, planning and
monitoring compliance. Pain Med.2008; 9:S145-S166.www.painandaddictiontreatment.com/node/1349
2.Opioid Risk Tool (ORT) Webster, Lynn R, Dove, Beth. Avoiding Opioid Abuse while Managing Pain: A Guide for Practitioners Chap 5, Page 95 &
Illustration Box V-8, Page 100. Sunrise River Press 2007
3.The Pharmacist’s Manual. An information outline of the Controlled Substance Act of 1970. April 2004. www.deadiversion.usdoj.gov/pubs/manuals/
pharm2/pharm_content.htm_manual.pdf
4. 45 CFR §164.512(f) (5).
Contacts
Michael O’Neil, PharmD.
Chairman, West Virginia Controlled
Substance Advisory Board
Associate Professor Dept. of Pharmacy Practice
Director Center of Excellence for the Education and
Prevention of Drug Diversion and Substance Abuse
University of Charleston School of Pharmacy
Charleston, WV 25304 | Office (304) 357-4347
Cell (304) 546-7746 | [email protected]
J.K. Lilly, MD, MS
Appalachian Pain Therapy
work: 304-925-2922
e-mail: [email protected]
Sgt. Michael Lafauci
WV State Police Drug Diversion
Unit (304) 766-5560.
Spinal Cord Stimulation as a Method of Reducing
Opioids in Severe Chronic Pain: A Case Report and
Review of the Literature
Timothy Deer, MD
President and CEO, The Center for Pain Relief,
Charleston
Christopher Kim, MD
Vice President, The Center for Pain Relief, Charleston
Richard Bowman, MD
Partner, The Center for Pain Relief, Charleston
Matthew Ranson, MD
Physician, The Center for Pain Relief, Charleston
C. Douglas Stewart PA-C
Director of Interventional Therapies, The Center for
Pain Relief
Wilfrido Tolentino, PA-C
Director of Clinical Monitoring, The Center for Pain
Relief, Charleston
Abstract
Opioid addiction and abuse are
growing problems in the United States,
particularly in Appalachian areas,13 which
has led to a major social health problem
costing millions of dollars in lost wages,
medical care and lost productivity. In some
patients with chronic moderate to severe
pain, opioids are indicated and can be
successfully used with proper monitoring.
In this report, we present a case where the
use of spinal cord stimulation (SCS) led to
an elimination of opioids, a return to work,
and to productive function. We also review
the literature on the use of SCS to reduce
opioid use and improve function based on
objective criteria.
Introduction
Spinal Cord Stimulation (SCS)
was first described in the literature
in 1967, when it was used by Shealy
to treat pain secondary to invasive
cancer involving the thoracic
nerve roots.1 Shortly after this
initial report, the Food and Drug
Administration (FDA) approved
the use of SCS for neuropathic pain
of the trunk and limbs. Prospective
studies have found the successful
use of this modality in patients
suffering from failed back surgery
syndrome, diabetic neuropathy,
complex regional pain syndrome,
cervical and lumbar radiculopathy,
post herpetic neuralgia, trigeminal
neuralgia, ischemic limb pain, and
intractable angina.2,3,4 This therapy
has been shown to be most effective
in patients who describe their pain
as burning, stabbing, shooting,
and/or throbbing. Once the device
is implanted the patients are placed
in a comprehensive rehabilitation
program to improve function.
Case Report
The patient was a 28 year old
male who was injured in the course
of a skydiving misadventure. He
suffered severe trauma to his aorta,
visceral organs, and spine. His spinal
trauma led to extensive surgical
reconstruction of his lumbar spine
and sacrum, which in turn led to
severe pain from failed back surgery
syndrome and arachnoiditis. His
function was very limited and he
was unable to walk independently,
requiring a wheelchair. His
medications included Methadone
200 mgs per day, Gabapentin 4 grams
per day, and baclofen 80mgs per day.
The methadone dose is considered
very high for chronic non-cancer
related pain syndromes. His side
effects from his oral pain regimen
included sedation, constipation,
irritability, and fatigue. At this
point the patient was referred for
consideration of a spinal cord
stimulation system. He met all
criteria set forth in the FDA approval
and was found to be psychologically
stable. Psychological clearance
included the absence of severe
untreated depression and anxiety. He
also did not demonstrate any findings
suggestive of personality disorders.
A spinal cord stimulation system
is placed in two steps. Initially, a trial
is performed by placing temporary
leads into the epidural space to
evaluate the patient’s response to
electrical current to the spinal cord.
The leads are placed in an attempt
to create a tingling sensation or
paresthesia in the area of neuropathic
pain. The paresthesia is created by
a balance of strategically arranged
cathodes and anodes that activate
spinal fibers involved in the pain
pathways. The patient was educated
about the goals of both the subjective
outcomes of pain relief of 50% or
more, and the mechanical goals of
Objectives
The objective of this submission is to provide information regarding the efficacy of Spinal Cord Stimulation, and the positive effects
of this therapy, including reduced dependence on opioids for the management of chronic pain conditions.
stimulation including “vibration in
the area of pain.” He was then given
informed consent, was educated
regarding the procedure, and was
evaluated for preoperative anesthesia
and sedation. He then underwent
an outpatient SCS temporary
implant. After receiving intravenous
vancomycin preoperatively, he was
taken to the operating theatre and
placed in the proper prone position
and prepped and draped in sterile
fashion. Fluoroscopic imaging was
used to identify the spine, and the
appropriate anatomic landmarks.
A laser guided approach was
used to guide the needle to the
epidural space to give access for
lead placement. The trial leads were
placed via a minimally invasive,
percutaneous approach, into the
thoracic spine with a target area of
T8 to T12. These targets were based
on previous mapping which suggests
these are the spinal regions best
impacted to produce paresthesia in
the areas of pain. (See figures 1, 2)
The leads were left in place for a
five day trial period at which time
the resulting paresthesia led to a
reduction of pain of 70%. The leads
were removed in the office on day
five. The patient wished to move
forward with the permanent implant.
Two weeks after the original trial
the patient underwent reimplantation
of the percutaneous leads in the
same target zone as the original
implant. A cutdown was then created
to the spinal fascia and ligaments.
Fatty tissue was debrided and the
needle and stylet were removed. At
this point, non-absorbable suture
was used to anchor the leads to
the spinal ligaments and fascia. A
subcutaneous pocket was made in
the area just above the beltline, and
a tunneling rod was used to tunnel
the leads from the midline incision
to the pocket. The device was then
connected to the rechargeable battery
with a hex wrench, and computer
programming was initiated by
wireless telemetry. (See s 3, 4, 5)
The patient underwent a six week
recovery period to allow the leads to
stabilize and scar into the tissue. At
this point the patient was placed into
a comprehensive twelve week spinal
rehabilitation program with goals of
improving strength and muscle mass,
improving flexibility and regaining
his functional status. At his one year
follow up he had totally weaned
from all controlled substances,
returned to work as a sky diving
instructor and was matriculating
in an advanced college program.
Figure 1.
Figure 2.
Lead position as viewed under fluoroscopy.
Discussion and Literature
Review
Spinal cord stimulation is a
minimally invasive therapy that
3000 Washington St. West
is used for intractable moderate to
severe pain of neuropathic origin.
Patients are selected based on failure
of reasonable conservative therapies,
and the absence of untreated
bleeding disorders, or active systemic
infection. The patient’s outcome
Lead placement.
Figure 3.
Securing the trial leads.
Figure 4.
Tunneling for lead placement.
Figure 5.
Placement of the permanent leads.
results are likely to be more favorable
if the patient has been treated for
any severe depression. Disease
states that have been shown to be
responsive to stimulation include
failed back surgery syndrome,
spinal radiculopathy, ischemic pain,
peripheral neuropathy, post herpetic
neuritis, traumatic nerve injury, and
complex regional pain syndrome.2
Prospective studies have shown
that (SCS) can be used to treat
chronic pain due to many disease
states, and in that application can
reduce the use of opioids and
improve function. North noted a
50% reduction in medication usage
among those reviewed,10 Cameron
noted a 45% reduction in medication
usage,11 and Taylor noted that 68%
no longer needed analgesics.12
In another prospective
study, North and colleagues
showed that pain reduction was
significantly improved in patients
treated with SCS as compared
to medical management.7 North
also demonstrated that SCS was
superior to reoperation after an
initial failed back surgery in patients
who had indications for repeat
operations. This was true for both
pain reduction and crossover to
the alternative therapy option.
When considering return to
work, Weber and his group at Fort
Bragg reported a return to active
duty in a cohort of service men
implanted for military related
pain syndromes.8 This return to
duty was also supported by work
by Verdolin in soldiers suffering
from trauma induced Complex
Regional Pain Syndrome (CRPS).9
Complications are sometimes
seen with the trial and permanent
phases of implanting a spinal
cord stimulation device. These
complications vary in their level of
severity. The most worrisome and
least common problems involve the
neuroaxis. These problems include
epidural hematoma, epidural
abscess, and spinal cord injury.
More common, but less damaging
complications include wound
infection, pocket hematoma or
seroma, and mechanical malfunctions
of the device. These mechanical
problems include lead movement,
fibrosis, and battery failure. Many of
these problems can be treated with
reprogramming of the device, but
sometimes require surgical revision.
Conclusion
Spinal cord stimulation is an
effective treatment of moderate to
severe chronic neuropathic pain. The
case presented in this paper shows
its applicability to those with severe
injury and functional disability that
have previously been treated with
high dose opioids. SCS should be
used earlier in the algorithm in the
chronic pain patient as a method
of reducing opioid dependence,
abuse and potential addiction.
References
1. Shealy CN, Mortimer JT, Reswick JB, D.
Electrical Inhibition of Pain by Stimulation
of the Dorsal Columns: Preliminary Clinical
Report. Anesthesia & Analgesia. JulyAugust 1967;46:4.
2. Deer T, Masone RJ. Selection of Spinal
Cord Stimulation Candidates for the
Treatment of Chronic Pain. Pain Medicine.
May/June 2008;9:1,S82–S92.
3. Deer TR, Raso LJ. Spinal Cord Stimulation
for Refractory Angina Pectoris and
Peripheral Vascular Disease. Pain
Physician. 2006; 9,347-352 ISSN 15333159.
4. Boswell MV, Shah R, Everett CR, Sehgal
N, Mckenzie-Brown AM, Abdi S, Bowman
R, Deer T, Datta S,Colson J, Spillane,
Smith HS, Lucas LF, Burton AW,Chopra P,
Staats PS, Wasserman RA, and
Manchikanti L. Interventional Techniques in
The Management of Chronic Spinal Pain:
Evidence-Based Practice Guidelines. Pain
Physician. 2005;8:1-47, ISSN 1533-3159.
5. Kumar K, North R, Taylor R, Sculpher M,
den Abeele C, Gehring M, Jacques L,
Eldabe S, Meglio M, Molet J, Thomson S,
O’Callaghan J, Eisenberg E, Milbouw G,
Fortini G, Richardson J, Buchser E, Tracey
S, Reny P, Brookes M, Sabene S, Cano P,
Banks C, Pengelly L, Adler R, Leruth S,
Kelly C, Jacobs M. Spinal Cord Stimulation
vs. Conventional Medical Management: A
Prospective, Randomized, Controlled,
Multicenter Study of Patients with Failed
Back Surgery Syndrome (PROCESS
Study). Neuromodulation. October
2005;8:4,213-218(6).
6. Mancaa A, Kumarb K, Taylorc RS,
Jacquesd L, Eldabee S, Megliof M, Moletq
J, Thomsonn S, O’Callaghani J, Eisenbergj
E, Milbouwk G, Buchserl E, Fortinim G,
Richarsonn J, Tayloro RJ, Goereep R,
Schulphera MJ. Quality of life, resource
consumption and costs of spinal cord
stimulation versus conventional medical
management in neuropathic pain patients
with failed back surgery syndrome
European Journal of Pain;12:8,1047-1058.
7. North R, Ewend M, Lawton M, Kidd D,
Piantadosi S. Failed Back Surgery
Syndrome: 5-Year Follow-Up after Spinal
Cord Stimulator Implantation.
Neurosurgery. May 1991;28:5.
8. Dragovich A, Weber T, Wenzell D, Verdolin
M, Cohen S. Neuromodulation in Patients
Deployed to War Zones. Anesthesia &
Analgesia. July 2009;109:1.
9. Verdolin M, Stedje-Larsen E, Hickey A. Ten
Consecutive Cases of Complex Regional
Pain Syndrome of Less than 12 Months
Duration in Active Duty United States
Military Personnel Treated with Spinal
Cord Stimulation. Anesthesia & Analgesia.
June 2007;104:6,1557-1560.
10. North RB, Kidd DH, Farrokhi, F, et. al.
Spinal Cord Stimulation versus reapted
lumbrosacral spine surgery for chronic
pain: a randomized controlled trail.
Neurosurgery. 2005; 56:98-107.
11. Cameron T. Safety and efficacy of spinal
cord stimulation for the treatment of
chronic pain: a 20-year literature review, J.
Neurosurg Spine. 2004;100(3):254-267
12. Taylor RS, Van Buyten JP, Buscher E.
Spinal cord stimulation for chronic back
and leg pain and failed back surgery
syndrome: a systematic review and
analysis of prognostic factors. Spine.
2005;30:152-160
13. An Analysis of Mental Health and
Substance Abuse Disparities & Access to
Treatment Services in the Appalachian
Region - Final Report May 2008
Presented to: Appalachian Regional
Commission Presented by: Zhiwei Zhang,
Ph.D. Alycia Infante, M.P.A. Michael Meit,
M.A., M.P.H. Ned English, M.S.National
Opinion Research Center (NORC) at the
University of Chicago & Michael Dunn,
Ph.D. Kristine Harper Bowers East
Tennessee State University.
CME Post-Test
22. Spinal Cord Stimulation is effective in managing chronic pain.
True or False?
23. At what point in the treatment algorithm should Spinal Cord Stimulation be utilized?
a. Prior to a repeat back surgery for the indication of pain.
b. Prior to using high dose oral opioids for neuropathic pain.
c. Prior to using a destructive procedure to destroy a nerve.
d. All of the above.
24.Spinal Cord Stimulation was successful in reducing possible opioid dependence,
and improving quality of life in the presented case.
True or False?
Buprenorphine Clinics: An Integrated and Multidisciplinary
Approach to Treating Opioid Dependence
Patrick J. Marshalek, MD
Chief Resident in Psychiatry, Department of
Behavioral Medicine and Psychiatry, West Virginia
University, Morgantown
Carl R. Sullivan, MD, FACP
Professor, Vice-Chair and Director,
Residency Training, Department of Behavorial Medicine
and Psychiatry, West Virginia University, Morgantown
Introduction
Opioid dependence remains
a very difficult problem facing
the state of West Virginia, be it
prescription opioids or heroin.
Access to care for those struggling
with opioid dependence continues
to be problematic as well.
By the time most individuals
with opioid dependence seek help
from treatment providers, they have
developed significant tolerance to
opioids and soon go into withdrawal
without using. Opioid withdrawal
produces significant physical
and psychological distress which
fuels continued use. This cycle
can continue for months to years,
and individuals find themselves
spending increasing time and
resources looking for and using
opioids. In the end, opioid dependent
patients rarely get “high,” but are
often just using to “feel normal”
and avoid withdrawal. They also
find themselves facing a variety of
stressors stemming from their use.
Any treatment plan enacted
by a medical provider for an
opioid dependent individual
should be multifaceted,
involving social, psychological
and biological interventions.
With respect to opioid
dependence, biological interventions
are commonly referred to as
medication assisted treatment (MAT).
Questions and Answers
What MAT options are there?
Prior to 2000, there were
essentially two medication assisted
treatments medical providers
could offer to patients. They could
either go on full agonist therapies
such as methadone, or on full
antagonists such as naltrexone.
Both of these options had relative
strengths and weaknesses.
A key change in legislation by
Congress in 2000 attempted to
address this problem. Better known
as the Drug Addiction Treatment Act
of 2000 (DATA 2000), the passage
of this law allowed physicians to
treat opioid dependent individuals
from their office with FDA approved
schedule III, IV and V medications.
This can be done by notifying
the Department of Health and
Human Services (DHHS) through
the Center for Substance Abuse
Treatment (CSAT) of intent to treat
by applying for and receiving a
waiver of the special registration
requirements defined in the
Controlled Substance Act (CSA).
In late 2002, the FDA approved
buprenorphine (schedule III)
as an office based treatment for
opioid dependence. It was made
available to physicians who
received the buprenorphine waiver,
allowing them to begin treating
opioid dependent patients from
their office. Without the proper
qualifications and waiver, a provider
is in violation of the CSA.
How do I qualify?
There are a variety of ways to
qualify for this waiver. They all
involve showing some degree
of familiarity, or expertise with
respect to treating addiction,
and with buprenorphine.
More detailed information
can be found at the CSAT
Buprenorphine Information Center.
866. BUP.CSAT or http://
buprenorphine.samhsa.gov
What is buprenorphine
and how does it work?
It is an opioid that works as a
partial agonist and has high affinity
for opioid receptors. These properties
allow it to act like several different
medications rolled into one. It is not
a full agonist like morphine, codeine,
Objectives
Explain what buprenorphine is, how it works, and why it is combined with naloxone.
Explain why it was approved to treat opioid dependence and how to qualify to be able to use it.
Explain how to integrate buprenorphine into a multidisciplinary treatment team.
Utilize resources to locate providers who use buprenorphine.
heroin, oxycodone, hydrocodone,
fentanyl or methadone, nor is it
a full antagonist like naloxone or
naltrexone. It is technically referred
to as a mixed agonist-antagonist due
to the aforementioned properties.1
What does that mean?
At doses normally prescribed
for opioid dependence, it acts
as an agonist, occupying opioid
receptors in a manner that prevents
withdrawal, reduces cravings,
and allows many patients to
“feel normal.” Methadone does
this as well, but that is where the
similarities end. Whereas increasing
dosages of methadone increase
the risk of respiratory depression,
increasing doses of buprenorphine
likely increases the risk of opioid
withdrawal. With buprenorphine,
there is a “ceiling effect”. This
occurs because buprenorphine
begins to function as an antagonist
at higher doses. It also acts as an
opioid blocker, once an individual
is at a steady state with respect to
their buprenorphine dose. This
effect is believed to occur because
buprenorphine tightly binds to
opioid receptors. Patients who
relapse and use opioids while on
buprenorphine often report feeling
little or no effect when they use
opioids. It is most commonly taken
in a sublingual fashion, and it’s long
half life allows for once daily dosing.1
What is a normally prescribed dose?
An average maintenance
buprenorphine dose for an opioid
dependent individual ranges from
8‑16 mg per day.1
Too good to be true?
Buprenorphine alone was found
to have some abuse potential upon
initial studies. Patients reported
injecting the medication to get high.
To combat this, a buprenorphine/
naloxone combination medication
was developed. This combination
is better known as Suboxone®.
Naloxone only exerts an effect
when injected, and is essentially
inert when taken sublingually.
Suboxone® has advantages over
buprenorphine alone, when used
to treat opioid dependence.1
A common question posed by care
providers, patients and their families
alike is “aren’t you just trading one
thing out for another?” There short
answer is ”yes you are” if that is all
you do as a provider and neglect to
implement a treatment plan focused
on addiction, with psychological
and social interventions.2,3
Unfortunately, addicts often
encounter buprenorphine on the
street that has been diverted. This
may be their first impression of
it. They often see other active
addicts using the medication
simply to keep from being sick or
in withdrawal. Often times, they
present to clinic partially detoxed
with Suboxone® or with it in their
system alongside other opioids.
Why provide more than
just medication?
Pharmacotherapy alone is rarely
sufficient for drug addiction.
Treatment outcomes demonstrate
a dose-response effect based on the
level or amount of psychosocial
treatment services that are provided.3
How best to provide more
than just medication?
Use buprenorphine as part of an
organized addiction treatment clinic.
What is a Buprenorphine Clinic?
It is a place where someone
struggling with opioid dependence
can go to get help from a
biological, psychological and social
standpoint, with the net result
being an entry into recovery.
What is recovery?
This can be a charged term,
with varied implications. For the
purpose of this article and the sake
of simplicity; it will be defined as
sobriety from drugs and alcohol plus
improvement in quality of life. 4
What should a Buprenorphine
Clinic consist of?
A Physician, Therapist,
Medical Assistant and Case
Manager functioning as a team.
The physician must apply for and
be granted the waiver to prescribe
buprenorphine. As mentioned
earlier, this involves showing
experience and knowledge with
respect to treating addiction and
using buprenorphine. There is more
than one way to go about doing
so. The physician is responsible for
starting, stopping, adjusting the
medication, and managing side
effects. They should rely heavily
upon the input from other members
of the treatment team as decisions
on when to start, stop and taper
buprenorphine can be complicated.
A valuable tool available to all
physicians comes by way of the
West Virginia Board of Pharmacy
and their Controlled Substances
Monitoring Program. This can be
applied for, and accessed online
by going to www.wvbop.com. The
program lists controlled substances
filled at pharmacies in West Virginia,
showing drug, strength, quantity,
physician, pharmacy, and date filled.
A therapist will need to have
some background in addiction,
and provide the bulk of the
psychological intervention. Therapy
is best applied in both a group
and individual setting. Therapists
will also be able to assist with the
assessment of new patients.
Case managers will help keep
the clinic running smoothly by
screening potential referrals,
addressing issues that arise with
respect to current patients, and
managing patient flow. This person
will answer many phone calls.
Medical assistants help administer
screening tools and in the assessment
of patients. The most important
of which remains the urine drug
screen. There are many different
screens available that test for a
wide range of substances with
good sensitivities and specificities.
Importantly, results should be
obtained during the clinic visit.
Since these results are qualitative,
the ability to obtain confirmation
via gas chromatography and mass
spectrometry (GC/MS) should be
available, and most screens offer
the ability to do so. In addition to a
quality screen, the treatment team
must be sure to obtain specimens in
a manner that is consistent and that
reduces the risk of patients tampering
with the sample, or providing
samples that are not their own.
The team should encourage the
key social intervention, including
requirement of regular attendance at
twelve-step facilitation meetings such
as AA or NA. Patients should keep a
log of meetings attended and provide
it to the team. The team should
also urge patients to seek a sponsor
and begin working the steps. These
meetings are available throughout
West Virginia and can provide a key
social support for those attempting
to stay clean. Meeting times and
places can easily be accessed online. 3
Buprenorphine Clinic
Contingencies?
It is important that patients are
well educated regarding the rules
and requirements of the clinic set
forth by the treatment team. They
should sign a contract that clearly
spells this out. Typical contracts
require things like safeguarding
of medication, frequency of clinic
attendance, honesty, regular
attendance of AA/NA meetings and
Medical Coding and Reimbursement
Maggie McCabe, PAHM, CPC, CPC-H, CPC-P
P. O. Box 13051
304-881-4633
[email protected]
Sharing in the joy of health care education!
random drug screens. Rules set forth
by the contract need to be strictly
and uniformly adhered to. With
respect to frequency of visits, patients
should initially be seen weekly
by the team until they stabilize in
their recovery. We recommend
they obtain a 12-step sponsor and
that they are regularly attending
meetings. In our clinic, four twelve
step meetings per week are required.
needs to involve the patient in this
decision and try to look closely at the
risks and benefits before a decision
is made. A key component is how
far a client has progressed with
respect to their recovery. Currently,
there is not a standard protocol
for weaning off buprenorphine.
What if more than a Buprenorphine
Clinic is needed?
It’s important to remind yourself
of the properties of buprenorphine.
Patients are given cards to carry to
show other clinicians in the event
of questions. This is especially
important when treating pain. In the
event of acute or severe pain, larger
than normally used amounts of
opioids can override buprenorphine.
Patients on buprenorphine also
may have to undergo elective
procedures. Coordination between
providers is key to avoid relapse or
complications, especially with respect
to perioperative pain management
as patients may need to go off of
buprenorphine for a short amount of
time before and after the procedure.
The Clinic is streamlined to treat
individuals with opioid dependence.
The treatment team needs to be
quick to note who is struggling and
refer them to the appropriate level
of care. Some patients will need
longer term treatment, or intensive
outpatient treatment addressing more
than just opioid dependence. Some
will need inpatient detoxification.
Some will need more of a dual
diagnosis approach to address
concurrent mental health issues.
How long to stay on the medication?
Buprenorphine is approved for
maintenance and detoxification. It
can be used for several days to years.
Most patients will not want to remain
on the medication forever, but will
express much anxiety with respect
to tapering off. The treatment team
What if you are taking care of
a patient on buprenorphine?
What if you see a patient you think
will benefit from buprenorphine?
The SAMHSA website has links
to locate providers. Physicians
should inquire whether a clinic
has additional therapies integrated
alongside the medication.
References
1. Rolley E. Johnson, Eric C. Strain, Leslie
Amass, Buprenorphine: how to use it right,
Drug and Alcohol Dependence, Volume
70, Issue 2, Supplement 1, Buprenorphine
and Buprenorphine/Naloxone : A Guide For
Clinicians, 21 May 2003, Pages S59-S77,
ISSN 0376-8716, DOI: 10.1016/S03768716(03)00060-7. (http://www.
sciencedirect.com/science/article/B6T63489B3YX-1/2/5f19388448ad2c67e5781f05
7860919f)
2. Amato L, Minozzi S, Davoli M, Vecchi S,
Ferri M, Mayet S. Psychosocial and
pharmacological treatments versus
pharmacological treatments for opioid
detoxification. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art.
No.: CD005031. DOI: 10.1002/14651858.
CD005031.pub3
3. Center for Substance Abuse Treatment.
Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid
Addiction. Treatment Improvement
Protocol (TIP) Series 40. DHHS
Publication No. (SMA) 04-3939. Rockville,
MD: Substance Abuse and Mental Health
Services Administration, 2004.
4. Thomas McLellan, What is recovery?
Revisiting the Betty Ford Institute
Consensus Panel Definition: The Betty
Ford Consensus Panel and Consultants,
Journal of Substance Abuse Treatment,
Volume 38, Issue 2, March 2010, Pages
200-201, ISSN 0740-5472, DOI: 10.1016/j.
jsat.2009.11.002. (http://www.
sciencedirect.com/science/article/B6T904XY4B3C-1/2/74928803e0b476d6a32054
2f7ec7cee5)
CME Post-Test
25.Buprenorphine is combined with naloxone
to reduce abuse potential.
True or False
27.What term best describes buprenorphine’s
mechanism of action?
26.In what year was buprenorphine approved
by the FDA to treat opioid dependence?
a. Full agonist
b. Full antagonist
a. 2002
c. Mixed agonist-antagonist
b. 1992
d. None of the above
c. 1982
d. 1972
Understanding the Cultures of Prescription Drug
Abuse, Misuse, Addiction, and Diversion
Michael O’Neil, PharmD
Associate Professor
The University of Charleston
School of Pharmacy
Karen L. Hannah
Epidemiologist
West Virginia Medical Institute
Abstract
Prescription drug abuse, misuse,
addiction, and diversion have reached
epidemic proportions in the United States.
The elimination of the burden of these
activities on the healthcare system, the
criminal justice system and society as a
whole requires a multifaceted approach.
Before resolution of these issues around
prescription drugs can occur, a clear
understanding of the cultures leading to
these activities is required.
Background
Prescription drug abuse, misuse
and addiction have reached alarming
proportions in both youth and adult
populations.1, 2, 3 Evidence published
by Hall et al. in 2008 indicated that
between 1999-2004, West Virginia
experienced the nation’s largest rise
(550%) in unintentional prescription
medication associated deaths.4
Records from the State’s Medical
Examiner’s office have shown a
continued increase in prescription
drug abuse and associated deaths
through 2006.5 The financial burden
of prescription drug abuse alone
on health care is not well known.
Prescription drugs are frequently
used in conjunction with alcohol
and other illicit substances and
patterns of abuse may vary due
to age, social trends and intent of
prescription drug use.6 Prescription
drug fraud, prescription drug
counterfeiting and fraudulent
schemes to obtain prescription
drugs from healthcare practitioners
have added dramatically to the
financial burdens in the healthcare
system. Law enforcement agencies
in West Virginia report an increasing
incidence of drug diversion
characterized by prescription
drug thefts, “doctor shopping”
and an increase in illegal internet
pharmacies (Smith M., personal
communication, December 2009). The
impact of prescription drug abuse,
misuse and diversion alone on law
enforcement and the legal system
are not well defined. However, from
2005-2008, the estimated financial
burden of all drug crimes on law
enforcement in West Virginia was
estimated to be $48,549,510.7
Individual motivations and
behaviors leading to the abuse,
misuse, and diversion of prescription
drugs vary significantly. Although
most medical practitioners, licensing
boards and law enforcement agencies
focus their efforts on controlled
substances, it is important to
recognize that a significant amount
of drug abuse, misuse, and diversion
occurs with prescription drugs
that are not controlled substances.
Some of these agents include, but
are not limited to, muscle relaxants,
anticonvulsants, non-controlled
analgesics, and antipsychotics.
Although multiple terms have been
used in the literature and media
to describe prescription drug use
behaviors, little information exists
to classify the cultures surrounding
the prescription drug epidemic.
Categorizing the cultures associated
with prescription drug abuse,
misuse, addiction, and diversion is
a necessary step to help facilitate
the education, treatment and
rehabilitation of these individuals
and the professionals who treat,
investigate, or prosecute them.
The purpose of this article is to
introduce the concepts and propose
taxonomy for the cultures involved
in prescription drug abuse, misuse,
addiction, and diversion.
Definitions
For the purpose of this article
prescription drug diversion,
prescription drug abuse, prescription
drug misuse and prescription drug
addiction are defined as follows:
Prescription drug diversion is
defined as the illegal transfer of
legend medications (i.e., any drug
which bears the legend, “Caution:
Federal law prohibits dispensing
without a prescription”) to recipients
outside the legal pathways as defined
Objectives
The purpose of the article is to meet the following objectives: Introduce the reader to new taxonomy categorizing the cultures of
prescription drug abuse and misuse. The article will discuss the factors that influence prescription drug abuse, misuse, addiction,
and diversion. The populations of prescription drug addiction will be delineated.
by the FDA, drug enforcement
agencies and state agencies.
Prescription drug abuse is defined
as the use of a legend drug in a
way not intended by an authorized
prescriber of the medication. The
intent of prescription drug abuse
is to obtain an altered state of
mood or behavior. Prescription
drug abuse frequently involves
circumventing the intended
route of drug administration.
Intentional prescription
drug misuse is the voluntary
administration of legend drugs for
medical indications other than the
indication and dosage intended by
the authorized practitioner for the
defined recipient of the prescription.
This often includes administration
of doses that exceed the directions
of the prescription. Misuse of
prescription drugs also includes use
of a legend drug for an appropriate
indication but not prescribed by an
authorized practitioner. Prescription
drug misuse predominately
involves “self medication”
with legend drugs, although
administration of prescription drugs
to children by adults is included
in prescription drug misuse.
Prescription drug addiction is a
chronic disease that is characterized
by motives, feelings or behaviors that
include drug craving, a compulsion
to use, continued use in spite of
known negative consequences and
loss of control over drug intake.
This disease may be characterized by
relapse: if prescription drug addiction
is untreated, it may lead to death.
The cultures of prescription
drug abuse, misuse, addiction, and
diversion can be divided into four
separate categories, each of which
Helping West Virginia pHysicians
have their own characteristics; the
sharing culture, the income-driven
culture, the substance-abuse culture
and the addiction culture. Each
category can be further divided to
identify subpopulations (See Fig.1).
The Sharing Culture
The sharing culture is defined as
the giving, lending or borrowing of
prescription medications to anyone
other than the person for whom the
prescription was intended. The intent
of the sharing culture is to help treat
an illness, symptoms of an illness or
a perceived physical or psychiatric
problem that may or may not have
been appropriately diagnosed
by a healthcare practitioner. The
sharing culture is characterized by
the perception that prescription
drugs are safe simply because
medical practitioners prescribe
take the right path…
…in litigation, privacy and security compliance, certificate of need, medical staff and professional
disciplinary matters, credentialing concerns, complex regulatory matters and business transactions.
Charleston
health care practice group
Ryan A. Brown
Robert L. Coffield
Alaina N. Crislip
J. Dustin Dillard
Sam Fox
Michele Grinberg
John D. Hoffman
Amy R. Humphreys
Justin D. Jack
Richard D. Jones
Edward C. Martin
Mark A. Robinson
Amy L. Rothman
Don R. Sensabaugh, Jr.
Salem C. Smith
Morgantown
Stephen R. Brooks
Stacie D. Honaker
Wheeling
David S. Givens
Phillip T. Glyptis
Robert C. James
Edward C. Martin, Responsible Attorney | [email protected] | www.fsblaw.com | (304) 345-0200 | (800) 416-3225
Figure 1.
The cultures of prescription drug abuse, misuse, addiction, and diversion.
Prescription Drug Abuse, Misuse,
Addiction, Diversion
SharingCulture
TheIncome
DrivenCulture
Substance
AbuseCulture
TheAddiction
Culture
Adult
Adolescent
to Adult /
Adolescent
Adultto
Child
Individual
orPatient
Experimenters
Practitioner
Mood
Modifiers
Active
Addicts
The
“Bridging”
Population
Addictsin
Physiologic
Withdrawal
Recovering
AddictsIn
Maintenance
Therapy
Recovering
Addictsin
Abstinence
Programs
them and pharmacists dispense.
The individuals do not take into
account individualized dosing,
drug-drug interactions, drug-disease
interactions, side effects or allergies
by the users of these medications.
There is little recognition that the
sharing of prescription drugs is illegal
and a type of drug diversion. Sources
of these medications include leftover
medications in the home or personal
prescriptions where the intended
user of the prescription shares a
part of their daily prescription with
someone. Economics and marketing
strategies for over the counter
medications (OTC medications) have
contributed to the development of
the sharing culture. Pharmaceutical
companies have advertised cough,
cold, allergy and OTC analgesic
medications, suggesting that buying
in bulk saves money and that
the medication may be taken by
the whole family. This sharing of
prescription medications is frequently
seen with adults and adolescents.
Petersen et al. reported that 28.8%
of women and 26.5% of men
admitted ever borrowing or sharing
prescription medications.8 In a survey
of adolescents, Goldsworthy, et al.
reported that 74% of borrowers did
so to avoid making an appointment
with a healthcare provider, 32.4%
eventually saw a healthcare
provider for the same indication
and 37.4 % reported a side effect.9
Commonly shared prescription
medications include opioids,
antibiotics, allergy medications,
antidepressants, and anxiolytics.
The adult to child sharing
culture is an intentional misuse
of prescription drugs. Although
the intent may be to alleviate a
child’s discomfort, administration
of prescription medications not
prescribed for a child can result
in overdose, hospital admission
and even death.10 Efforts to deter
the sharing culture of prescription
medications are predominately
focused on education, starting in the
elementary schools. Instructions to
patients by healthcare professionals
regarding the health risks and
illegality of sharing prescription
drugs and disposal of unused
prescription drugs are warranted.
The Income-Driven Culture
Prescription drug theft,
prescription forgeries, doctor
shopping, and illegal internet
acquisition of prescription drugs
are all methods patients or other
individuals use to obtain prescription
drugs. The income-driven culture
is motivated by financial profit
obtained from selling prescription
drugs. Drug task force members in
West Virginia estimate that 5% to
70% of prescription drug related
arrests are individuals acting solely
as distributors of prescription drugs
(Landis T. personal communication.
April 2010). These prescription
diversion practices are similar to
those of the international drug
cartels. However, at the community
level, prescription drug sales are
usually the only source of income
available to these dealers. This
activity should not be unexpected
when oxycodone may sell for $0.80$1.25 per milligram on the street.
Another characteristic of this
culture is that these individuals rarely
misuse or abuse prescription drugs
themselves, and are usually not
addicted to prescription medications.
The recognition of the absence
of addiction in this population
has major societal implications.
Recognizing that an arrest related to
prescription drug diversion does not
always mean the perpetrator is an
addict may allow behavioral health
professionals to focus their resources
on those with prescription drug
addiction and other psychological
issues. A second subgroup in
the income-driven culture are
persons who are appropriately
prescribed medications, but choose
to sell some of their prescription
medications for income.
A third subgroup are the
healthcare practitioners who operate
“pill mills”. These operations are
characterized by extremely large
numbers of individuals who must
pay cash for their prescriptions and
are required to return monthly to
get a new prescription. Medical
documentation in these operations
is often missing, inaccurate or
fraudulent. Clients frequently travel
hundreds of miles for a single visit.
A fourth subgroup consists of
medical practitioners who knowingly
prescribe requested prescriptions
such as opioids or anxiolytics that are
not the optimal drug of choice for a
patient’s symptoms and diagnosis.
If the prescriber fails to comply with
the person’s request for a specific
drug, he or she may threaten to
take their business elsewhere.
Pharmacies also may operate in an
income-driven environment that
is characterized by the filling of
every prescription presented to the
pharmacy without the practice of due
diligence to ensure against illegal
activities such as doctor shopping,
fraud or other deceptive practices.
Substitution of brand prescription
drugs with generic, dispensing less
than the prescribed number of dosage
units, dispensing drugs without a
prescription, dispensing counterfeit
drugs, or the use of legitimate
medicines that have been obtained
outside the normal distribution
system (so-called “gray market
drugs” that have often not been
stored or handled properly and may
be of reduced potency), may illegally
bolster the pharmacist’s income.
Investigations into the medical, legal
and professional activities of these
healthcare practitioners is extremely
time consuming and costly. Financial
and manpower resources for
licensing boards, law enforcement
agencies, prosecutors and expert
consultants are limited and make
it difficult to expedite prosecutions
and curtail illegal activities.
The Substance-Abuse Culture
Prescription drug abuse has been
around since before the Institution
of the Harrison Narcotic Tax Act of
1914. The intent in the creation of
this act was two-fold; to regulate
the medical use of drugs with abuse
potential and to criminalize any
nonmedical use of these drugs.11
This restriction in the use of
medications, specifically the opiates
and cocaine derivatives, led to the
opportunity for the first illegal
“prescription drug abuse”. The
intent of prescription drug abuse is
to obtain an altered state of mood or
behavior. The culture of substance
abuse can be divided into two
major subgroups; the experimenters
and the mood modifiers.
The experimenters try a
prescription drug to evaluate their
likes or dislikes of the drug’s effects,
or to “fit in” (peer pressure). Little
thought is put into consideration
of the potential dangers. If the
experience produced is perceived as
positive and leads to a more routine
use of the prescription drug, the user
may then be classified in the moodmodifying subculture. Frequently
the experimentation is encouraged
by peer pressure or as an acceptable
group behavior. An example of this is
readily seen in the teen trend known
as “pharming” parties”.12 Pharming
parties require participants to bring
prescription medications from
any source, usually the medicine
cabinet, and empty the contents of
the prescription bottle into a fish
bowl or container. As part of that
night’s experimental experience, the
participants are required to randomly
take and ingest one to five pills from
the container. The effects achieved
are quite varied and dangerous. This
culture ingests prescription drugs
that have known effects beyond what
the medication was prescribed such
as euphoria, sedation or anxiolysis.
The doses are intentionally increased
beyond the recommended dosage to
try to achieve these enhanced effects.
The mood-modifying subculture
consists of individuals who abuse
prescription drugs on more than one
occasion for several reasons such as;
optimizing their “social performance”
at parties, improving their focus
and energy to enhance their
academic performance, creating an
environment of escape from reality,
and self medicating with excessive
doses to achieve relief of physical
pain or psychiatric symptoms. The
latter example is commonly seen in
patients who originally take opioids
for management of pain but then
recognize the medication gives
them an added boost of energy or
relief from anxiety. The individual
then increases the dose of the
medication to achieve the effects
produced from the drug beyond the
intended pain management. This
self medicating frequently leads
to prescription drug addiction.
Long-term prescription drug abuse
has significant consequences to
the physical and mental health of
individuals and contributes to the
financial burden of health care.
The Addiction Culture
The true prevalence of the disease
of prescription drug addiction
is unknown for several reasons:
many addicts mix illicit drugs or
alcohol with prescription drugs,
many addicts remain untreated,
and many addicts have entered
recovery. Rarely do treatment centers
report treatment numbers of addicts
for prescription drug abuse and
misuse alone. Most prescription
drug addicts are prescription drug
abusers or misusers before the onset
of the disease of addiction. The most
common prescription drugs seen
in addiction include the opioids,
benzodiazepines and stimulants.
The addiction culture may be
divided into five subcategories;
active addicts, the “bridging
population”, addicts in physiologic
withdrawal, patients in recovery
via maintenance programs, and
patients in recovery with abstinence.
Active prescription drug addicts
are abusing daily to achieve their
desired psychological effects and to
prevent drug withdrawal. The active
addict’s day is characterized by
motives, feelings and behaviors that
include drug craving, a continued
compulsion to misuse, continued
misuse in spite of known negative
consequences such as self injury,
injury to others and loss of control
over their drug intake. Although
active addicts have their preferred
prescription drug, they often will
use whatever they can obtain in
the same drug class, licit or illicit.
The bridging population consists
of addicts abusing and misusing
prescription drugs that are not
routinely part of the addict’s daily
drugs of choice. Traditionally these
prescription medications are used in
opiate maintenance programs and
include methadone, buprenorphine
(Subutex®) or buprenorphinenaloxone (Suboxone®) combinations.
For the active addict, routinely
prescribed medical doses of these
agents do not produce the euphoria
or desired psychological effects seen
with the prescription drugs they
abuse daily. However, the use of
these medications may significantly
minimize the physiological and
psychological withdrawal symptoms
until they can obtain their drug of
choice. The prevention of physical
and psychological withdrawal is
termed “bridging” since these agents
are only intermittently used to get
the patient to their next “high” or
intoxicating event without significant
physiologic consequences.
Addicts experiencing physiologic
withdrawal from their addictive
medications often abuse other
prescription drugs to treat
the symptoms of withdrawal.
Antihypertensive medications such as
metoprolol (Lopressor and clonidine
(Catapress®) and antiemetics like
promethazine (Phenergan®) and
ondansetron (Zofran®) are often
self-prescribed to treat symptoms
of prescription drug withdrawal.
These drugs are also readily available
from various sources other than a
legitimate prescriber or pharmacy.
Recovery patients in opiate
maintenance programs consist of
individuals that are medically treated
with methadone, buprenophine
(Subutex®) or buprenorphine-
naloxone (Suboxone®) combinations.
These programs can allow patients
with opiate based drug addiction
to return to normal personal,
social and professional activities
without being impaired from opiate
drugs they used during active
addiction.13. The addict in recovery
is less likely to abuse these agents
since prescribing and dispensing
is strictly regulated and the agents
provide minimal if any effects that
are desired by the active addict.
The final group, the addict in
recovery with abstinence, maintains
their prescription drug sobriety
without the use of the previously
mentioned maintenance medications.
Therapy for the recovery
patients whether in maintenance
For a free brochure on our nationally recognized addiction
professionals alcohol and drug treatment program visit us
at: www.FarleyCenter.com/Journey or call 877-389-4968
programs or not, is optimized with
counseling and therapy addressing
underlying psychological issues
or psychiatric diseases including
the disease of addiction.
Conclusion
Understanding the cultures that
make up prescription drug abuse,
misuse, addiction, and diversion
allows important insight into the
recognition, detection, deterrence
and treatment of these individuals.
It is also important to recognize
that many individuals may be
part of multiple prescription drug
cultures. For example, a parent
may be part of the sharing culture
by giving their own prescription
drugs to a child for pain, anxiety,
The FarleyCenter
AT WILLIAMSBURG PLACE
allergies, etc. This same parent may
be personally abusing their own
pain medications and potentially
selling some of the prescription for
income to buy more drugs or pay
bills, thereby continuing the cultures
of sharing, substance abuse and
income generation. Intervention
and treatment of persons is likely to
involve family members, healthcare
professionals and law enforcement
agencies depending on severity of the
abuse and quantities of prescription
drugs involved. The long-term
outcome for these individuals varies
and is often unpredictable. With
further research and sharing of
information, the negative outcomes
associated with these prescription
drug cultures may be minimized.
References
Services Administration. (2009). Results
from the 2008 National Survey on Drug
Use and Health: National Findings (Office
of Applied Studies, NSDUH Series H-36,
HHS Publication No. SMA 09-4434).
Rockville, MD.
2. National Institute on Drug Abuse.
Monitoring the Future. National Results on
Adolescent Drug Use. Overview of Key
Findings 2008 (http://www.drugabuse.gov/
drugpages/MTF.HTML). Bethesda, MD:
NIDA, NIH, DHHS. May 2007.
InfoFacts: Prescription and Over-theCounter Medications (http://www.nida.nih.
gov/Infofacts/PainMed.html). Revised July
2009.
4. Hall Aron J., Logan JE, Toblin RL, Kaplan
JA, Kraner JC, Bixleret D et al. Patterns of
Abuse Among Unintentional
Pharmaceutical Overdose Fatalities
JAMA. 2008; 300(22):2613-2620.
5. Hall Aron J. Epidemiology of Fatal Drug
Overdoses in West Virginia. Presentation
to the West Virginia Partnership for
Community Well Being Epi-Workgroup
meeting. Dunbar, WV. Jan 2008. http://
www.prevnet.org/Funding%20Study/
PDF/2009-07-FS-CJ.pdf
6. Martin, Christopher S. Timing of Alcohol
and Other Drug Use. Alc. Res. Hlth. 2008
April;31(2):96-99
7. The Financial Burden of Substance in
West Virginia: The Criminal Justice
System, 2009, from http://www.oas.
samhsa.gov/2k6State/WestVirginia.htm.
8. Petersen EE, Rasmussen SA, Daniel KL,
Yazdy MM, Honein MA. Prescription
Medication Borrowing and Sharing
among Women of Reproductive Age. J
Womens Health. Sept. 2008;17(7):10731080.
9. Goldsworthy RC, Mayhorn CB.
Prescription medication sharing among
adolescents: prevalence, risks, and
outcomes. J Adolesc Health. 2009
Dec;45(6):634-7.
10. American Association of Poison Control
Centers. NPDS Annual Report 2000-2009.
www.aapcc.org/dnn/NPDSPoisonData/
AnnualReports. Cited March 15,2010.
11. The Harrison Narcotics Act (1914)Public
Law No. 223, 63rd Cong. December 17,
1914.
12. Banta C.Trading for a High. Time
magazine. 2005. July 24. www.time.com/
time/magazine/article/0,9171,1086173,00.
html
13. McGlothlin WH, Anglin MD, Long-term
Followup of Clients of High- and Low-Dose
Methadone Programs, Arch Gen
Psychiatry, 1981: 38(9):1055–1063.
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CME Post-Test
28.Which of the following BEST describes the
categories of prescription drug cultures?
a. Categories are based on intent
of prescription drug use
b. Categories are based on the source
of the prescription drugs
c. Categories are based on the
diagnosis of disease
d. Categories are based on criminal
abuse of prescription drugs
29.Which of the following may be part of the
income driven culture of a Pharmacy?
a. Counterfeiting
b. Shorting patient’s prescription medications
c. Failing to practice due diligence
when filling prescriptions
d. Inappropriately filling prescriptions for
brand name drugs with generics
e. All the above
30.Which of the following cultures has a false
since of security with prescription drugs
in adult and adolescent populations?
a. The sharing culture
b. The income driven culture
c. The substance abuse culture
d. The addiction culture
Approach to Pain Management in a Large Outpatient
Clinic Population
Brittain McJunkin, MD, FACP
Professor of Internal Medicine, West
Virginia University Health Sciences
Center, Charleston Division
Mary Ann Riley, DO
Assistant Professor of Internal Medicine,
West Virginia University Health Sciences Center,
Charleston Division
JK Lilly, MD, MS
Clinical Professor of Anesthesiology, West Virginia
University Health Sciences Center,
Charleston Division
Amy Casto, RN, MSN, FNP-BC
Charleston Area Medical Center Outpatient
Care Center
Adina Bowe, MD
Resident in Internal Medicine and Psychiatry ,
West Virginia University Health Sciences Center,
Charleston Division/Charleston Area Medical Center
prescribed medications, mainly
opioids.3 This trend does not appear
to be abating. The illicit drug trade
also results in disruption of families,
financial hardship, violence, and
sometimes homicide. Our internal
medicine outpatient teaching
program (West Virginia University
Health Sciences Center, Charleston
Division/Charleston Area Medical
Center) serves a relatively large
population, significantly indigent.
As it is our ethical obligation to
address pain issues, we have sought
Table 1. General Approaches to
Pain Management
General approaches to
chronic pain syndromes
While pain management is not
the intended primary focus of
outpatient clinics, about one-third
of the United States population
experiences chronic pain, and pain is
the most common reason for patient
visits.1 Providing compassionate
and effective control of persistent
pain while avoiding inappropriate
prescribing of controlled substances
remains a perplexing daily challenge,
particularly in our region. From
1999 to 2004, West Virginia had the
highest increase in unintentional
drug overdose mortality (550%)
in the United States,2 the majority
occurring with drug diversion of
•
•
•
•
•
Non-judgmental emotional
support
Evaluation for depression and
psychosocial issues
Physical interventions
(physical therapy/exercise,
etc.)
Pharmacologic therapy
- Acetaminophen/NSAIDs
- TCA/gabapentin/pregabalen
in neuropathic pain,
fibromyalgia, CPRS, etc.
- Local corticosteroid/lidocaine
injections, topical NSAID, etc.
- Tramadol
- Opiates
Consultations: pain clinic,
substance abuse programs,
psychiatry, surgery, etc.
a practical modification of known
guidelines and resources4-7 to provide
more effective opioid screening and
monitoring, taking into account
difficult time constraints and patient
complexity. We write this current
communication hoping to provide
some practical information, but
also to help us better organize
and evaluate our own program.
Chronic nonmalignant pain, usually
musculoskeletal or neuropathic, will
be addressed primarily. In general,
we attempt to use several combined
approaches to treat chronic pain,
initially without opioids, if possible,
Table 1. These approaches will be
briefly reviewed first, followed by
discussion of our efforts at opioid
screening and management.
Non-judgmental emotional
support: Cynicism often tends to
develop when caring for patients
with long-standing pain. With our
residents and students, emphasis is
placed on showing unbiased empathy
to establish a relationship that may
optimize care. Exhibiting respect,
including hand-shake and sitting face
to face with patients to obtain history,
appears to maximize “buying-in” to
the treatment plan. We attempt to
define expectations and limitations
of treatment, and emphasize that
effort will be required by both patient
and physician. Goals are to improve
quality of life and coping, not for cure
except in rare conditions that may
Objectives
Our main objective was to provide a relatively concise review of the daunting issues facing primary care physicians in regard to
management of chronic pain. We have presented approaches which may allow for improved opioid screening and adequate pain
control in the face of significant time constraints and patient complexity. We also have reviewed combined use of various modalities
and disciplines, as monotherapy is clearly insufficient in caring for patients with persistent pain.
be completely reversible. In patients
found to have substance abuse
problems or potential, we attempt to
maintain an even but firm approach
in regard to pain management.
Evaluation for depression and
psychosocial issues: Lifetime
prevalence of major depressive
disorder appears to range from 10
to 20% in the general population,8
and nearly half of patients with
major depressive disorders have
chronic pain.9 Further, in those with
unexplained chronic pain syndromes,
the prevalence of underlying mood
disorders may approach 80%.10
Since treating depression may
provide significant diminution of
pain in many patients, and because
depression alone may be a risk
factor for opioid abuse,11 nearly
all clinic patients with persistent
pain, are evaluated for underlying
depression using the PHQ-9
depression scale.12 We are presently
considering implementation of the
M-3 checklist,13 which may provide
additional screening for bipolar,
anxiety and post traumatic stress
disorders. If significant depression is
determined, we provide support, and
treat accordingly, commonly with a
serotonin reuptake inhibitor. Other
agents may be considered depending
on concomitant clinical presentation
such as fibromyalgia or neuropathic
pain (see below). Depending on
the severity of depression and/or
other psychiatric illness (e.g. bipolar
disorder, obsessive-compulsive
disorder), we co-manage with
psychiatry or refer for psychiatric
consultation and follow-up. Other
approaches may be considered
such as cognitive behavioral
therapy, depending on coverage
and availability. Social and spiritual
services are also employed to address
significant environmental issues.
Physical interventions: Most
chronic nonmalignant pain
syndromes are musculoskeletal
in origin and may be amenable
to physical therapy or other
approaches including exercise,
massage, stretching regimens, spinal
manipulation, and acupuncture.
Back pain syndromes are particularly
common, with a lifetime prevalence
of nearly 80%.14 Acute or subacute
back syndromes are usually selflimiting and managed conservatively,
with only brief bed rest, then
gradually increasing activity with
a goal of maintaining functionality
even if resolution is not complete.14,15
We avoid opioids early on depending
on presentation. Patients with
persistent pain over several weeks,
regardless of musculoskeletal
syndrome, are referred for physical
therapy. Emphasis is placed on
improved strength, increased
range of motion, improved
functionality, and self-management
skill development. Imaging, pain
management consultation, and/or
surgical intervention are considered
in patients with neurologic
deficits or intractable pain.
Pharmacologic therapy: A
combination of agents is usually
required to adequately manage
chronic pain syndromes. An initial
trial of acetaminophen and/or
NSAIDs is begun depending on the
cause of pain. If failure of response
with one NSAID, switching to a
different agent can be surprisingly
useful. In general, we avoid NSAIDs
in the elderly based on current
guidelines (see below).6 Tramadol (a
partial opioid agonist with serotonin
and norepinephrine reuptake
inhibition) may then be added to the
regimen in increasing doses, up to
400 milligrams daily (300 milligrams
in the elderly). Advantages include
relatively low abuse potential and
no narcotic schedule restrictions. In
those with chronic neuropathic pain,
low-dose tricyclic anti-depressants
(TCAs) used as “pain modulators”
appear to be effective, safe, and
inexpensive relative to other agents,
and their use is well supported by
guidelines.16 These medications
may be beneficial in other disorders
as well, including migraine,
fibromyalgia, and insomnia, and
may be prescribed to manage several
ongoing syndromes in an individual
patient. A recent study determined
that the combination of nortriptyline,
(mean tolerated dose 50.1 mg) and
gabapentin (mean tolerated dose
2180 mg) was more effective than
either agent alone.17 The combination
regimen is recommended if there
is an inadequate response using a
single medication. Nortriptyline
has the fewest TCA associated
anti-cholinergic adverse effects,
and may be prescribed in older
patients, albeit in lower doses.
Serotonin norepinephrine reuptake
inhibitors such as duloxitine and
venlafaxine are also useful for
neuropathic pain, although cost
issues may be problematic. Local
injection (methylprednisolone
and 1% lidocaine) of isolated
joint spaces, bursae, or trigger
points in conjunction with PT or
stretching, often provides at least
temporary relief over several
weeks and sometimes avoidance
of more potent systemic agents.
Topical NSAID (diclofenac) or
lidocaine can also be used in
localized musculoskeletal pain.
Other adjuvant agents, including
corticosteroids, bisphosphenates, and
short courses of muscle relaxants,
may be utilized in certain cases.
Rheumatology consultation is often
required for advanced DMARD
therapy, e.g. methotrexate and/or
anti-tumor necrosis factor antibody
in appropriate conditions.
If other approaches have
not provided adequate control
of symptoms, opioids are then
considered. As mentioned, these
agents are first line therapy only in
certain circumstances. A consistent
screening process is employed prior
to opioid prescribing, to be discussed
below. We initially prescribe short
acting agents such as hydrocodone
in low doses and titrate dosage
depending on response over several
weeks. Explained goals are improved
quality of life and increased
functionality, not complete resolution
of pain. We may eventually
consider long-acting agents for
intractable pain, with short-acting
medications taken as needed for
“break-through.” High doses of
opioids are avoided in general,
and dosage titration of long acting
agents must be monitored carefully
to avoid potentially fatal toxicity,
particularly in the aging patient.18
Assessing appropriate
candidates for long-term
opioid therapy
Treatment of certain acute pain
syndromes with short term doses of
opioids is appropriate and humane.
An extremely common dilemma
arises when patients present to the
clinic complaining of subacute or
persistent severe pain, requesting
medication for relief. Depending on
the age and sex of the patient, risk
may vary in regard to substance
abuse potential. Young males are at
greatest risk for substance abuse and
drug diversion, particularly if they
are unemployed, under educated,
single or divorced.3 Additional risk
factors include smoking, alcohol
or illicit drug use history, pain at
multiple sites and long-term pain
after motor vehicle accidents.19 Not
uncommonly, these patients present
to the medical clinic with persistent
complaints, having been prescribed
opioids for acute or recurrent
symptoms in the emergency room.
Middle-aged females who have seen
many doctors for their symptoms
(“doctor shoppers”) also have
significant substance abuse potential,
especially with a history of sexual
abuse or familial alcoholism.
In the past year, using
modifications based on existing
guidelines,4-7 we have developed a
practice policy in regard to opioid
prescribing, Table 2. This policy is
posted in the clinic nursing stations.
Individual items will be discussed:
Documentation: Prior to initiation
of opioids, optimum documentation
of disease entity or disorder is
essential. Imaging studies or prior
consultations from specialists
(e.g. orthopedics, neurology, and
pain management) are the usual
form of documentation. Clearly,
some patients have disorders
which are diagnosed clinically,
such as fibromyalgia or complex
regional pain syndrome (CRPS),
and require clinical judgment in
regard to prescribing of opioid
agents, usually after other
approaches have been exhausted.
Urine drug screen: Integral to
compliance monitoring, the patient
must initiate an Opioid Access
Agreement and Consent to Treatment
document which permits sampling of
body fluid for prescribed controlled
medication and high risk substances
(including amphetamine-type
stimulants, cocaine, and marijuana).
CMS has just introduced new codes
for Drug Screening/ Detection
Test. As of January 2010, G0430
replaced 80100 for qualitative
multiple drug screen test kits.
Initial urine drug screen (UDS) is
required in all patients considered for
controlled substances. If a controlled
substance not listed on the patient’s
documented medication list, and/or
an illicit substance is detected, the
specimen is submitted for highly
accurate confirmation testing using
Mayo Clinic chromatography
or spectrophotometric testing.20
Generally, either circumstance
excludes a patient from controlled
substance prescribing through our
clinic, though each case is reviewed
individually. Discrepancy on initial
UDS may be a cue for referral
to a pain or addiction specialist.
Table 2. Controlled Substances Prescribing Policy
Except in rare situations, opioid agents will not be prescribed on initial patient
visit with complaint of chronic or persistent pain. The following information will
be required before completion of a controlled substances contract:
• Documentation of disease entity
• Initial and random urine drug screening (UDS)
• West Virginia Board of Pharmacy review
• Substance abuse survey
Table 3. Substance Abuse Survey
CAGE-AID
In the past, have you ever:
1)Tried to cut down or change your pattern of alcohol or drug use?
2)Been annoyed or angry by others’ concerns about your alcohol or drug
use?
3)Felt guilty about the consequences of your drinking or drug use?
4)Had a drink or used a drug in the morning (“eye opener”) to decrease a
hangover or withdrawal symptoms?
TICS
1)In the last year, have you ever drunk alcohol or used drugs more than you
meant to?
2)Have you ever felt you wanted or needed to cut down on your drinking or
drug use in the last year?
RAFFT
1)Do you drink/drug to relax, feel better about yourself, or fit in?
2)Do you ever drink/drug while you are by yourself (alone)?
3)Do you or your closest friends drink/drug?
4)Does a close family member have problems with alcohol/drugs?
5)Have you ever gotten into trouble from drinking/drugging?
Interpretations of tests: In Webster L. Avoiding opiate abuse while managing pain. North Branch,
MN. Sunrise River Press. 2007.Chapter 5. Book located at all clinic stations.
In addition to initial screening,
we perform random UDS on
all patients who are prescribed
controlled substances. Absence of
the prescribed controlled medication
on a random sample may indicate
diversion and results in closer
scrutiny. More than one discrepancy
generally results in termination of
controlled substance prescribing.
Pill counts also are periodically
used to provide additional
assessment for drug diversion.
Because there are many nuances
to urine drug screening,20 and to
provide continuity, every urine
drug screen is reviewed by our
Nurse Practitioner. Results may
require interpretation of various
drug metabolites and reports
regarding diluents or adulterants
(such as vinegar or bleach) used
to mask detection. Based on the
results, recommendations are
made to the patient’s primary
physician in the clinic. Collaboration
and communication between all
entities involved including the
physician, nurse practitioner,
clinic staff, patient, and laboratory
personnel are required in order
to interpret results accurately.
Board of pharmacy review: The
controlled substance monitoring
program, the West Virginia Board
of Pharmacy, is utilized as another
means to initially vet patients for
opioid use, and to assess compliance
with controlled substances
prescribing. This database provides a
record of prescribers and pharmacies
where prescriptions are filled.
Limitations include no interstate
data sharing (national data-base)
or real-time capabilities at present.
Nonetheless, documentation of
multiple opioid prescribers and/or
pharmacies strongly indicates “doctor
shopping” and would preclude
initial or continued opioid therapy.
Substance abuse survey:
Numerous risk assessment tools
are available which vary in
sensitivity, specificity, and time
of administration. The purpose
to these tools is to predict which
patients will require the most intense
monitoring, or detect patients who
represent too great a risk for opioid
administration in the primary care
setting. The latter should be referred
to a pain care and/or addiction
specialist, if available. Our current
confidential screening format has
included three well known risk
assessment tools, i.e. CAGE-AID
(modified for drugs and alcohol),
TICS, and RAFFT,21-23 which may be
self-administered and completed
in a short time period, Table 3. The
use of these surveys, along with
routine screening for depression,
should provide a relatively high
sensitivity for substance and opioid
abuse concerns. We are currently
considering routine use of other
screening tools, the Screening and
Opioid Assessment for Patients
with Pain (SOAPP)24 and the Opioid
Risk Tool,25 Table 4, which include
questions regarding age, smoking,
marijuana use, loss of medications,
psychosocial history, sexual abuse
history, and arrests. Although more
time consuming, these tools may
enhance prediction of medication
abuse, drug diversion, and doctor
shopping. Skepticism may be raised
as to the validity of patient responses,
but we emphasize providing
accurate answers, as responses will
be “verified” whenever possible.
Regardless, the survey provides an
additional indication to patients
that our program will be strictly
monitored and enforced.
Proceeding with opioid treatment
Controlled substances contract:
If the guidelines criteria reveal
low likelihood of substance abuse
potential and the documented pain
syndrome is deemed severe enough
and only partially responsive to other
measures, opioids are considered
and a standard controlled substances
Table 4. Opioid Risk Tool
contract (agreement) is reviewed
with the patient. Goals, risks, and
responsibilities are explained in a
non-threatening fashion, emphasizing
that all patients must comply with the
document. Grounds for termination
of opioid therapy are explained. Main
points are briefly mentioned here.
Patients are required to choose one
pharmacy and only one physician to
prescribe their therapy, and emphasis
is made on locking up medications to
avoid diversion by family members
or others. Prescriptions are not
re-filled for lost medications. Two
missed consecutive appointments
will not be acceptable. After thorough
explanation of the contract, and
if the patient is in agreement, the
contract is signed, placed in the
chart, and a copy is given to the
patient. Any violation of the contract
results in a review and consideration
of termination of opioid or other
controlled substances therapy. If
the agreement is dissolved, we
avoid a judgmental approach,
taper and discontinue the opioid,
and offer continued management
of other medical problems.
Concern remains that patients with
documented severe pain syndromes
and ongoing or potential substance
abuse will not be adequately
managed. In difficult cases, we
commonly seek consultation from a
pain clinic specialist and/or addiction
specialist, though limited numbers of
these specialists and payment issues
affect availability. We often are left
to use best judgment and intuition.
For example, in a patient with
well documented severe complex
regional pain syndrome but known
history of substance abuse, we may
opt to place him/her on controlled
substance contract with extremely
close follow-up, including frequent
clinic appointments , frequent urine
drug screens, board of pharmacy
review, and immediate termination if
there is any question of discrepancy.
Careful documentation of disease
entity/substance abuse issues and
justification for plans are essential.
Monitoring: Because we follow
a large number of patients with
complex medical histories, we seek a
means of providing brief but effective
and consistent monitoring of patients
on opioids and other controlled
substances. In addition to employing
random UDS and periodic board of
pharmacy review, we also commonly
utilize an easily remembered and
implemented tool, “The Four A’s,”26
when performing follow-up history:
Analgesia (effectiveness of pain
control), Activity level (physical
and psychological), Adverse events
(adverse effects of controlled
medication), and Aberrant drug
taking (evidence of addictive/abuse
behavior). Indicators of drug seeking
behavior are posted in the clinic
Table 5. Drug Seeking Behavior
• Multiple visits for same complaint
•Unable to focus on anything
other than the medicine
• Lost prescriptions
• Doctor unavailable
•Allergic to new narcotic
alternatives
• Desires narcotics
•Common conditions that cannot
be measured
a. Headache
b. Urethral colic
c. Toothache
d. Abdominal pain
• “Unbearable” pain
• Wearing-you-down approach
• Overly creative requests
• Appearance change or alias
judicious use of opioids if failure
of response to acetaminophen.
NSAIDs should be “considered
rarely, and with extreme caution” in
older patients because of potential
for significant adverse effects,
including fluid retention, renal
toxicity and gastrointestinal bleeding.
Appropriate opioid use in the elderly
is believed to improve quality of life
and functional capacity. It is critical
to assess competency of patient or
caregiver and observe for adverse
opioid effects, particularly sedation
and constipation. As previously
emphasized, diligent, limited dosage
titration, particularly of long-acting
agents, generally minimizes concern
for overdose.18 Gastrointestinal
symptoms are usually obviated
by concomitant initiation and
continued use of a laxative agent
(e.g. senna one to two daily plus
a stool softener) with opioid.
Summary
nursing stations,27 Table 5. Problems
noted in any of the “Four A’s” should
prompt re-evaluation of relevant
aspects of the treatment program.
Approach to the elderly
patient with chronic pain
The elderly with chronic pain
appear to be a separate patient
population and should be managed
as such. First, documentation of
severe painful conditions, e.g.
markedly deforming arthritis,
is relatively straightforward
as compared to many younger
patients. Second, the potential
for substance abuse/addiction
behavior is significantly less
than is often seen in the younger
population. Therefore, we have a
lower threshold for using opioids
in the elderly, and we may forego
intensive substance abuse screening
in given patients. According to
2009 American Geriatrics Society
Guidelines,6 the first line analgesia
for chronic pain in the elderly should
be acetaminophen, followed by
Though it is our ethical imperative
to minimize discomfort, physicians
often struggle to manage pain
effectively, mainly due to time
constraints, lack of training, and
fear of litigation regarding overprescribing of controlled substances.
In addition, physicians also now must
face potential litigation for under
treatment of persistent pain. This
dilemma often leaves the physician
with a sense of insecurity and stress.
We have provided a brief review of
our approach to seek improvement
in excluding substance abusers/
drug diverters from those in need of
aggressive pain management in the
internal medicine outpatient clinics
of a teaching institution. Multiple
combined treatment modalities
are usually employed, including
physical interventions, evaluation
and treatment of concomitant
depression and psychosocial issues,
pain modulators and analgesics,
and consultations as indicated by
clinical presentation. Experience
and intuition are required in many
cases. In our large volume, high
complexity clinic setting, we continue
to pursue guidelines to improve and
streamline screening for substance
abuse or the potential for abuse,
particularly in younger individuals.
In the elderly, since abuse potential is
less likely and disease documentation
is often more readily apparent,
we feel relatively comfortable
in initiating careful prescribing
of opioid therapy early on.
As we become more adept
at our approach toward pain
management issues, we will attempt
some assessment of outcomes
by observing changes in several
parameters, including numbers of
opioid prescriptions and comparative
adequacy of pain control over time.
National and local pain/addiction
information and referral resources
are available as follows: http://
www.nationalsubstanceabuseindex
.org and http://www.wvupc.
org/charleston/painlist
References
1. Hardt J, Jacobsen C, Goldberg J, et al.
Prevalence of chronic pain in a
representative sample in the United States.
Pain Med. 2008;9:803-812.
Prevention: Unintentional poisoning deaths
– United States, 1999-2004. MMWR Morb
Mort Weekly Rep. 2007;56:93-96.
3. Hall AJ, Logan JE, Toblin RL, et al.
Patterns of abuse among unintentional
overdose fatalities. JAMA 2008;300:26132620.
4. Chou R, Fanciullo J, Fine P, et al. Opioid
treatment guidelines: Clinical guidelines for
the use of chronic opioid therapy in chronic
noncancer pain. J Pain. 2009;10:113-130.
5. Webster L. Avoiding substance abuse
while managing pain. North Branch MN.
Sunrise River Press, 2007.
6. Pharmacological management of
persistent pain in older persons. American
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pharmacological management of persistent
pain in older persons. J Am Geriatr Soc
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7. Gourlay DL, Heit, MD, Ahlmahrezi A.
Universal precautions in pain medicine: a
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8. Williams DR, Gonzalez HM, Neighbors H,
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Caribbean blacks, and non-Hispanic
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American Life. Arch Gen Psychiatry.
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9. Ahayon MM. Specific characteristics of the
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10. Aquera L, Failde J, Cervilla JA, et al.
Medically unexplained pain complaints are
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11. Paulozzi LJ, Ryan GW. Opioid analgesics
and rates of fatal overdose drug poisoning
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2006;31:506-511.
12. Lowe B, 8Unutzer J, Callahan CM, et al.
Monitoring depression treatment outcomes
with the patient questionnaire-9. Med Care.
2004;42:1194-201.
13. Gaynes BN, Deveaugh-Geiss J, Weir S, et
al. Feasibility and diagnostic validity of the
M-3 checklist: self rated screen for
depressive, bipolar, anxiety and posttraumatic stress disorders in primary care.
Ann Fam Med. 2010;8:160-169.
14. Wilson JF. In the clinic – low back pain.
Ann Intern Med. 2008 ITC5 1-16.
15. Chou R, Qaseem A, Snow V, et al.
Diagnosis and treatment of low back pain:
A joint clinical practice quideline from the
American College of Physicians and the
American Pain Society. Ann Intern Med.
2007;147:478-491.
16. O’Conner AB, Dworkin RH. Treatment of
neuropathic pain: An overview of recent
guidelines. Am J Med. 2009;122:S22-S32.
17. Gilron I, Bailey JM, et al. Nortriptyline and
gabapentin, alone or in combination for
neuropathic pain: a double-blind,
randomized, placebo controlled crossover
trial. Lancet. 2009;374:1252-1261.
18. Dunn KM, Saunders KW. Opioid
prescriptions for chronic pain and
overdose: A cohort study. Ann Intern Med.
2010;152:85-92.
19. Manchikanti L, Cash KA, Damron KS, et al.
Controlled substance abuse and illicit drug
use in chronic pain patients. An evaluation
of multiple variables. Pain Physician. 2006;
9:215-225.
20. 2008 Drug Testing: An overview of Mayo
Clinic Tests Designed for Detecting Drug
Abuse. www.Mayo Medical Laboratories.
com.
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21. Brown RL, Rounds LA. Conjoint screening
for alcohol and other drug abuse: criterion
validity in a primary care practice. Wis Med
J. 1995;94:135-140.
22. Brown RL, Leonard T, Saunders LA,
Papasouliotis O. A two item conjoint screen
for alcohol and other drug problems. Am J
Fam Pract. 2001;14:95-106.
23. Bastiaens L, Riccardi K, Sakhrani D. The
RAFFT as a screening tool for adult
substance use disorders. Am J Drug
Alcohol Abuse. 2002;28:681-691.
24. Butler SF, Budman SH, Fernandez K,
Jacobson RN. Validation of a screener and
opioid assessment measure for patients
with chronic pain. Pain. 2004;112:65-75.
25. Webster LR, Webster RM. Predicting
aberrant behaviors in opioid treated
patients: preliminary validation of the
Opioid Risk Tool. Pain Med. 2005;6:432442.
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27. Vukimir RB. Drug seeking behavior. Am J
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CME Post-Test
a. Kentucky
33.If pain control is inadequate with acetaminophen
in the elderly patient, which category of
medications should be considered next?
b. West Virginia
a. NSAIDs
c. Louisiana
b. Opioids
c. Anticonvulsants
31.Which state has experienced the nation’s
largest increase in drug overdose mortality?
32.Which class of medications may be useful
as an adjunct in treating several forms
of chronic pain, including neuropathic
pain, fibromyalgia, and migraine?
a. Opioids
b. Corticosteroids
c. Tricyclic antidepressants
Continuing Medical Education
Opportunities at CAMC Health Education
and Research Institute
The CAMC Health Education and Research Institute is dedicated to improving health through
research, education and community health development. The Institute’s Education Division
offers live conferences, seminars, workshops, teleconferences and on-site programs to health
care professionals. The CAMC Institute’s CME program is accredited by the Accreditation
Council for Continuing Medical Education to sponsor continuing medical education for
physicians. The CAMC Institute designates this educational activity for a maximum of 1 AMA
PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the
extent of their participation in the activity. For more information on these and future programs
provided by the Institute, please call (304) 388-9960 or fax (304) 388-9966.
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©Charleston Area Medical Center Health System, Inc. 2010
22112-F10
Cocaine Abuse Among Patients: A Study at the
Charleston Area Medical Center
Molly John, MD
Assistant Professor, Department of Internal Medicine,
RCBHSC, WVU, Charleston Division
Rachael Trout, MA EdL
Administrator, Department of Medicine, RCBHSC, WVU,
Charleston Division
Bobbi Nicholson, PhD
Professor, Marshall University Graduate School of
Education and Professional Development
Michael Cunningham, EdD
Professor, Marshall University Graduate School of
Education and Professional Development
Carli Williams, MSII
West Virginia University School of Medicine
Elaine Davis, RN, EdD
CAMC Health Education and Research Institute,
Outcomes
Abstract
Cocaine, an addictive central nervous
system stimulant that can be inhaled,
intravenously injected or smoked, is the
second most commonly abused illicit drug
in the United States. Its use is associated
with numerous medical problems, as well
as psychiatric disorders.1 This study 1)
describes the clinical and demographic
features of adult patients presenting with
positive cocaine screens at Charleston
Area Medical Center (CAMC) Emergency
Room in 2006; 2) reports the percentage
of those patients who volunteered their
drug- use information; 3) reports the
percentage of trauma patients who tested
positive for cocaine use; 4) identifies other
illicit drugs patients use with cocaine; and,
how often these patients have psychiatric
diagnoses.
Findings: In this study, the mean age
of users was 35 years with a range of 1857 years, many of whom had multiple
visits to the hospital in the same year.
Among the patients in this study, 24% had
a history of depression and 15% had a
history of bipolar disorder. Of the patients
that tested positive for cocaine use, only
42% volunteered their drug-use history.
The majority were found to have
concurrent illicit drug use. The most
common reasons for patients in this study
to seek medical treatment were psychiatric
and drug problems as opposed to medical
reasons.
Introduction
According to the 2006 National
Survey on Drug Use and Health,
approximately 35 million Americans
over the age of 12 have tried cocaine
in their lifetimes.3 Patients present
to hospitals with various complaints
that are associated with drug
use and, according to one study,
cocaine causes the highest number
of emergency department visits
among users of illicit drugs.8 Since
approximately one-third of users do
not volunteer information concerning
their drug habits, unnecessary
resources are expended in diagnosis.18
The most widely used diagnostic
method for detection of cocaine use
is a urine drug screen (UDS), which
returns very few false positive tests
for cocaine.10 Urine drug screens
can detect cocaine metabolites for as
long as 24-48 hours after use, and in
chronic users for up to 22 days.9,10
Throughout the United States,
cocaine is the second most commonly
abused illicit drug, and the typical
national age range for users is 1825 years old.5, 8 In West Virginia,
however, cocaine is the fourth
most commonly abused drug
(9.9%), behind alcohol, opiates, and
marijuana according to the Treatment
Episode Data Series report of 2006.
17
The typical age of West Virginia
users ranges from 21-45 years old,
depending upon the route of use.17
The purposes of this study are 1) to
describe the clinical and demographic
features of patients presenting with
positive cocaine screens at Charleston
Area Medical Center (CAMC)
Emergency Room in 2006; 2) to
report what percentage of patients
volunteer their drug use information;
3) to establish what percentage of
trauma patients tested positive for
cocaine; 4) to reveal what other illicit
drugs patients use with cocaine;
and 5) to find out how often these
patients have psychiatric diagnoses.
Methods/Data Analysis
This is a non-experimental,
descriptive, retrospective study of
positive cocaine drug screens in the
year 2006. Descriptive statistical
analyses were used to determine
frequencies, percentages, and means.
The population for this study were
adults who presented to the ER with
a positive cocaine screen at CAMC
in 2006. Patients under 18 years old
were excluded as were those patients
Objectives
The initiation of this study of cocaine positive UDS at Charleston Area Medical Center’s Emergency Room had several objectives.
The first objective was to determine if the patients presenting to the Emergency Room with positive UDS were seeking treatment
for medical related issues or drug related issues. The second objective was to determine if patients volunteer their illicit drug use
information. Illicit drug use causes numerous medical problems and can complicate treatment; this knowledge is valuable to the
treating practitioner. Failure to disclose the information can delay or complicate treatment for medical related issues. The third
objective was to determine if cocaine positive UDS is more prevalent in patients seeking treatment for trauma.
Table 2
whose charts lacked adequate clinical
information. There were a reported
1,152 positive urine drug screens
for cocaine at CAMC ER in 2006.
In total, a randomized 628 charts
were reviewed with 429 meeting the
criteria (n=429). Patients’ electronic
medical records were reviewed.
Table 2. Psychiatric
Diagnosis
Psychiatric Diagnosis
Findings
psychiatric disorder. Specifically
22% had depression, and 15%
had bipolar disorder (Table 2).
The mean age of patients
presenting with cocaine-positive drug
screens in this study was 35 years
with a range of 18-57 years, with 61%
being male and 39% being female.
About 21% of patients complained
of drug-related problems, including
drug abuse and overdose. The most
common discharge diagnoses in
2006 were psychiatric conditions
and drug-related problems (drug
abuse and drug overdose), at
30% and 62%, respectively.
Of patients presenting with
cocaine-positive drug screens, 42%
volunteered their histories of drug
abuse. Of the total sample reviewed,
12% involved a trauma priority
patient. Furthermore, of the trauma
population reviewed, the cocainepositive sample involved three times
as many males as females. For the
total sample, the most common
concurrently abused drug was THC
(41%), followed by benzodiazepines
(30%) and opiates (28%) (Table 1).
Of the total sample reviewed (429)
42 patients (10%) presented to the
ER in the year prior (2005) with
positive UDS. Similarly, of the total
sample (429) 59 patients (14%) had
returned to the ER in the following
year (2007) with positive UDS.
Of the population reviewed,
40% had some sort of concurrent
Table 1
Table 1. Concurrent
Drugs
Concurrent Drugs
THC
206*
Benzo
150*
Opiates
138*
ETOH
102*
Amine
33*
*Several patients were using multiple
drugs at the same time.
Depression
Bipolar Disorder
Anxiety
Schizophrenia
Unknown
Other
Borderline Personality
41%
28%
18%
8%
2%
2%
1%
Discussion
Cocaine, extracted from the
Erythroxylum coca plant, is a
Schedule II drug because of its
high potential for abuse. It can,
however, be used medically as
a local anesthetic.2 Cocaine is a
white powder that can be inhaled
or intravenously injected, while its
derivative, crack, is a rock crystal that
can be heated and smoked. Users feel
the euphoric effects within minutes of
intake, followed by a dysphoric crash.
Various street names for
cocaine include “blow,” “snow,”
and” nose candy.”17
Kedia et al (2007) found 78%
of cocaine abusers were involved
in polydrug abuse situations,
defined as concurrent or sequential
abuse of more than one drug with
dependence on at least one. 4 The
drugs most frequently abused with
cocaine are alcohol and marijuana.5
National Institute on Drug Abuse
researchers have found that
cocaine and alcohol combine in
the liver to produce cocaethylene,
a compound that intensifies the
euphoria while simultaneously
increasing the severity of danger.11
Drug abuse is known to fluctuate
over time as abusers recover and
relapse repeatedly. Additionally,
the estimated level of lifetime
dependence on cocaine is 2-3%.15
The morbidity and mortality rates
of cocaine users are attributable to
its cardiovascular effects, overdose
potential, suicides and AIDS.8 In the
United States, overdose accounts
for 22% of the deaths related to
cocaine use.12 Cardiovascular
diseases caused by cocaine include
myocardial infarctions (MI), angina,
atherosclerosis, myocarditis,
cardiomyopathy, arrhythmias,
hypertension, aortic dissection,
and endocarditis, etc.8 The most
common complaint patients present
with is chest pain, which is 40% of
emergency department (ER) visits.9
According to recent studies, up to
6% of chest pain is due to MI,9 while
approximately 18% is non-cardiac
chest pain.13 Cocaine-induced MI has
the highest level of incidence within
the first hour after intake, but can
occur up to four days after use.4, 13
A study by McCord et al (2008)
found that approximately 66% of
cocaine-induced MIs occur within
three hours of intake,8 attributable to
several factors. First, cocaine inhibits
the reuptake of catecholamines
(specifically dopamine), causing
hypertension and tachycardia.12
Next, cocaine causes coronary
artery spasm and platelet activation,
causing the vascular occlusion
and myocardial infarction.7, 12
Additionally, cocaine has been
found to cause rhabdomyolysis,
intracranial hemorrhage, stroke,
and seizure among other medical
problems. Another study found
that 20% of intracranial hemorrhage
cases in patients aged 18-49 were
related to drug abuse because
of sudden vasospasm.7
The comorbidity of drug abuse
and psychiatric disorders is regularly
seen in the literature. Havassy
and Arns (1998), for example,
found schizophrenia to be the most
common psychiatric diagnosis to
accompany drug abuse, followed by
bipolar disorder and depression.4
A later study reported that up to
72% of patients with a drug use
disorder had at least one concurring
psychiatric disorder; additionally, for
cocaine abuse specifically, 20-30% of
patients have bipolar disorder.1 Drug
abuse has been found to increase the
rate of suicide by as much as five
Table 3
Table 3. Reason for Encounter
Reason in
for2006.
Encounter in 2006
Other (psychiatric disorders, drug abuse,
272
aches and pains, GI and GYN complaints)
Decreased level of consciousness
67
Chest Pain
61
Seizure
14
Cardiac arrhythmia
10
Intracranial bleed
3
Rhabdomyolysis
1
Stroke
1
Hypertension
None
times,16 with 39% of suicide victims
testing positive for cocaine.14
The mean age of the patients
in our sample (35) was within the
range for the national average
(18-45)5; we did, however, note
the mode age seen at CAMC was
48 years old. The number of male
users in this study was slightly
higher than that of female users,
a figure for which a comparative
number is difficult to find as sex
differences vary in most studies.
Most, however, report more male
than female users, and our data are
consistent with that reporting. 6, 9, 18
Weber et al (2003) found in their
study that 18% of cocaine users did
not report their cocaine use. 18 In
our sample, however, nearly 58%
withheld that information. Many of
our patients also tested positive for
other drugs such as THC, opiates,
and benzodiazepines, with the
number one concurrent drug being
THC, consistent with a finding by
Kedia et al (2007).4 There were also
a number of polydrug abusers,
with at least nine patients showing
cocaine, THC, benzodiazepines,
opiates, and amines in their UDS;
however, UDS do not take into
account the prescription drugs that
patients use for various medical
and psychiatric illnesses.
The most common psychiatric
diagnoses in this study were
depression and bipolar disorder,
and most patients in the sample
visited the ER for drug-related
or psychiatric problems. Many of
these patients made repeat visits
over 2005-2007 period, consistent
with Havassy and Arns’(1998)
study showing that patients with
substance abuse disorders and
psychiatric disorders have higher
rates of rehospitalization.4
Very few of the patients in this
sample presented with medical
problems (see table 3). Only 14%
Charleston WV
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304-485-6584
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of this study’s cocaine-positive
patients, in fact, presented with
chest pain, a figure far below the
40% cited by McCord et al (2008).8
The retrospective nature of this
study constitutes a limiting factor
because analysis was confined
to the information found in the
charts. Moreover, those data were,
in part, self-reported by patients.
Another limiting factor was that
not all patients underwent a UDS,
so it is possible the study is not
representative of the true number
of cocaine abusers who were seen.
Conclusion
Based on the findings that 12% of
the total population were trauma,
further reviews would need to be
performed to determine if there is a
correlation between specific trauma
events and cocaine positive UDS.
As noted previously, Weber et
al (2003) found that 18% of their
patients did not report drug abuse
while nearly 58% of the study
population did not report. Based on
these findings further investigation
is warranted to determine possible
reasons behind the failure of the
population to volunteer illicit
drug abuse information. Possible
conclusions could be the rather
“closed” Appalachian culture, fear of
law enforcement notification, and/or
ignorance to the need to provide
such information. Additionally,
the question presents if standard
ER protocol should include a UDS
for anyone who presents to the ER
regardless of chief complaint.
Kedia et al (2007) reported that
patients with substance abuse
disorders and psychiatric disorders
have higher rates of re-hospitalization
than the general population4. Given
the fact the majority of the population
in this study presented with drug
related and/or psychiatric issues as
opposed to medically related issues,
it is appropriate to conclude there
is a documented need for ample
mental health resources in the ER.
To the best of the researchers’
knowledge this is the first study
from West Virginia which reviewed
a pattern of cocaine use in the ER
setting. Despite the limitations of
this study, the data strongly suggest
there be further investigation into the
utilization of UDS in the ER as well
as a review of resources available
to treat both illicit drug abuse and
associated mental health disorders.
References
1. Brady KT. Comorbidity With Substance
Abuse. Available at http://www.medscape.
com/viewarticle/457178. Accessed
September 6, 2007.
2. Dattilo PB, Hailpern SM, Fearon K, Sohal
D, and Nordin C. B-Blockers are
Associated with Reduced Risk of
Myocardial Infarction After Cocaine Use.
Annals of Emergency Medicine 2008;
51:117-125.
3. Drug Enforcement Administration.
Stimulants. Available from http://www.
usdoj.gov/dea/pubs/abuse/5-stim.htm.
Accessed July 10, 2008.
4. Kedia S, Sell MA, and Relyea G. Monoversus polydrug abuse patterns among
publicly funded clients. Substance Abuse
Treatment, Prevention, and Policy 2007.
5. Kerr M. Intracranial Hemorrhage in Young
Adults Linked to Drug Abuse. Available at
http://www.medscape.com/
viewarticle/523964. Accessed September
6, 2007.
6. Kloner RA and Rezkalla SH. Cocaine and
the Heart. The New England Journal of
Medicine 2003;348:487-488.
7. Lange RA and Hillis LD. Cardiovascular
complications of cocaine use. N Engl J
Med. 2001;345:351-358.
8. McCord J, Jneid H, Hollander JE, de
Lemos JA, Cercek B, Hsue P, Gibler WB,
Ohman EM, Drew B, Philippides G, and
Newby LK. Management of CocaineAssociated Chest Pain and Myocardial
Infarction. A Scientific Statement From the
American Heart Association Acute Cardiac
Care Committee of the Council on Clinical
Cardiology. Circulation 2008;117.
9. Moeller KE, Lee KC, and Kissack JC.
Urine Drug Screening: Practical Guide for
Clinicians. Mayo Clinic Proceedings
2008;83:66-76.
10. Office of National Drug Control Policy.
Cocaine Facts and Figures. Available at
http://www.whitehousedrugpolicy.gov/
drugfact/cocaine/cocaine_FF.html.
Accessed July 10, 2008.
11. Pavarin, RM. Cocaine consumption and
death risk: a follow-up study on 347 cocaine
addicts in the metropolitan area of Bologna.
Ann Ist Super Sanita 2008;44:91-98.
12. Rezkalla SH and Kloner RA. CocaineInduced Acute Myocaridal Infarction.
Clinical Medicine & Research
2007;5:172-176.
13. Roy, A. Characteristics of CocaineDependent Patients Who Attempt Suicide.
American Journal of Psychiatry
2001;158:1215-1219.
14. Schuckit, MA. Drug Abuse and
Dependence: Epidemiology. (2006)
Available at http://www.medscape.com/
viewarticle/534454. Accessed September
6, 2007.
15. Schuckit, MA. Drug Abuse and
Dependence: Usual Clinical Course.
(2006) Available at http://www.medscape.
com/viewarticle/534457. Accessed
September 6, 2007
Services Administration, Office of Applied
Studies. Drug Abuse Warning Network,
2005: National Estimates of Drug-Related
Emergency Department Visits. DAWN
Series D-29, DHHS Publication No. (SMA)
07-4256, Rockville, MD, 2007.
Services Administration, Office of Applied
Studies. Treatment Episode Data Set
(TEDS) Highlights—2006 National
Admissions to Substance Abuse Treatment
Services. OAS Series #S-40, DHHS
Publication No. (SMA) 08-4313, Rockville,
MD, 2007.
18. Weber, JE, Shofer, FS, Larkin, GL, Kalaria,
AS, and Hollander, JE. Validation of a Brief
Observation Period for Patients with
Cocaine-Associated Chest Pain. The New
England Journal of Medicine.
2003;348:510-517.
CME Post-Test
34.Cocaine use is a serious problem?
True or False
35.Patients presenting to the ER with cocaine positive UDS, are seeking medical care?
True or False
36.Fifty-eight percent of the ER population volunteered their illicit drug use information?
True or False
Special Issue Commentary
Opiate Addiction and Prescription Drug Abuse:
A Pragmatic Approach
by Khalid M. Hasan, MD and
Omar K. Hasan, MD
D
uring this second decade of
the 21st century, the United
States is in the midst of a
major public health problem. At near
epidemic proportions, the abuse of
prescription drugs and especially
opiates significantly contributes
to escalating care costs, increasing
patient hospitalizations, and growing
numbers of untimely deaths.
Although tobacco, alcohol,
and marijuana traditionally have
represented the drugs of choice
for adolescents, recreational use of
pharmaceuticals has the potential to
become as prevalent. This is due to
prescription medications’ relative
low cost, ready availability, and
accepted medical usage. In addition,
the problem is exasperated by a
small percentage of unscrupulous
providers who for financial gain
play a major role in this epidemic.
Some may question the usage of
the term epidemic; however, statistics
bear the appropriateness of this
appellation. Approximately 14%
of American adults are estimated
to be using pain medications for
nonmedical purposes, and the
recreational usage of opioids has
steadily risen during the past decade.
From 2002 to 2006, the percentage of
young adults aged 18 to 25 abusing
prescription opioids increased
from 4.1% to 4.6%. These figures
suggest that approximately 1.5
million young adults are regularly
abusing these medications.
Additionally, opioid-related
emergency room visits increased
126% from 2004 to 2008. Treatment
admissions for non-heroin opioid
abuse and dependence are also
on the rise. From 1996 to 2006, the
numbers of these treatments nearly
quadrupled nationally from 16,605
to 74,750. In West Virginia, this
trend especially has been severe.
During the same ten-year period,
non-heroin opioid treatments soared
in the Mountain State from two
treatments per every 100 thousand
to 78 in every 100 thousand.
Currently, West Virginia has the
third highest non-heroin opioid
treatment rate in the nation.
While we believe that the majority
of physicians are treating patient
pain appropriately, a number
indiscriminately prescribe opiates.
This is done without a proper
treatment plan of when and how
to use the medications, without
assessing the illness for the need of
such medications, and a lack of use
of standardized pain assessment
instruments. Some physicians
routinely neglect alternatives
to narcotics for treatment such
as psychosocial and behavioral
techniques as well as non-addictive
adjunctive medicines to reduce
dependencies on opioids. The result
has created a culture of iatrogenic
drug addiction, and the offending
providers are ascribed as being
“legalized drug pushers.” It is our
intention to propose pragmatic
changes to physician practices to
address this ever growing problem.
Pain Management: Prescription
of narcotics for non-cancer pain
should be a treatment that is timelimited and of a last resort. It should
only be used when non-narcotic
and psychosocial interventions
have failed. Even when legitimately
used, the prescriptions should
include a dosage, quantity, and
treatment duration that is adequate
to treat the pain. Monitoring the
usage of these medications reduces
the risk of patient abuse and
dependence, and it decreases the
likelihood of diversion through the
drug’s sale or theft. Since diverted
prescription pain medications are
the leading source of opioid access
for adolescents, the importance of
limiting quantities of prescribed
narcotics cannot be overstated.
Opioid Treatment Dependence:
Although methadone and levaacetylmethadol (LAAM) have
been used as agonist replacement
treatments for opioid dependence,
the Substance Abuse and Mental
Health Services Administration are
now recommending buprenorphine
(Subutex®) and Suboxone®, a
combination of buprenorphine
and naloxone, as office-based
treatment alternatives for opioid
addictions. Physicians can be
licensed to prescribe buprenorphine
with minimal training and are
only required to be able to refer
patients for adjunctive psychosocial
treatments. Unfortunately,
buprenorphine has developed a street
value. The duration of treatment
dosage of Suboxone® has been
debated, but the medication has been
successful in the treatment of opioid
addicts. We believe, however, that
unless these medications are properly
controlled, they will meet the same
fate and notoriety of methadone.
Motivation: Another factor
that plays an important role in
the prognosis and treatment of
drug addiction is motivation.
Detoxification is not a cure. When
utilized without adequate support
measures and proper follow-up,
detoxification has proven to be
ineffective. While continually
problematic, assessing an
individual’s motivation is subjective.
Although psychological tools exist,
consequences or losses associated
with drug use and abuse is a more
accurate predictor of a patient’s
motivation. These consequences
may include being ostracized
socially and religiously and may be
indicated by the losses of income,
jobs, professional licensures, and
intimate relationships. As society
becomes more tolerant to these
issues, drug addiction and abuse
becomes more pronounced. Often
the patient’s family and friends
ignore or enable the addiction.
Recommended Treatment
Guidelines: While general
guidelines for drug abuse
treatment should be observed,
we recommend the following:
a. Restricting the patient to
use one pharmacy of his or her
choice throughout the treatment.
b. Requiring the patient to attend
regular Narcotics Anonymous,
Alcoholic Anonymous, or
other treatment support group
meetings. The patient should
attend at least three sessions
per week during the first three
to four months of treatment.
These meetings can be gradually
lessened after this time period.
c. Obligating the patient to pay copayments in advance. Third parties
can assist by keeping co-pays as low
as possible ($10 to $20 per session). In
addition, we recommended requiring
Medicaid patients to pay a nominal
fee of $5 to $10 to demonstrate
responsibility towards the treatment
process. If patients fail to attend
designated treatment and/or
counseling sessions, prescriptions
should be withheld until such time
as the patient returns to compliance.
d. Reporting excessive charges
by physicians and counselors to
the appropriate state agencies.
e. Using standardized tests,
such as pain assessment tools, as
absolutely necessary. Documenting
the use of adjunctive treatment
modalities remains important.
f. Administering a goal-directed
therapy with gradual tapering
of medication as the patient
progresses through treatment.
g. Constructing a patient
agreement that includes random
pill counts and monitored drug
screening that is strictly adhered
to by the physician or therapist.
h. Monitoring and documenting
the patient’s weaning process of
the medication. This is especially
critical when dosages have
been increased or have been at
a high level for long periods.
i. Requiring physicians to complete
periodic training and continuing
education when dispensing narcotics
on a long-term basis. Licensure
renewal may be tied to the successful
completion of this training.
j. Collaborating between
physicians and addiction specialists is
critical.
k. Limiting the Suboxone®
treatment, in most cases, to not exceed
16 mg per day.
l. Documenting objective factors
in detoxification including blood
pressure, pulse, respiration, diarrhea,
rhinorrhea, and lacrimation.
These should be combined
with subjective symptoms to
individualized treatment.
While the above mentioned
treatment recommendations
represent a practical approach
employed by physicians, these
are only part of the equation. We
believe that these steps alone are
insufficient and additional action
at the public policy level is needed.
These include the following:
First, the DEA’s regulations
for Schedule II drugs with a high
likelihood for abuse need to be
seriously evaluated. Such drug
dispensing should be restricted
and time-limited. Medicaid in West
Virginia presently limits this to one
month’s duration. In addition, triple
prescription copies are warranted.
One copy would be kept on file
with the prescribing physician, one
with the dispensing pharmacist,
and one submitted to the Drug
Enforcement Agency in order to
review and verify that the drugs
are being dispensed properly.
Second, the Board of Medicine
should conduct periodic audits of
patients’ charts and other physician
records for compliance with good
clinical practice guidelines. This is
especially critical in regard to cases
where physicians are prescribing
large numbers of narcotics.
Third, an increased level of public
education regarding opiates and
their inherent dangers needs to
be promoted via the media at the
national and local levels. Patients
must be educated on the proper
disposal of leftover portions of opioid
prescriptions. This will contribute to
a decrease in the number of diverted
pain medications sold on the street.
Fourth, there should be greater
enforcement of providers accepting
private or government insurance
(Medicaid and Medicare). Physicians
engaged in abusive charges in
exchange for prescribing narcotics
need to be reported to the Board of
Medicine. Conversely, patients guilty
of doctor or pharmacy shopping
should be investigated by the proper
authorities and the appropriate
charges be filed against the patient.
Finally, controlled prospective
studies need to be conducted to
determine treatment effectiveness of
Suboxone® across multiple social and
economic domains. Post treatment
follow up needs to be conducted
by interviews and random drug
testing for an additional year.
Success would be determined upon
the patient’s ability to resume,
maintain, and fulfill social and
personal role obligations. Results
would be triangulated through the
comparison with other studies.
While prescription drug abuse
exists in epidemic proportions, it
has the potential to spiral out of
control to conditions not yet seen in
modern society. The implementation
of more stringent guidelines
and broad-reaching educational
programs are imperative to stop
this continually developing trend.
Special Issue Commentary
Drugs and Alcohol: Palliation of a Ubiquitous Reality
by Joseph B Reed, MD
A
fter 42 years of family medical
practice in Buckhannon,
Upshur County, West Virginia,
I offer some thoughts and insights
on the problem of substance use and
abuse in this rural county, suspecting
that these observations may apply
elsewhere. To sharpen my focus, I
interviewed 16 people from Upshur
County including representatives
from the courts; city and county
police; public school and West
Virginia Wesleyan College (WVWC);
St. Joseph’s Hospital medical,
pharmacy, and records personnel;
a retail pharmacist; Appalachian
Mental Health Clinic; local residential
treatment facility; faith based
groups; and community activists.
From these perspectives, I offer the
following thoughts and suggestions.
1. Alcohol causes more problems
and has a wider use than other
addicting substances. By WVWC
student survey “e-Chug”, 80%
of the college students use
alcohol to some extent. For 10%,
this will predictably eventually
become a significant problem.
(This is from national statistics).
Prohibition didn’t solve this
problem. With legalization, we
have control of production and
taxation of the product. The
effects of alcohol are factors in
many cases of domestic violence
and felonies (where people
steal to pay for their habits).
2. Marijuana is readily available,
relatively cheap ($20-50 per
ounce), unregulated, widely
used, illegal, has lesser societal
side effects (compared to alcohol
and narcotics), and is frequently
contaminated. If it were
legalized, this would remove
the black market value, increase
3.
control, decrease the health risk
from contamination, and provide
for taxation opportunities. There
is doubt legalization would lead
to increased use. Some portion
of law enforcement’s time and
talents are used in pursuing
marijuana use and abuse. If it
were legalized, this would allow
them to devote this portion of
their efforts to other causes, or
to actually decrease the need for
their services, thus saving dollars.
Management of pain, acute
and chronic, is a complex issue,
both for patients and medical
providers.
Medical providers are urged
to adequately treat patients’ acute
pain, which frequently involves
the use of narcotics, which are
potentially addicting. Sometimes,
acute pain transitions into
chronic pain and an appropriate
end point for narcotics is difficult
to discern. Treatment of chronic
pain does not enjoy universally
accepted guidelines or total
patient relief.
Patients with chronic pain
suffer the gamut from severe
cancer pain to malingering. It is
frequently difficult for both the
patient and the medical provider
to accurately assess the degree of
pain and disability.
Because of the legal climate,
the narcotic regulations, and the
above difficulties, many primary
care medical providers choose to
not provide care for these chronic
pain problems and sometimes
not to these patients at all. Such
patients, who may or may not
have legitimate chronic pain,
may seek relief of their pain,
and/or maintenance of their
addiction, by resorting to illegal
sources of drugs and frequently
thus removing themselves
from legitimate medical care.
This may lead to further illegal
activity such as stealing and
selling of drugs in order to
support their needs or habits.
4. There have been and will be
accidents and problems related
to alcohol and drug use, such as
multiple teenage deaths from
driving under the influence of
alcohol. Having an appropriate
educational and activity plan
to immediately institute,
(in addition to counseling)
when a significant incident
happens, would capitalize on
the “teachable moment.”
5. I suspect that public housing
and providing public assistance
to those who are able of mind
and body without expecting
something in return contributes
to addicting activity because of
idle time and close proximity to
many other people. Dependence
is an addiction in itself and
may contribute to the use
of addicting substances.
6. Basic drug and alcohol
information is provided to our
young people through schools
and colleges with the assistance
of the police in the public schools.
If our faith based organizations
and extension service programs
were more involved in this
education, it might provide a
positive leavening influence.
At present, many of our
faith based and extension
professionals are not prepared
to work with these issues.
Drug use and abuse have been
part of our society since recorded
time. We cannot cure it; we can
only palliate it. In addition, we
cannot legislate morality.
| New Members
We would like to welcome the following physicians to the WVSMA:
Hancock County Medical Society
Monongalia County Medical Society
Manuel Ballas, DO
Matthew Ranson, MD
Shaun Spielman, MD
Mercer County Medical Society
Thomas Miller, MD
Ohio County Medical Society
Viswanathan Chokkavelu, MD
Albert Jellen, MD
Please direct all membership inquiries to: Mona Thevenin, WVSMA Membership Director
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Bureau for Public Health | NEWS
Epidemic: Fatal Pharmaceutical Abuse in West Virginia
1991-2008
James A. Kaplan, MD
Lauren L. Richards-Waugh, PhD
Kristen M. Bailey, MS
and James C. Kraner, PhD
Office of the Chief Medical Examiner, Charleston, WV
Pursuant to WV State Code,
the Office of the Chief Medical
Examiner (OCME) investigates and
certifies all deaths that occur in West
Virginia as the result of accidental
and other non-natural causes, such
as injury or intoxications, by cause
and manner of death. OCME death
certification protocol requires local
investigation by trained OCME
forensic death investigators to
precede autopsy, with toxicology
analysis performed routinely.
Finally, all pertinent findings are
recorded by death certificate.
By OCME practice, the death
certificate recording a toxicology
death must list certain relevant
data in order to place autopsy
and toxicology findings in proper
context. In all toxicology deaths,
each detected physiologically
relevant medication is listed on
the death certificate. These include
non-opioid sedative/anxiolytic
medications, even when within
therapeutic blood concentrations,
in addition to detected alcohol and
illicit drugs. Circumstances identified
as potentially contributing to death,
which are captured on the death
certificate, include non-medical
routes of drug administration noted
by death scene investigation, or
use of regulated pharmaceuticals
without prescription access. Listed
additionally are co-occurring
natural disease conditions which
might contribute to fatal respiratory
arrest due to pharmaceutical drug
abuse, such as sleep apnea, chronic
heart and lung conditions, acute
lung conditions, obesity, and other
causes of respiratory dysfunction.
Compiled cause of death findings
and identified contributory factors
developed by medical examiner
investigations and autopsy, as
memorialized by archived death
certificate information, provide an
easily accessible epidemiologic tool
for surveilling the state of health
and safety of our population. What
follows is a summary of findings
previously reported in a 2008
JAMA study jointly authored by
the Centers for Disease Control
Epidemic Intelligence Service and
National Center for Injury Prevention
and Control, and the West Virginia
Resources1 which is primarily based
on findings of medical examiner
death investigations for the year
2006; followed by an overview of the
drug abuse phenomenon in West
Virginia over the period of 1991 to
2008, as abstracted from completed
medical examiner death certificates.
In November 2009, Governor Joe
Manchin identified drug abuse as
a major public health problem in
his Comprehensive Strategic Plan
to Address Substance Abuse in
West Virginia. In fact, West Virginia
experienced the greatest increase in
drug related deaths in the country
over the years 1999 to 2004, and
by 2004, WV had the highest rate
of opioid deaths in the nation2.
The history of this burgeoning
drug abuse phenomenon is relatively
recent. Between 1991 and 1996, West
Virginia consistently experienced a
relatively low number of toxicology
deaths per year, with a range of 39 to
68 deaths throughout that time period
(Figure 1). Further, these deaths were
primarily due to alcohol and illicit
drug abuse, such as cocaine or heroin.
In 1997, national medical
associations representing
anesthesiology and clinical pain
management medicine specialties3,4,
with the support of the Federation of
State Medical Boards, promulgated
new guidelines for the expanded
use of opioid pharmaceuticals for
clinical management of a broad
range of conditions causing chronic
pain. Beginning that same year,
the OCME experienced a marked,
steady increase in the number
of drug fatalities that appeared
to be caused by these same
medications (Figure 1, Figure 2).
In an attempt to further gauge the
contribution of pharmaceuticals to
the marked increase in toxicology
related fatalities in West Virginia,
DHHR and CDC Epidemic
Intelligence Service and National
Center for Injury Prevention and
Control collaborated on a death
certificate based epidemiologic
study of toxicology related deaths
associated with pharmaceutical
medications abuse which occurred
in West Virginia in 20061.
Methods
A total of 581 intoxication
deaths were identified in WV
in 2006 by OCME pathologist
staff peer review of death scene
investigation findings, autopsy
results including co-occurring
natural disease conditions considered
to be potentially contributory to
death, assessed in conjunction with
Bureau for Public Health | NEWS Continued
toxicology findings, and review of
decedent medical and prescription
monitoring program records.
Indicators for fatal drug
intoxication included: one or more
measured drug concentrations
at or above published fatal drug
concentration ranges5, or multiple
drugs in combination judged to be
potentially fatal; evidence of nonmedical routes of drug administration,
such as drug “snorting” or needle
drug abuse, as documented by
death scene investigation findings;
and witnessed signs of significant
drug toxicity such as lethargy,
labored breathing or development
of pulmonary edema as suggested
by frothy nasal exudates. Potentially
lethal concentrations of drugs in
the blood were more likely to be
implicated as a cause of death in
cases where there was evidence of
drug diversion, defined as drug
use in the absence of documented
prescription access to the identified
pharmaceuticals within 30 days of
the decedent’s death. Evidence of
Schedule II to IV drug diversion
was documented by review of
prescription monitoring program
and medical records review in
each case. Relatively high ratios
of parent to metabolite drug
concentrations, suggestive of naïve
or intermittent drug use, where
significant development of drug
tolerance would be unexpected, were
also used to assess the role of these
pharmaceuticals in causing death.
As part of this 2006 study of fatal
pharmaceutical intoxications, 295
deaths were identified as the result
of clearly accidental fatal drug abuse,
rather than suicidal drug over-use
or drug use circumstances unclear
for intentionality, where one or more
pharmaceutical medications were
significantly contributory to death.
Figure 1.
Figure 2.
Bureau for Public Health | NEWS Continued
Findings
Of the 295 deaths studied,
decedents were positive for multiple
drugs in 234 deaths (79%), opioid
pharmaceuticals were involved in
275 cases (93%), 186 (63%) were
associated with drug diversion,
and 22.4% of decedents (66 deaths)
utilized non-medical routes of drug
administration in the setting of
recreational pharmaceutical drug
abuse, such as snorting, smoking,
or injection of oral preparations of
pharmaceutical opioids. A significant
number of decedents (21%) were
identified as “doctor shoppers”,
defined as having received a
prescription for controlled substances
from 5 or more clinicians during the
year preceding death. In general,
the demographics of drug use
fatalities in West Virginia reflect a
large male predominance (67%) and
a very broad age range with 92% of
all fatalities between the ages of 18
and 54. Review of census based per
capita incomes by county of death
identified poverty as a direct factor1.
Beyond the findings reported
in the JAMA publication, a recent
OCME review of patterns of fatal
pharmaceutical drug abuse utilizing
cause of death statements from death
certificates covering the years 2001
to 2009 is displayed in (Figure 2),
which records the most commonly
detected drugs resulting in nonsuicidal fatal drug intoxications.
Tabulated results do not reflect
relative drug toxicities, but rather
prevalence of specific drug use where
each drug has a mechanism of injury
considered to be contributory to fatal
toxicity. Factors involved with trends
in the prevalence of fatal drug use,
such as the recent marked increase
in alprazolam or oxycodone use
remain unclear, and are probably
multi-factorial and complex.
Specifically, evolving OCME
toxicology testing practices over this
same time period have consistently
followed generally recognized
forensic strategies that promote
comprehensive drug detection and
confirmation, and would not be
expected to affect the appearance
of changing drug use patterns.
Comments
West Virginia is currently
experiencing an epidemic of fatal
drug intoxications, primarily fueled
by pharmaceutical opioid drug
abuse, resulting in a greater than 10
fold increase in fatalities from 1997
to 2008 (Figure 1). A recent letter to
this journal acknowledged the risks
of opioid therapy and listed 10 best
physician practices regarding safe
and effective dispensing of opioid
pharmaceuticals6. In West Virginia,
the majority of fatal pharmaceutical
drug abuse is associated with
drug diversion, and an additional
significant percentage of these
deaths occur in the setting of “doctor
shopping” behaviors. We suggest
that very significant patient (and
community) benefits will result from
formally establishing a standard of
safe prescribing practices requiring
physicians’ and pharmacologists’
utilization of prescription monitoring
program records, as well as other
recently listed best clinical practices.
References
1. Hall, A.J., Toblin, R.L., Logan, J.E., Kaplan,
J.A., Kraner, J.C., Bixler, D., Crosby, A.E.,
and Paulozzi, L.J. Prescription drug use
and abuse among unintentional overdose
fatalities. Journal of the American Medical
Association (JAMA), 300:2613-2620, 2008.
2. Testimony of Dr. Leonard J. Paulozzi,
“Trends in Unintentional Drug Poisoning
Deaths.” Energy and Commerce
Committee, Subcommittee on Oversight
and Investigations. U.S. House of
Representatives, October 24, 2007.
Accessed December 4, 2009.
3. American Society of Anesthesiologists.
Practice guidelines for chronic pain
management: a report of the American
Society of Anesthesiologists Task Force on
Pain Management, Chronic Pain Section.
Anesthesiology.1997;86(4):995-1004.
4. American Academy of Pain Medicine and
American Pain Society. The use of opioids
for the treatment of chronic pain: a
consensus statement from the American
Academy of Pain Medicine and the
American Pain Society. Clin J Pain. 1997;
13(1):6-8.
5. Schulz, M. and Schmoldt, A. Therapeutic
and toxic blood concentrations of more
than 800 drugs and other xenobiotics.
Pharmazie, 58:447-74, 2003.
6. Moss A.H. Prescription opioids and
physician responsibility. WV Med J. 105:8,
2009.
Marshall University Joan C. Edwards School of Medicine | NEWS
Marshall Research Sheds Light on Meth Addiction
In West Virginia, teens
rank near the top nationally in
methamphetamine use, meth lab
incidents outnumber those of all
states in the northeast combined
-- and Marshall research has
identified three mechanisms that
help account for the drug’s virulently
addictive and neurotoxic profile.
With work that has garnered a
grant from the National Institute for
Drug Abuse (DA-254452), invited
presentations at the national level,
and several awards, MD/PhD
student Melinda Asbury uses an
in vitro model to identify how the
blast of dopamine released by meth
abuse leads to the death of brain
cells in the nucleus accumbens,
where neurodegeneration is known
to have a causative role in the
early development of addiction.
“Methamphetamine is a
particularly devastating drug,” she
said. “Its abuse has been shown
to cause localized brain damage
equivalent to that seen in patients
with early dementia and greater than
that seen in those with schizophrenia.”
She noted that the brain damage, in
turn, makes it more difficult for meth
abusers to come clean – by reducing
impulse control, for example.
In an abstract presented at
the Neuroscience 2009 meeting,
Asbury presented her findings that
three mechanisms of dopaminerelated damage can be targeted to
prevent the associated apoptosis
in an in vitro system that closely
resembles meth abusers.
• Restoring antioxidant capacity.
Untreated neural cells began
dying within 24 hours of being
exposed to amounts of dopamine
equivalent to those released in
meth abuse. Cells pretreated
with an antioxidant, however,
survived exposure to up to
50 micromolars of dopamine
(the normal range in vivo is
1-10). Asbury said the findings
raise the interesting possibility
that nutritional intervention
could be one avenue involved
in treating addiction.
• Blocking receptor activation that
produces apoptosis. Exposure
to a D1 agonist caused more
cells to die, and to die more
quickly. However, using a D1
antagonist and blocking a related
signal eliminated dopaminerelated apoptosis. While research
elsewhere has found D1 agonists
to encourage abstinence and
prevent relapse in an animal
model, Asbury said the Marshall
research suggests that brain
damage may be occurring despite
the desirable change in behavior.
• Inhibiting the action of the
DNA transcription factor
activator protein 1 (AP-1). Using
a dominant negative to knock
out all AP-1 in the cells similarly
prevented dopamine-related
apoptosis. This finding, Asbury
said, has great implications
for research into potential
gene therapy for addiction.
Asbury said she hopes the findings
will enable the development of
new therapeutic approaches that,
when given as a pre-treatment,
will minimize further neurological
damage to those struggling with
the disease of meth addiction.
Dysfunctional Family Red Flag for Drugs in Pregnant Patients
Elsewhere in this issue, Stitely
et al discuss their study showing
that nearly one in five infants born
in West Virginia has a significant
drug or alcohol exposure.
Dr. David Chaffin, the
corresponding author and director of
Marshall’s Division of Maternal Fetal
Medicine, has seen “an enormous
explosion” of drug-addicted mothers.
“Managing these patients brings
home all the more that substance
abuse is a social problem even
more than a medical problem,”
he said. The most consistent
commonality among the patients,
he said, is a dysfunctional family,
with drug problems sometimes
spanning four generations.
Physicians who see indicators
that a patient has such a setting
might want to explore the possibility
of substance abuse more fully, he
said: often there are no visible clues
suggesting patients are addicted.
“The most important thing in
getting patients off the drug habit or
onto an alternative is to get them out
of that dysfunctional milieu,” he said.
Based on interviews with his
patients, he said the percentage of
addicts who started as recreational
users appears smaller than those
who became hooked during medical
treatment involving narcotics.
He described one patient whose
journey started with a prescription
for a narcotic painkiller with three
refills: “By the end of that time
she was hooked, and she’s been
hooked ever since,” he said.
West Virginia Medical Foundation | NEWS
Foundation Announces First Excellence In
Medicine Awards, Gala Set for August 27
T
he West Virginia Medical Foundation recently announced the inaugural recipients of the
Foundation’s prestigious Excellence in Medicine Awards. The awards will be presented during
a black tie optional gala at the West Virginia State Medical Association’s Healthcare Summit at The
Greenbrier on Friday, August 27 according to Foundation CEO Helen Matheny. This year’s
recipients are James L. Comerci, MD of Wheeling, Wayne C. Spiggle, MD of Short Gap and
Robert J. Marshall, MD of Huntington. Robert L. Ghiz, MD, of Charleston also will be recognized
for his outstanding service to the West Virginia physician community.
Matheny said the awards program was established to
recognize outstanding efforts by members of the West Virginia
State Medical Association who help the Foundation fulfill its
mission: To improve the health of all West Virginians by promoting
health education, leadership and research; encouraging healthy
lifestyles and enhancing access to quality healthcare.
Sponsors of the awards program include the West Virginia
Mutual Insurance Company, Chesapeake Energy and the
Kanawha Medical Society. For information about tickets, call
304‑925-0342 or visit www.wvsma.com.
“Each year the Foundation will honor a select group of physicians who exemplify the medical profession’s highest
values: commitment to service, community involvement, altruism and leadership in the medical profession,” Matheny
said. “We have a very dedicated and accomplished group of West Virginia physicians that we will recognize at the
Healthcare Summit.”
The Excellence in Medicine Award for Enhancing Access to Quality Healthcare will be
presented to the physician who has demonstrated extraordinary interest and efforts toward
improving access to healthcare or reducing healthcare disparities in West Virginia. This award will
be presented to James L. Comerci, MD of Wheeling, WV.
Matheny said Dr. Comerci has been a leader in providing access to care for the low income,
uninsured and working poor in West Virginia for more than twenty years. He has been a volunteer
physician at Wheeling Health Right since it’s inception in 1985, served six years on the Board of
James L. Comerci, MD
Directors and has been volunteer Medical Director since 1994. Board certified in Internal Medicine,
Dr. Comerci has championed access to healthcare for the low income uninsured with his peers and
has encouraged more than 120 physicians in the upper Ohio Valley to volunteer their services for the patients of Wheeling
Health Right.
Not only is Dr. Comerci the Volunteer Medical Director, but he continues to see patients in his office daily and every
other week at the clinic. A graduate of the West Virginia University School of Medicine, Dr. Comerci completed a Family
Medicine residency at Wheeling Hospital. He is in the private practice of family medicine since 1983 on a continuous
basis. In addition, Dr. Comerci has had significant experience in medical management working as a Medical Director for
Third Party Payer’s and a large IPA in the Northern Panhandle of West Virginia.
West Virginia Medical Foundation | NEWS Continued
The Excellence in Medicine for Leadership in Public Health will be presented to the physician
who has made a real difference in creating and nurturing a caring health promotion and disease
prevention environment. The recipient of this award is Wayne C. Spiggle, MD of Short Gap, WV.
A native of Davis, WV, after residency Dr. Spiggle co-founded the Braddock Medical Group in
Cumberland, MD., a practice serving patients (regardless of ability to pay) within Maryland,
Pennsylvania and West Virginia.
He was a founder of Alleghany Health Right (AHR), a “clinic without walls” collaborative effort of
Wayne C. Spiggle, MD
physicians, hospital representatives, pharmacists, dentists and community leaders to serve the
uninsured of Alleghany and Mineral counties.
After leaving full-time practice after 40 years, Dr. Spiggle became even more active in efforts to improve delivery of
preventive and primary care services to populations in need, including continuing to see patients at the Tri-State
Community Health Center in Cumberland and Preston-Taylor Community Health Centers in Mount Storm and Newburg,
WV. He also was a member of Governor Manchin’s Affordable Insurance Taskforce (AIW). As a Mineral County
Commissioner, Dr. Spiggle organized and facilitated that county’s community-based wellness program, Healthy Mineral
County Coalition.
Dr. Spiggle served on the West Virginia Pharmaceutical Cost Management Council and West Virginia Medical
Foundation’s Board of Trustees, convening multiple stakeholders to establish a subcommittee to explore establishing a
central fill pharmacy. His dedication and perseverance was instrumental in assisting the establishment of WVRX, an
automated, central fill pharmacy model that has been actively assisting patients throughout the State for the last few years.
Dr. Spiggle has been an active member of the West Virginia State Medical Association, continuing to serve as a
Council member and a founding board member of the West Virginia Medical Foundation, the WVSMA entity established to
promote public health. He served as a facilitator for the Foundation’s tobacco cessation training programs. Also, he has
been active in Rotary International AIDS education efforts in Malawi and several domestic “missions” to provide medical
and dental care to disenfranchised populations.
Dr. Spiggle earned an agriculture degree from Berea College. He was in the last two-year class at West Virginia
University School of Medicine and completed medical school at the Medical College of Virginia. He completed a rotating
internship at Memorial Hospital in Charleston, WV. In addition, he completed a residency in Internal Medicine at West
Virginia University under the renowned Dr. Edmund Flink.
The Excellence in Medicine for a Lifetime of Distinguished Service recognizes a West
Virginia physician who throughout his or her career has exemplified the medical profession’s
highest values: commitment to service, community involvement, altruism and leadership in the
medical profession. The individual must have practiced medicine for at least 25 years. The
recipient of this award is Robert J. Marshall, MD of Huntington, WV.
Dr. Robert Marshall is entering his 50th year of medical practice since moving to West Virginia. In
1960 he was recruited from the Mayo Clinic as one of the initial clinical faculty of the then newly
Robert J. Marshall, MD
established four year School of Medicine of West Virginia University, in the role of Professor of
Medicine and Chairman of Cardiology. He was responsible for developing a clinical practice; for
teaching internal medicine and cardiology to medical students and house staff; for planning and developing (in cooperation
with colleagues in pediatric cardiology and cardio-thoracic surgery) West Virginia’s first custom-built facilities for cardiac
catheterization and open heart surgery; for obtaining financial support from the (then) National Heart Institute (NIH) and the
American Heart Association to develop a program of cardiovascular research and to help fund future colleagues in
cardiology; and for providing continuing education for physicians, nurses and allied health professionals from across the
State of West Virginia.
His service to the state was exemplified by his key role in the development of the West Virginia Regional Medical
Program during the presidency of Lyndon Johnson in the 1960s. In 1976, Dr. Marshall changed his direction, leaving
West Virginia Medical Foundation | NEWS Continued
academia for the private practice of internal medicine and cardiology. He joined several of his former students in the
Huntington Internal Medicine Group and helped start the cardiac catheterization and cardiac surgery programs in
Huntington. As a Clinical Professor, he helped in early development of Marshall University School of Medicine.
Dr. Marshall, a native of Northern Ireland, graduated from the Faculty of Medicine of Queen’s University, Belfast, in
1948. Following internship he served for three years as Instructor in the Department of Physiology and Anatomical
Pathology at Queen’s, before completing residency and fellowship in internal medicine and cardiology. He was admitted to
membership and subsequently fellowship of the Royal College of Physicians (London) and the Royal College of
Physicians of Ireland. In 1957 he was a Research Fellow at the Baker Institute and Melbourne University, Australia, where
he published some of the earliest studies of vascular reactivity in hypertension.
Dr. Marshall, in receipt of a Fulbright Fellowship, spent three years at the Mayo Clinic as Research Associate in the
section of Physiology and Biophysics. His work included studies of the cardiovascular response to exercise in man and
animals and of the pulmonary circulation in health and disease, in addition to performing diagnostic cardiac catheterization
in the earliest days of open heart surgery at Mayo. In 1961 he moved to West Virginia as one of the founding faculty of the
WVU School of Medicine, serving as Professor and Chair of Cardiology and as Professor of Physiology. He spent a
sabbatical year as Visiting Professor of Cardiovascular Medicine at Oxford University. In 1976 he moved to Huntington to
join the Internal Medicine Group, and helped to develop the initial facilities for cardiac catheterization and open heart
surgery at St. Mary’s Hospital. At the time, he served as a Clinical Professor of Medicine for WVU.
In 1994 he retired from full time private practice, but not from work. Ever since then he has conducted the cardiac
clinic at the Ebenezer Centre. He also works as a cardiology consultant for Office of Disability Adjudication and Review of
the Social Security Administration. His commitment to these two organizations occupies some 40 hours per week.
Dr. Marshall is now entering his 62nd year of medical practice.
Dr. Marshall completed a four-year term as Governor of the West Virginia Region of the American College of
Physicians (ACP). During his tenure his region won the Evergreen Award in two successive years. In 1996 he received
the ACP-WV Laureate Award. In 1998 he became a master of the American College of Physicians, an award previously
bestowed on two other distinguished West Virginia physician educators the late Dr. Warren Point of Charleston and the
late Dr. Edmund Flink of Morgantown. Dr. Marshall served as Governor of the American College of Cardiology, President
of the West Virginia Heart Association, Vice-President of American Heart, Chairman of the Middle-Atlantic Region of
American Heart, and Region Advisor for the Royal College of Physicians of Ireland. He coauthored three textbooks and
has published more than 80 papers in peer-reviewed journals concerning cardiac function in health and disease.
Also during the awards program the West Virginia Mutual Insurance Company will present the
first “Robert L. Ghiz Award for Outstanding Service to the Physician Community of West
Virginia” to Robert L. Ghiz, MD.
Dr. Ghiz is an Orthopedic Surgeon and the retired president of Bone and Joint Surgeons, Inc.
located in Charleston, WV. He is a member of the American Medical Association, the West Virginia
State Medical Association and the American Academy of Orthopedic Surgery. He holds a medical
license from the West Virginia Board of Medicine.
Robert L. Ghiz, MD
Dr. Ghiz completed his undergraduate work at West Virginia University and then attended
Northwestern University for his medical degree. He studied orthopedic surgery while at
Northwestern University at the Cook County Hospital.
Dr. Ghiz has been an active member of the medical community in West Virginia, serving most recently as the founding
Chairman of the West Virginia Mutual Insurance Company, a professional liability insurance carrier established in 2004 to
meet the crisis needs of West Virginia’s physicians for affordable medical malpractice insurance.
Registration
2010 HealtHcare Summit
Friday, august 27 - sunday, august 29
Please indicate which registration/events you and your party will be attending.
PleaSe PriNt clearlY
Name:_ ____________________________________________________________________________________________________
Spouse/Guest (Name as it should appear on the name badge):_________________________________________________________________
Street Address:______________________________________________________________________________________________
City:___________________________________________________________State:________________ Zip:_____________________
Phone:______________________________________ E-mail Address:__________________________________________________
cme & aNNual meetiNG actiVitieS
Pre-Summit
On-Site
q WVSMA Member
$225
$250
q Non-Member Physician
$275
$300
q Retired Physician
$175
$200
q Office Manager or Medical Staff
$175
$200
excellence in medicine awards Dinner and Program - Friday, august 27, 7-9 p.m.
(includes dinner with wine and special awards program)
____1 ticket: $125
____tickets for a couple: $200
____tickets for a table of
WVSma Officer installation luncheon - Saturday, august 28, 11:30 a.m.
q _I plan to attend the WVSMA officer installation luncheon on Saturday, August 28.
For paid Healthcare Summit registrants and spouse/guest, there is no additional fee.
Number of Tickets ________
$__________________
$__________________
$__________________
$__________________
10: $1,500
$
N/C
tOtal amOuNt Due $__________________
Payment method:
q Check Enclosed
q American Express
q MasterCard
q Visa
Card No:_____________________________________________ Expiration Date: _____ V Code:_________________
(Three digit number on the back of the card.)
Name As It Appears On Card:________________________________________________
Signature:________________________________________________________________
For more information or additional registration forms, visit the WVSma website at www.wvsma.com or call (304) 925-0342 ext. 12
Please fax a copy of this form to (304) 925-0345
Or mail to: West Virginia State medical association, P.O. Box 4106,
charleston,
25364
SUBSTANCE
ABUSE IN WV WV
| Vol. 106 97
BOOK REVIEW
Have you ever wondered why physicians have a burnout rate of
about 67% annually and why we struggle to work our way out of
this rut? After all, we are very smart, creative, and well-meaning
people. It should be easy to address our own unhappiness. The
medical profession is unique, particularly as practiced in the
United States, with extraordinary challenges and demands
made upon its members….a practitioner tax per-se. Life balance
is often a goal, a moving target not achieved on a day-to-day
basis. Recently, I read Lee Lipsenthal’s “Finding Balance in a
Medical Life” which I felt compelled to share.
FINDING
BALANCE IN A
MEDICAL LIFE
...THE SEESAW IS
ALWAYS IN MOTION
I
n the first half of his book, Lee describes how we are set up for
burn out, fatigue and a state of feeling incomplete. Part of this is
due to the increasing complexity of our health care system and
associated stress with 28% of doctors showing above threshold levels.
Another facet of this is due to the underlying personality type that
is attracted to medicine in the first place. We are intelligent, caring,
inquisitive, sensitive and people oriented individuals. We are also
type A, perfectionist (predisposed to a self-righteous and judgmental
attitude), compulsive, hyper-focused, goal oriented and competitive
who have a tendency toward co-dependency and “over-caring” to our
own detriment. Although these attributes are not considered by most
to be positive, it may very well be difficult to survive medical school
and postgraduate training without them. However, they don’t serve us
well in our personal lives. We are so busy caring for others that we
no longer take care of ourselves. The challenge is not learning how
to be a great doctor, but learning how to live a great life while being
a doctor. These attributes are further engrained and enhanced in the
training process. Fear of failure enhances type A and competitive
behaviors. Fear of error enhances perfectionism to obsessive levels.
Social isolation is increased with our long hours and exhaustion. The
learned emotional dissociation (dehumanization), in order to remain
objective and functional under extreme stress, tends to shut down our
compassion and ability to connect with others, especially those outside
the patient/doctor relationship. This is exemplified when referring to
patients as “the chest pain in room 201, etc”. The emotional connection
needs to be with self, social, family and others outside the emotional
disconnection required at times in the workplace.
In his book through a process of self-analysis, self-awareness and a
deeper level of understanding of influences and expectations, Lee
teaches us how to be better teachers and leaders for our communities,
patients, students and families; ultimately, enhancing the ability to obtain
life balance. The book expounds on various techniques to be utilized for
maintenance, restructuring, and crisis. He shows us a simple way
to balance extrinsic and intrinsic life values by monitoring the
four key areas of life and development: the physical, emotional,
mental, and spiritual.
Physical Well-Being
The basic body needs must be met. This includes food, water,
exercise, and sleep. The first two, physicians do well with; it is
the latter where we are deficient. Lee describes how our physical
health affects our emotional health, mental well-being and
ultimately our performance and happiness in life.
Emotional Well-Being
Lee leads us through many steps towards emotional well-being
as follows:
 Stop whining and complaining. This is energy draining and
leads to no positive outcomes in the long run. Those who can
use this energy to think creatively and solve problems can
create positive changes in their practices and lives. The ego
centric central position of “it’s all about me” is a sure fire way
to remain out of balance and unhappy in life.
 Accept that life is change. Change is inevitable. Do not let
change in medicine or your life upset you more than necessary.
To paraphrase John Lennon, “Life is what happens when you
are busy making other plans.”
 Be willing to give up some control. Physicians live and work
within a large, interdependent system. Be realistic about what
you can change. As the serenity prayer says, “God, grant me
the serenity to accept the things I cannot change (other people,
places and things), the courage to change the things I can (my
action and attitudes), and the wisdom (which requires some
serenity and preferentially a power greater than yourself) to
know the difference.”
 Forgive yourself the errors you have made. As physicians, we
make multiple decisions daily, at work and at home. Which
one of us does not make mistakes in the course of a year?
Remember, we are human and have the right to be perfectly
imperfect. It is reasonable to review these errors to learn from
them. It is unreasonable to obsess about these errors and drive
yourself crazy! Ask yourself, “What would I say to a colleague
who made this same error?” We are often much kinder to our
patients and friends than to ourselves.
 Learn to manage stress. Yoga, meditation, exercise, prayer,
family time, and hobbies are all great stress management
techniques. If you have one that works for you, do it at least
four times weekly. If you don’t, consider finding your own
outlet or take a class.
 Enhance the relationships in your life. Spend time with and be
in contact with those whom you most care about. Be grateful
that you have these relationships! An emotional connection
with others makes us happier and more complete.
Mental Well-Being
He gives us concepts and tools to enhance our mental well-being
including the processes of learning, creating, and experiencing
personal growth. He also discusses the concept of emotional
intelligence, the idea that emotions affect your functionality,
performance, and outcomes.
Spiritual Well-Being
Lee also addresses spirituality and how it can be defined in many
ways that incorporate religious practices and beliefs or can be
of a non-religious nature. His approach is non-sectarian and
supportive of religious endeavors. He defines spirituality as a
sense of connection with others and a connection with something
larger than us.
Putting it all together
Lee puts this all together in a way that becomes manageable, not
adding more to your plate, but showing you how to shift your
perception and creativity to manage what is already on your plate.
I might add that I would like to see the concepts of his book being
taught in medical schools and residency programs. Fortunately,
it already is. Lee has created a curriculum that is being used in
multiple residencies and medical schools throughout the country.
I highly recommend this book to all of us; young, old, in private
practice and in academics. As we approach the changing world
of medicine for the future, we need to learn to create and flow
with change and not to resist and then complain! If we help create
the next chapter of medicine with love and compassion toward
ourselves, our families and our patients, it will be a better vision
of the health care system than exists today. “Finding Balance in a
Medical Life” is a must read personal call to action that may help
you save a very important life – yours!
P. Bradley Hall, M.D.
Medical Director, WVMPHP
RENAL CONSULTANTS in West Virginia is recruiting nephrologists for
Boone and Kanawha Counties. Practice consists of busy CKD clinic, ESRD
patients, home dialysis and post-transplant care. Applicant must be BC/
BE and prepared to be busy immediately. Salary awarded proportionate to
productivity. J1 Visas welcomed.
8
E-mail resume to: [email protected]
Physician Practice Advocate | NEWS
CMOM Success
T
The WVSMA is proud to be the
exclusive West Virginia partner with
the Practice Management Institute.
he Inaugural CMOM class
was a great success! Thirtythree ambitious office
administrators attended the four day
inaugural class, which was sponsored
by the WVSMA and hosted by St.
Francis Hospital in Charleston, West
Virginia. The course, held on two
consecutive weekends, was taught
by Practice Management Specialist
Rose Moore, CPC, CPMA, CEMC,
CPC-I,CCP, PCS, CMC, CMOM,
CMIS, CERT, CMA-ophth, a very
capable instructor whose highly
motivating teaching style kept the
class fully engaged at all times.
In addition to completing the
course, participants are required to
pass the certification exam in order
to become Certified Medical Office
Managers. In order to maintain their
certification, they also must recertify
every year by taking at least 12 hours
of CEUs (Continuing Education
Units). Becoming a CMOM not only
demonstrates that a manager has
advanced skills and knowledge; it
demonstrates his/her commitment
to further continue his/her education
in all areas of practice management.
The knowledge and skills that a
CMOM has can help guard the
medical practice against risks,
increase the practice’s revenue and,
most importantly, help the practice
reach the ultimate goal of providing
better healthcare for all patients.
The WVSMA believes very highly
in education for our physicians
and their practices and will
continue to provide outstanding
educational opportunities. In
addition to the CMOM class, we
recently held a Physician Chart
Auditing Workshop and will be
holding additional workshops of
this type in the coming months.
Due to the high demand for the
CMOM class, the WVSMA has
scheduled an additional class which
will be offered again in Charleston
in September. As before, the class
will be held on four days over the
course of two weekends. The dates
for the class are Friday/Saturday,
September 10/11 and Friday/
Saturday, September 17/18.
More details will be coming soon.
If you’re interested in the class, please
contact Barbara Good (Barbara@
wvsma.com) or Karie Sharp (Karie@
wvsma.com) to ensure that you
receive priority reservations.
Practice Management Institute
(PMI) is one of only three entities
whose certification is recognized
by Medicare. The WVSMA is
proud to be the exclusive West
Virginia partner with the Practice
Management Institute.
Barbara Good, CMOM
WVSMA Physician Practice Advocate
The WVSMA Congratulates
the Inaugural CMOM Class
OFFICE M
OF HEALTH
OFFICE MANAGERS ASSOCIATION
OF HEALTHCARE PROVIDERS, INC.
Kathy Asbury, Charleston
Marguerite Hotz, Dayton, Ohio
Jenny Bowling, South Charleston
Sharon Hoy, Charleston
Goriann Caudill, Charleston
Joyce Johnson, Charleston
Bettie Chapman, Huntington
Jennifer Ketchum, South Charleston
Cheryl Cline, Bluefield
Melissa Cox, Pt. Pleasant
Bobbie Cross, Elkins
Sharon Cross, Elkins
Denise Dahlin, South Charleston
Elizabeth Doran, Charleston
Marlene Eddy, Westover
Tressia Eggletonl, Scott Depot
www.offic
We invite you to join our organization which cons
who manage the daily business of healthcare
Our objectives are to promote educational opportunities,
and to provide channels of communication
managers in all areas of healthcare. We curr
eleven chapters in West Virginia.
www.officemanagersassociation.com
24th
Annual
Education
Conference
Visit us on our website for more informati
We invite you to join our organization which consists of members
Donna Zahn (President) at 740-283-4770 e
who manage the daily business of healthcare providers.
Tammy Mitchell (Membership) at 304-32
Our objectives are to promote educational opportunities, professional knowledge
and to provide channels of communication to office
managers in all areas of healthcare. We currently have
eleven chapters in West Virginia.
Maggie McCabe, Charleston Visit us on our website for more information or contact
Donna Zahn (President) at 740-283-4770 ext. 105 or
Tammy Mitchell (Membership) at 304-324-2703.
Debbie O’Neil, Ripley
Carole Parkins, Charleston
Doshia Petry, South Charleston
Tammy Rehee, Kingwood
Teresa Shinn, South Charleston
Kristine Simon, Clarksburg
Najma Faheem, Beckley
Christine Teagarden, Wheeling
Stephanie Gibbs, Parkersburg
John Vickers, Parkersburg
Patty Hamilton, Charleston
Donna Walton, Westover
Cherie Hanna, Princeton
Lawanna Wright, Charleston
Rita Hope, Scott Depot
Barbara Good, Charleston
October
14th & 15th
We invite you to attend our
24th Annual Educational
Conference on October 14th
and 15th at the Pullman Plaza
Hotel in Huntington, WV.
Our speakers will provide
you with the tools you need
to run your office to increase
productivity and efficiency.
For further information
and a list of our
speakers contact:
Toni Charlton at
[email protected]
Pam Shafer at
[email protected]
Donna Zahn at
[email protected]
and visit our facebook
page at State OMA.
WV Medical Insurance Agency | NEWS
The Patient Protection and Affordable Care Act
(“PPAACA”): What Does It Mean To Me And
My Employees?
On March 23, 2010, President
Obama signed into law sweeping
legislation that, in most citizens’
eyes, is as big, or even bigger, than
any in the history of the United
States of America. Of course we
are referring to the health care
bill; officially called The Patient
Protection and Affordable Care
Act of 2010. Whether we agree
or disagree with it, as with all
other laws that are put into
place, becoming informed about
the changes taking place will
create a better transition for
utilization of the changes.
What do we know about this
new legislation? There are many
things we will have to “wait and
see” to interpret how Congress and
the courts clarify and determine
certain phrases and clauses, but
for now, we need to focus on the
“immediate” aspects of the law.
What does “immediate” mean
to the Federal Government? As
we could expect with the farreaching implications of a new
set of rules such as this, it isn’t
simply “immediate”. It means that
health insurance plan years, or new
plans that begin after September
23, 2010 (six months after the
President signed the bill), will have
several new provisions included;
therefore, the “immediate”
provisions could be put in place
as late as September 1, 2011.
The following changes will
go into effect for plans with
anniversaries or for new plans
effective after September 23, 2010:
1. Unlimited Benefits: Most
carriers currently have a
$2,000,000 (individual/group)
lifetime maximum benefit.
Plan years, as well as new
business, that begin after
September 23rd will have
that changed to “unlimited”;
therefore, allowing benefit
limits to be uncapped.
2. Dependent Children: No
Pre-Existing Condition:
For dependent children (up
to age 19); no pre-existing
condition waiting period
will apply. These individuals
will be covered from the
first day of the policy for
pre-existing conditions,
even if they had no prior
health insurance coverage.
3. Dependent Children:
Requirements: A “Dependent
Child” can stay on a parent’s
plan up to end of the month
after their 26th birthday.
No student requirement; no
“50% financially dependent”
requirement; no “unmarried”
requirement. The only
restriction is that the child is
not eligible to be on his/her
own employer’s group plan.
Most insurance carriers have
stepped up to the plate, and
have announced that the
changes to the dependent
age limits will be made
effective June 1, 2010. They
did not want any graduating
students to have to be
without insurance until at
least after September 23rd.
4. Federal Tax Credit: Small
employers with fewer than
25 employees will receive a
maximum credit, based on
number of employees, of up
to 35% of premiums for up
to 2 years if the employer
contributes at least 50% of the
total premium cost. Businesses
do not have to have a tax
liability to be eligible. Nonprofits are eligible for this
provision also. The average
salary must be $50,000 or less
for the employees covered.
5. Preventative Services
Benefits: Certain preventative
service benefits will be
added to health insurance
programs. For all group
and individual health plans,
mandated coverage of specific
preventative services with
no cost sharing will be put
into plans as they renew.
The exact services that
will be covered under this
provision are not known yet.
This is not at all a complete
listing of the “changes” resulting
from the new legislation. We
are involved in the process and
trying to be a resource for you
to help you make sure that you
understand what you need to
utilize to make your practice
profitable and successful.
A recent survey found with
these economic conditions, over
70% of the employees surveyed
said they valued the group benefits
plan that their employer provides
and having employee benefits
was a major reason that they
stay with their employer. With
that response in mind, we would
welcome the opportunity to assist
you in creating a competitive
benefits package that will help
keep your employees with you
longer, provide a more stable
workforce, and that should equal
more profit for your practice.
As we can help you evaluate
your group (or individual) health
insurance or employee benefit
package needs, please call Steve
Brown, Agency Manager, at 1800-257-4747 ext 22 (or locally at
304-925-0342 ext 22), or contact
him by e-mail at steve@wvsma.
com to arrange an appointment
or schedule an evaluation.
This article is authored by John
C. Snodgrass. John serves as a
consultant to the West Virginia
Medical Insurance Agency on
group health insurance and assists
the Agency in its marketing of
group health insurance products.
OBSTETRIC
ANESTHESIOLOGIST
writes his memoirs:
His journey from
India to America
By
Shreeniwas Jawalekar
His book entitled:
Open drops to open hearts!
Available on
amazon.com/Barnes&Noble
Welcome
Dave Mueller, Physician Services Specialist
Dave Mueller joins the staff of the West Virginia Medical Insurance
Agency, returning home to West Virginia after serving physicians in the
Southeastern United States for the past 11 years.
Steve Brown (right), Agency Manager,
welcomes Dave Mueller (left) as Dave begins
his role as Physician Services Specialist with
the Agency.
To Contact Dave Mueller
Call: 1-800-257-4747 ext. 29 | Cell: 304-767-0027
Fax: 1-304-925-3166 | Email: [email protected]
Obituaries
The WVSMA remembers
our esteemed colleagues…
D. Ewell Hendricks, MD
Dr. D. Ewell Hendricks, 76, a
well-known surgeon of Martinsburg,
died May 22, 2010, at City Hospital.
Born April 23, 1934, in
Jefferson County, he was the son
of late Gilbert Hendricks and
Evelyn Maddox Hendricks.
A native of Jefferson County and
graduate of Shepherdstown High
School, Hendricks attended Shepherd
College and West Virginia University
where he earned his Bachelor of
Science Degree. In 1957 he obtained
a combined Medical Degree from
the WVU School of Medicine and
the Medical College of Virginia.
Following an internship at
Bellevue Hospital and the Memorial
Center for Cancer in New York,
Hendricks returned to Richmond to
complete his residency in general
surgery at the Medical College of
Virginia. In January 1963, he opened
his general surgery practice in
Martinsburg at Kings Daughters
Hospital and later City Hospital.
In addition to his service to local
hospitals, Hendricks was a clinician
with the Bureau of Tuberculosis
Control with the local health
departments in Berkeley, Jefferson,
and Morgan counties as well as seven
other counties in West Virginia. He
was a Diplomat of the American
Board of Surgery, an assistant
professor of surgery for the WVU
School of Medicine, and a member
of many professional societies,
including the Eastern Panhandle
Medical Society (EPMS) since 1964.
In 1998 he won the Rural Physician
of the Year Award. This is the only
time a member of the EPMS has
ever won this award. He attended
every EPMS meeting and most
of the WVSMA annual meetings
held at the Greenbrier Resort.
According to a statement
released by City Hospital on
behalf of the Hendricks family,
he was surrounded by family and
friends at the time of his death.
“Dr. Hendricks has been a pillar
of the Eastern Panhandle community
in many capacities, both medical
and non-medical,” stated several
of his physician colleagues. “As a
practicing physician, he provided
compassionate and quality care to
local residents for over 40 years.”
Ewell is survived by his wife,
Barbara Ellen Painter Hendricks, who
he married July 1, 1976; daughters,
Susan Lindsay and husband, Raymond,
of Charlottesville, Va., and children,
Jacob and John; Angela Bean and
husband, Michael, of Hedgesville,
and children, Peyton, Rheagan
and Andrew; Elizabeth Daugherty
and husband, Quentin, of Inwood,
and children, Evelyn and Joseph;
son, Daniel Jr., and wife, Krista, of
Corvallis, Ore., and child, Katharine
Elisabeth; brother, Dr. Gilbert Leo
Hendricks of South Carolina; two
sisters, Sarah “Sally” Anderson of
Richmond, Va., and Evelyn “Betty”
Reinhart, of Sharpsburg, Md.
Memorial contributions may be
made to the Berkeley County Humane
Society, 554 Charles Town Road,
Martinsburg, WV 25405; Dr. Ewell
Hendricks Medical School Scholarship
Fund, P. O. Box 1149, Martinsburg,
WV 25402; or a charity of one’s choice.
Paul Saville, MD
Dr. Paul Saville, a retired
rheumatologist, died at Hubbard
Hospice House due to complications
from melanoma. He was 84.
He was born in London, England,
and came to the United States with his
wife in 1958 to work for the Department
of Rheumatic Disease in New York.
Throughout his career, he had
11 teaching and research positions,
including West Virginia University.
The Savilles raised five children
and now have three grandchildren.
They lived in New York
City and Omaha, Neb., before
coming to West Virginia.
In 1975, they moved to Charleston
where Paul Saville was associate
attending physician at CAMC
and opened a private practice in
rheumatology. He and his wife also
were active in community theater
productions over the years.
He retired from his medical
practice about 12 years ago, but stayed
abreast of research. His work has
been published in 66 publications.
Regulars at Taylor Books in
Charleston, WV enjoyed chatting
with Dr. Saville, who was well
versed on topics from medicine
and politics to news events.
“The bookstore opened 15 years
ago,” said Ann Saville, a registered
nurse in her native England before
coming to America. “He regarded the
business as mine, but he enjoyed it
very much. It’s smack in the middle
of town with wonderful customers.
After he retired, we could have gone
anywhere, but we loved it here.”
Also surviving are sons David
and John, both of Charleston,
George of Seattle, Wash., Ted, of Los
Angeles, Calif.; daughter, Sarah, of
Charleston; and three grandchildren.
James Lebrect Steele, MD
Dr. James Lebrect “Jim” Steele, 81,
died peacefully on Saturday, May
15, 2010, at CAMC General Hospital,
Charleston, after a brief illness.
Jim Steele was born January 5, 1929,
in Welch and grew up in the heart of
the coalfields in McDowell County
with his father, George Lebrect, his
mother Alma, and his four sisters,
Mildred, Sybil, Virginia, and Minnie.
Jim graduated from Big Creek High
School and went to work at age 16
in the battery shed at the local coal
mine. He later entered the Army and
was a private in the infantry in the
Korean War, where he was wounded
in action and received a Purple Heart
for his service. His war experience
and recovery in the Army hospital
profoundly affected him: he decided
to go into medicine so he could help
people. From 1954 to 1958, he attended
WVU on the GI Bill and then entered
a joint medical program between
WVU School of Medicine and the
Medical College of Virginia (MCV)
in 1958. He received his Doctor of
Medicine from MCV in 1962. In his
first year of medical school he met Ida
May Hogshead, and they married in
1959. After completing his residency
in internal medicine at Lewis-Gale
Hospital in Roanoke, Va., he and Ida
May moved to Nitro, where they raised
their four daughters. Jim worked as an
emergency room physician for 30 years
at several hospitals in the Charleston
area: Thomas Memorial Hospital,
Charleston Memorial, Charleston
General, and Cabell Huntington. In
the early 1980s he became one of the
first doctors to earn a specialty in
emergency medicine. He was one of the
early physician advocates for training
of EMS (emergency medical service
personnel) in life support protocols and
trained both EMS and many resident
physicians over the years. He was
beloved by both his colleagues and
patients for his directness, kindness,
patience, and sense of humor.
He is survived by his second
wife, Stephanie W. Steele; daughters,
Laura Steele, Linda Steele, Valerie
Steele, and Rachel Steele; sisters,
Sybil Largent and Virginia Meredith;
grandchildren, Hattie Marie Campbell
and Ethan Steele Glaun; stepchildren,
Ann Walker, Chris Walker, Monica
Walker, Terry Walker, and Patrick
Walker; stepgrandchildren, Jessica
Walker, Jessica Youngquist, Matthew
Walker, and Nicholas Walker; and
step-great-grandchild, Janda Dijarnette.
In lieu of flowers, you may
wish to donate to the Disabled
American Veterans Charitable
Service Trust, 3725 Alexandria
Pike, Cold Spring, KY 41076, www.
cst.dav.org, in Jim’s memory.
Don’t pay malpractice.
Don’t work 24/7.
DON’T FORGET WHY YOU CHOSE
MEDICINE IN THE FIRST PLACE.
Remember when you wanted to save the world and heal those in need? As a leading outsourced medical
provider for for correctional facilities, Wexford Health can finally give you the chance. At the same time, you’ll
enjoy a quality of life unheard of in healthcare. For more than 15 years, we’ve been here to help. How about you?
We are currently accepting applications from Physicians for the following positions in West Virginia correctional
facilities:
MEDICAL DIRECTORS
Full- and Part-Time
Mount Olive Correctional Complex
Mount Olive, WV
Lakin Correctional Center
West Columbia, WV
Join us, and be part of a medical staff of more than 1,200 who’ve discovered how rewarding a
career with Wexford Health can be. Our engaged and empowered workforce combines industry
expertise with innovative new concepts to continually exceed the high expectations of our clients.
For more information, visit our website at http://jobs.wexfordhealth.com/ or contact Michelle Perella
at [email protected] or 1 800-903-3616 ext. 219.
Wexford Health is an Equal Opportunity Employer.
CME Answer & Registration Form This special issue of the West Virginia Medical Journal is jointly sponsored by CAMC Health Education and Research Institute, a
continuing education enduring material.
Name:_ ____________________________________________________________________________________________
Degree/Specialty:__________________________________Hospital/Institution:__________________________________
Address:_ __________________________________________________________________________________________
Phone:___________________________________________Email address:_______________________________________
Answers (please circle your response)
1) a b
c
10) a b
c d e
19) a b
2) a b
c
11) a b
c d e
20) T F
3) a b
c
12) a b
c d
21) a b
4) a b
c d
13) a b
c d
22) T F
5) a b
c
14) T F
23) a b
6) a b
c
15) T F
7) a b
c d
16) T F
8) a b
c
17) a b
9) T F
18) T F
c d
c d e
28) a b
c d
29) a b
c d e
30) a b
c d
31) a b
c
32) a b
c
24) T F
33) a b
c
25) T F
34) T F
c d e
c d
26) a b
c d
35) T F
27) a b
c d
36) T F
Please copy and fax both pages to CAMC Research and Education Institute at (304) 388-9966 or mail to:
CAMC Health Education and Research Institute | 3110 MacCorkle Ave., SE, Charleston, WV 25304
Content relevant to my practice
Score Relevance
No
1
2
Some
3
4
Very
5
Review of Individual Article
Score Article
Poor
1
Satisfactory
2
3
4
Excellent
Poor
Satisfactory
Excellent
5
1. Physicians Perceptions of Doctor Shopping
2. WV Birth Score: Maternal Smoking & Drugs of Abuse
3. Bringing All the Players to the Table: The West Virginia Controlled Substance Advisory Board
4. Prescription Drug Abuse & Addiction: Past, Present and Future: The Paradigm for an Epidemic
5. The Face of Hillbilly Heroin and Other Images of Narcotic Abuse
6. Preliminary Evaluation of the WV Prescription Drug Abuse Quitline
7. Prevalence of Drug Use in Pregnant WV Patients
8. Spinal Cord Stimulation in Reducing Opioids in Severe Chronic Pain
9. Buprenorphine Clinics: An Integrated and Multidisciplinary Approach to Treating Opioid Dependence
10. Understanding the Cultures of Prescription Drug Abuse, Misuse, Addiction and Diversion
11. Approach to Pain Management in Large Outpatient Clinic Population
12. Cocaine Abuse Among Patients: A Study at CAMC
Course Evaluation
1
2
3
4
5
Score Presentation 1 to 5
Extent to which the course objectives were met
Potential impact on your practice
Appropriate, qualified authors
Avoided commercial bias or influence
Article topics
Your overall evaluation of the course
What practice gaps were covered by the material presented in this issue?_______________________________________________________
_ __________________________________________________________________________________________________
What will you do differently in your practice as a result of your participation in this course?`____________________________________________
_ __________________________________________________________________________________________________
Additional comments about this course?___________________________________________________________________________
_ __________________________________________________________________________________________________
Suggestions for future topics?_________________________________________________________________________________
_ __________________________________________________________________________________________________
Manuscript Guidelines
Originality: All scientific and special topic
manuscripts for the West Virginia Medical Journal will
not be considered for publication if they have already
been published or are described in a manuscript
submitted or accepted for publication elsewhere. All
scientific articles should be prepared in accordance
with the “Uniform Requirements for Submission of
Manuscripts to Biomedical Journals.” Please go to
www.icmje.org for complete details.
Authors: A cover letter from the corresponding
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persons listed as authors should have participated
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Format: All articles may be submitted by email or on
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are acceptable. All tables or figures should be
created separately from the body of the manuscript
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corresponding file names such as,Table 1, Figure 1,
etc. Legends should be included for all tables and
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References: References should be prepared in
accordance to the “American Medical Association
Manual of Style.” These instructions for authors are
available online at www.jama.com.
Photographs: Please submit digital files either from
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and an indication of “top.” Do not write on the back of
photos or scratch them with paper clips.
Note to authors: The WV Medical Journal inside pages
traditionally print in black and white. If authors wish to
have photos and figures printed in color, there is a
$1,000 charge per article to help defray the printing
costs to the Association. Please indicate your preference
when submitting an article. If your article is accepted for
publication, you will be invoiced for the charges in
advance of publication.
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AANA....................................................................... 71
Air National Guard.....................................Back Cover
Alpha Financial Solutions........................................ 37
Bradford Health Services......................................... 21
CAMC Health Education & Research Institute........ 79
Chapman Printing..................... Inside Back Cover, 57
CPR Solutions........................................................... 2
EN&T Associates..................................................... 33
Eye & Ear Clinic......................................................... 7
Flaherty Sensabaugh & Bonasso ........................... 65
Green Clean............................................................ 70
HIMG....................................................................... 40
March of Dimes....................................................... 52
McCabe Medical Coding......................................... 62
McLain Surgical Supply Co. ................................... 78
Mountain State Vital Care........................................ 87
Office Managers Association................................. 101
Perinatal Partnership............................................... 18
Physician’s Business Office..................................... 61
Prestera Center....................................................... 73
Randall Clifford, MA................................................. 25
Renal Consultants................................................... 99
Shreeniwas Jawalekar, MD................................... 103
Standard Register.................................................... 43
Stationers................................................................ 90
Suttle & Stalnaker.................................................... 82
Take Care RX.......................................................... 15
The Farley Center at Williamsburg Place.......... 29, 59
Unicare...................................................................... 8
Wexford Health Source.......................................... 105
WV Medical Insurance Agency.............................. 103
WV Mutual Insurance Co. ....................................... 47
WV Psychological Association................................. 53
WV Medical Professionals Health Program....... 14, 31
WVU...............................................Inside Front Cover
Advertising Policy
The WVSMA reserves the right to deny advertising space to any individual,
company, group or association whose products or services interfere with
the mission, objectives, endorsement agreement(s) and/or any contractual
obligations of the WVSMA. The WVSMA, in its sole discretion, retains the
right to decline any submitted advertisement or to discontinue publishing any
advertisement previously accepted. The Journal does not accept paid political
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The fact that an advertisement for a product, service, or company appears
in the Journal is not a guarantee by the WVSMA of the product, service or
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reserves the right to enter into endorsements, sponsorship and/or marketing
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Subscription Rates:
Please address articles and cover letter to the editor at
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F. Thomas Sporck, M.D., F.A.C.S.
P.O. Box 4106
or email your article with cover letter to:
Angela L. Lanham, Managing Editor
[email protected]
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$100 a year in foreign countries
$10 per single copy
POSTMASTER: Send address changes to the West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.
Periodical postage paid at Charleston, WV.
USPS 676 740 ISSN 0043 - 3284
Claims for back issues should be made within six months after
publication. Microfilm editions beginning with the 1972 volume are
available from University Microfilms International, 300 N. Zeeb Rd.,
Ann Arbor, MI 48106.
©2009, West Virginia State Medical Association
HAMPION
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9/8/09 11:33 AM
P.O. Box 4106
www.wvsma.com
AIRGUARD
Even the best medical schools
can’t prepare you for what comes next.
Nobody can teach you about challenge and adventure. But you can experience them for yourself, serving part-time as a health professional
in the Air Guard. Whether you’re currently in school or working in the medical profession, you can find success as a vital member of our
exceptional medical team. The opportunities are limitless, and could involve everything from providing in-flight care to sick or injured
patients, to helping to save countless lives in a field hospital. All while receiving excellent benefits and the chance to work a flexible
schedule. Most important, you will experience the satisfaction that comes from serving the Charleston community and your country.
Talk to a recruiter today, and see how the Air Guard can help you take the next step.

Substance Abuse in WV (Special CME Issue)

Transcription

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