Substance Abuse in WV (Special CME Issue)
Transcription
Substance Abuse in WV (Special CME Issue)
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. 5REHUW&%\UG +HDOWK6FLHQFHV&HQWHU 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 » » » » » » » » » 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 Successful EHR implementation is affordable and attainable. CPR Solutions Group offers three EHR packages at various price points and the industry’s best EHR. We go beyond selling software. We provide solutions. OnDemand: hosted solution; minimal upfront investment; no server, no software OnSite: premise-based solution using existing equipment OnSite Plus: premise-based, turnkey solution Greenway G ree Guarantee—Greenway’s Certication, C e rtt i Interoperability, and Meaningful M e an Use Commitment Contact us NOW 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 Charleston, WV 25304 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. West Virginia Medical Journal 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 The sensible choice for specialized care. 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West Virginia Medical Journal 0909 WV0015533 9/09 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 Substances Monitoring Program 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 12 West Virginia Medical Journal 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 Special Issue | Scientific Article 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 Substances Monitoring Program 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 Substances Monitoring Program 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. SUBSTANCE ABUSE IN WV | Vol. 106 13 Scientific Article | Special Issue 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 14 West Virginia Medical Journal Scientific Article | Special Issue 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. 16 West Virginia Medical Journal Special Issue | Scientific Article (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 SUBSTANCE ABUSE IN WV | Vol. 106 17 Scientific Article | Special Issue 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 18 West Virginia Medical Journal 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] Scientific Article | Special Issue 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. 4. Centers for Disease Control and 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 20 West Virginia Medical Journal 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 Scientific Article | Special Issue 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.” 22 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 23 Scientific Article | Special Issue 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 24 West Virginia Medical Journal 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. Special Issue | Scientific Article 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. SUBSTANCE ABUSE IN WV | Vol. 106 25 Scientific Article | Special Issue 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. 26 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 27 Scientific Article | Special Issue 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 28 West Virginia Medical Journal 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 Special Issue | Scientific Article 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 at: www.FarleyCenter.com/Journey or call 877-389-4968 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 SUBSTANCE ABUSE IN WV | Vol. 106 29 Scientific Article | Special Issue 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 30 West Virginia Medical Journal 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 Special Issue | Scientific Article 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. ALL CALLS ARE CONFIDENTIAL West Virginia Medical Professionals Health Program PO Box 40027 Charleston, WV 25364 (304) 414-0400 | www.wvmphp.org SUBSTANCE ABUSE IN WV | Vol. 106 31 Scientific Article | Special Issue 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. 9. National Institute on Drug Abuse. NIDA InfoFacst: Treatment Approaches for Drug Addiction. Washington D.C.: U.S. Department of Health and Human Services. 2008 (June): all 10. Hall AJ, Logan JE, Toblin RL, Kaplan JA, 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) 32 West Virginia Medical Journal 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) Ears, nose and throat medical and surgical care | Audiological testing | Inhalant allergy testing and treatment Hearing aid evaluation and placement services | | Computed Tomography (CT) for sinuses and ears Appointments 304.340.2200 Hearing Aid Center 304.340.2222 entchas.com • 500 Donnally Street • Charleston, WV • Suite 200 Complete Comprehensive Services BoARD CERTIFIED SPECIALISTS D. Richard Lough, MD Michael R. Goins, MD P. Todd Nichols, MD G. Stephen Dawson, MD F. Thomas Sporck, MD, FACS Scientific Article | Special Issue 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. 34 West Virginia Medical Journal Special Issue | Scientific Article 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. SUBSTANCE ABUSE IN WV | Vol. 106 35 Scientific Article | Special Issue 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 36 West Virginia Medical Journal 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 Special Issue | Scientific Article 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. Alpha Financial Solutions Comprehensive Physician Billing Service •Physician Billing Service •Electronic Health Records •Consultation Services •Monthly Practice Analysis •E & M Level Chart Audits •Assistance in Pay for Performance Initiatives Knowledgeable and Experienced Team •Experience in over 20 physician specialties •Billing for over 80 physician practices •Monthly collections of over $2.5 million Call for a Confidential Meeting 304-243-3070 ext. 324 www.AlphaFinancialSolutions.org WHEELINGPITTSBURGH 137 Waddles Run Road 500 Commonwealth Drive Wheeling, WV 26003 Warrendale, PA 15806 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? SUBSTANCE ABUSE IN WV | Vol. 106 37 Scientific Article | Special Issue 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. 38 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 39 Scientific Article | Special Issue 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 Join our team! 0RIMARY#ARE7OMENS3ERVICES At HIMG, we listen to our patients. As our patient base continues to grow, they have requested that we provide primary care services focused on the needs of our female patients. 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Our 150,000 square-foot facility and our business practices have been a model for many operations throughout the nation. s0ARTTIMEORFULLTIMEOPPORTUNITIESAVAILABLE s*OBSHARING s!CTIVELYRECRUITING-$S$/S0!SAND.0S s!LLINQUIRIESKEPTSTRICTLYCONlDENTIAL WWWHIMGWVCOM 5170 U.S. Route 60 East Huntington, WV 25705 40 West Virginia Medical Journal (304) Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 41 Scientific Article | Special Issue 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 42 West Virginia Medical Journal 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 Special Issue | Scientific Article 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 treatment appointment as a result of 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 treatment appointment as a result of calling the WVPDAQ. If those who Today, over 25 prescriptions were filled for patients of Dr. Peter Williams. Problem is, he only wrote 10 of them. You may not think about it, but every day, practices just like yours fall victim to the growing problem of prescription fraud. And while you may think your current prescription pads are secure, the truth is, very few pads are capable of offering the level of security that you’ll get from a ScripPlus® prescription pad. Protect yourself from embarrassment and serious liability by purchasing the most secure prescription pads in the industry at www.standardregister.com/wvrx or by calling 1-866-741-8488. SUBSTANCE ABUSE IN WV | Vol. 106 43 Scientific Article | Special Issue 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 44 West Virginia Medical Journal 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 Special Issue | Scientific Article 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, SUBSTANCE ABUSE IN WV | Vol. 106 45 Scientific Article | Special Issue 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. 2. Centers for Disease Control and 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. 4. Hall AJ, Logan JE, Toblin RL, Kaplan JA, 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. 46 West Virginia Medical Journal Experience. Success. Teamwork. Commitment. The Mutual provides you access to a successful, local claims management team with a thorough understanding of the fragile West Virginia malpractice market. During our five years of operations, your Mutual has a ninety-two percent success ratio when cases are taken to trial. We win cases on behalf of our physician owners. We are your advocate. We are your company. We are your Mutual. (304) 343-3000 • (888) 998-7642 www.wvmic.com Scientific Article | Special Issue 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. 48 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 49 Scientific Article | Special Issue 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. 50 West Virginia Medical Journal 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 Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 51 Scientific Article | Special Issue 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 Charleston, WV 25304 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? 52 West Virginia Medical Journal 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. 54 West Virginia Medical Journal & 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. SUBSTANCE ABUSE IN WV | Vol. 106 55 Scientific Article | Special Issue 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. 56 West Virginia Medical Journal Special Issue | Scientific Article 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. SUBSTANCE ABUSE IN WV | Vol. 106 57 Scientific Article | Special Issue Figure 3. Securing the trial leads. Figure 4. Tunneling for lead placement. Figure 5. Placement of the permanent leads. 58 West Virginia Medical Journal 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 Special Issue | Scientific Article 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? SUBSTANCE ABUSE IN WV | Vol. 106 59 Scientific Article | Special Issue 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. 60 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 61 Scientific Article | Special Issue 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 62 West Virginia Medical Journal 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 Charleston, WV 25360 304-881-4633 [email protected] Sharing in the joy of health care education! Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 63 Scientific Article | Special Issue 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. 64 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 65 Scientific Article | Special Issue 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 66 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 67 Scientific Article | Special Issue 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 68 West Virginia Medical Journal 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. Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 69 Scientific Article | Special Issue 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 1. Substance Abuse and Mental Health 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. 3. National Institute on Drug Abuse. NIDA 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. GREEN CLEAN Green Clean is a licensed West Virginia Business and a Chemical Free Cleaning Company A new way of cleaning! Safe Healthy No harsh chemicals on surfaces or in the air Reduce sickness and allergies in your office. We use only green products & steam. Office: 304-925-0840 Cell: 304-415-7885 Fax: 304-982-5234 [email protected] 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 70 West Virginia Medical Journal 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 Scientific Article | Special Issue 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. 72 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 73 Scientific Article | Special Issue 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 74 West Virginia Medical Journal 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 Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 75 Scientific Article | Special Issue 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 76 West Virginia Medical Journal 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 Special Issue | Scientific Article 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. 2. Centers for Disease Control and 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 Geriatric Association panel on the pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:1331-1346. 7. Gourlay DL, Heit, MD, Ahlmahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-112. 8. Williams DR, Gonzalez HM, Neighbors H, et al. Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from a National Survey of American Life. Arch Gen Psychiatry. 2007;64:305-315. SUBSTANCE ABUSE IN WV | Vol. 106 77 Scientific Article | Special Issue 9. Ahayon MM. Specific characteristics of the pain/depression association in the general population. J Clin Psychiatry. 2004;65 Suppl 12;5-9. 10. Aquera L, Failde J, Cervilla JA, et al. Medically unexplained pain complaints are associated with underlying unrecognized mood disorders in primary care. BMC Fam Pract. 2010;11:17. http://www. biomedcentral.com/1471-2296/11/17 [epub ahead of print] 11. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal overdose drug poisoning in the United States. Am J Prev Med. 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. MEDICAL EQUIPMENT & SUPPLIES Since 1858 Equipment Leasing Also Available 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. (New & Used) McLAIN SURGICAL SUPPLY A West Virginia Company 205 Leon Sullivan Way Charleston, WV 25301-2408 26. Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Adv Ther. 2000;17:70-83. Phone: 304-343-4384 800-729-3195 FAX: 304-343-4385 27. Vukimir RB. Drug seeking behavior. Am J Drug Alcohol Abuse 2004;30:551-575. 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 78 West Virginia Medical Journal 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. SEMInARS No conferences during July and August LIfE SuppORt tRAInIng Log-on to our web site to register at www.camcinstitute.org Advanced Cardiovascular Life Support (ACLS) – Provider July 6, 21; Aug. 10, 16 Pediatric Advanced Life Support (PALS) - Renewal July 15, 16; Aug. 12, 19 Pediatric Advanced Life Support (PALS) – Provider July 13; Aug. 25 Sepsis Simulation July 14; Aug. 4 Trauma Nurse Core Course Aug. 23 CME OnLInE pROgRAMS/ARCHIvEd July 8, 23; Aug. 9, 18 guESt LECtuRE Advanced Stroke Life Support pROgRAMS Advanced Cardiovascular Life Support (ACLS) – Renewal July 27 Basic Life Support (BLS) – Health Care Provider July 6, 20; Aug. 3, 17, 31 Log-on to our web site at www.camcinstitute.org Web Browser: Microsoft’s Internet Explorer 5.0 or above or Netscape Navigator 4.7x. (Do not use Netscape 7.1) Video Player: Windows Media Player 6.4 or better. Dial-Up or Broadband Connection. Minimum Speed, 56k (Broadband is Recommended) OtHER ARCHIvEd CME OppORtunItIES: Geriatric Series Ethics Series Research Series NET Reach library System Requirements Environment: Windows 98, SE, NT, 2000 or XP Resolution: 800 x 600 ©Charleston Area Medical Center Health System, Inc. 2010 22112-F10 Scientific Article | Special Issue 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. 80 West Virginia Medical Journal Special Issue | Scientific Article 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 SUBSTANCE ABUSE IN WV | Vol. 106 81 Scientific Article | Special Issue 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 800-788-3844 Parkersburg, WV 304-485-6584 Providing professional services to physician practices for over 35 years: 8 Practice Analysis & Benchmarking 8 Tax Planning & Preparation 8 Core Accounting Services 8 Practice Operation Improvement 8 Regulatory Compliance www.suttlecpas.com 82 West Virginia Medical Journal Special Issue | Scientific Article 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 16. Substance Abuse and Mental Health 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. 17. Substance Abuse and Mental Health 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 SUBSTANCE ABUSE IN WV | Vol. 106 83 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 84 West Virginia Medical Journal 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. SUBSTANCE ABUSE IN WV | Vol. 106 85 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 86 West Virginia Medical Journal 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 A West Virginia company bringing quality home infusion services to your home! 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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 88 West Virginia Medical Journal 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 Department of Health and Human 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. SUBSTANCE ABUSE IN WV | Vol. 106 89 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 90 West Virginia Medical Journal 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. SUBSTANCE ABUSE IN WV | Vol. 106 91 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. 92 West Virginia Medical Journal 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 SUBSTANCE ABUSE IN WV | Vol. 106 93 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. 94 West Virginia Medical Journal 96 West Virginia Medical Journal 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 98 West Virginia Medical Journal 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] SUBSTANCE ABUSE IN WV | Vol. 106 99 Physician Practice Advocate | NEWS CMOM Success T The WVSMA is proud to be the exclusive West Virginia partner with the Practice Management Institute. 100 West Virginia Medical Journal 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. SUBSTANCE ABUSE IN WV | Vol. 106 101 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; 102 West Virginia Medical Journal 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] SUBSTANCE ABUSE IN WV | Vol. 106 103 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 104 West Virginia Medical Journal 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. SUBSTANCE ABUSE IN WV | Vol. 106 105 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 106 West Virginia Medical Journal 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?_________________________________________________________________________________ _ __________________________________________________________________________________________________ SUBSTANCE ABUSE IN WV | Vol. 106 107 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 author should be submitted with the manuscript. All persons listed as authors should have participated sufficiently in the work to take public responsibility for the concept. Format: All articles may be submitted by email or on CD. Microsoft Word is preferred, but other programs are acceptable. All tables or figures should be created separately from the body of the manuscript as .tif, .jpg or .pdf files in a high resolution format with corresponding file names such as,Table 1, Figure 1, etc. Legends should be included for all tables and figures. 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. 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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..................... 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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.