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Nursing Regulatory Boards’ Efforts to Provide Guidance to Nurses About

Mitigating Prescription Medication

Abuse/Diversion

Cathy Carlson, PhD, APN, FNP-BC

Aaron Gilson, MS, MSSW, PhD

�Authors Conflicts of Interest:

� C. Carlson, No Conflict of Interest

� A. Gilson, No Conflict of Interest

Participants should:� Understand the current epidemiological evidence about the non-medical use

of prescription opioid medications in the U.S., as well as important

considerations when interpreting this information, including the role of diversion

� Understand the methodology used to evaluate all states’ nursing board

websites to identify content related to prescription opioid medication abuse

and diversion

� Identify the variety of ways that state nursing board websites are used to

inform licensees about mitigating prescription opioid medication abuse and

diversion

� Identify the different content available through state nursing board websites about reducing prescription opioid medication abuse and diversion

� Define quality indicators of state nursing boards’ efforts to reduce

prescription opioid medication abuse and diversion

� Recognize additional approaches that state nursing boards could use to

encourage licensees to incorporate in their practice to reduce prescription

opioid medication abuse and diversion

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�Deaths involving prescription opioid analgesics outnumber

deaths from heroin and cocaine combined

National Institute on Drug Abuse. (December, 2015). Overdose death rates.

Retrieved from http://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Overdose Deaths Involving Opioid Analgesics, Cocaine, & Heroin:

U. S. 1999-2014

Opioid Analgesics** Cocaine Heroin

� Sources of drugs for non-medical users, 2012-2013

0

10

20

30

40

50

60

70

80

90

100

Friend or relative forfree

Friend or relative forcost

Friend or relative woknowledge

Drug dealer or stranger Other illicit sources Prescription

Percent

Substance Abuse and Mental Health Services Administration. (September, 2014). Summary of National Findings.

Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

77.2%

“Prescription

medication”

Prescribed

medication≠

Essential to determine whether

valid prescription was involved

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Senate Testimony:

“Over the past several

years…hundreds of millions of dosage units

of controlled

substances were

diverted into the illicit marketplace across the

United States.”

(July, 2012, p. 5)

Factors to Consider

� Diversion (i.e., no prescription found)

� Doctor-shopping (i.e., diversion)

� Motivations??

� Non-medical routes of administration

� Co-morbidities (e.g., substance use history)

� Poly-pharmacy

� Previous overdose episodes

� Little clinical information

� Not a linear effect

� Not causal

Methadone

Legitimate Patients?

Practitioner Education

Drug Formularies

Treatment Benefit/Risk Evaluations

Safeguarding Prescription PadsED Guidelines

Analgesics with No Abuse Potential

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�2-week evaluation period (June 1- June 14)

�CC & AG separately reviewed each state’s website

� Content created on or after January 1, 2013

� Reviewed websites for territories – lack of websites

or information excluded them from final analysis

�Excluded content:

� Policy/laws

� Nurse impairment/nurse abuse & diversion

�Met on June 14 to coordinate findings

�AG created categories for content and methods to relay information

�Inter-rater reliability = 0.234 (Fair agreement)

�CUMULATIVELY – identified at least most of the recent information

�No content = 15 states (29%)

�Some websites had older content, and were not tallied

�Some resources not directly accessible via nursing board website

� CT, MI

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�Single page

� CO, MN, NH, OR, RI, TX, WY

�Resources only available through APN section

�Some under Pain Management

�Most states had information strewn throughout site

Availability of Information

Mechanisms for

Relaying Information

DC

Slide Show (3 states)

No Slide Show (48 states)

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Video (3 states)

No Video (48 states)

7

News (11 states)

No News (40 states)

Practice Notices (14 states)

No Practice Notices (37 states)

8

DC

Newsletter (16 states)

No Newsletter (35 states)

9

DC

Links (20 states)

No Links (31 states)

Topics

Offered

PDMP information (20 states)

No content (24 states)

PDMP information and registration (5 states)

PDMP registration (2 states)

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REMS (1 state)

No content (42 states)

Substance Abuse & REMS (2 states)

Substance Abuse & CS Rx (1 state)

PDMP (1 state)

Controlled Substances Prescribing (1 state)

Substance Abuse (3 states)

DC

Take Back (2 states)

No content (37 states)

Securing Medications (1 state)

Prescription Fraud Reporting (1 state)

Drug Disposal/Wasting (3 states)

Aberrant Behaviors/Drug Seeking (3 states)

Diversion (4 states)

DC

Drug Misuse & Abuse/Prescription Safety (14 states)

No Content (37 states)

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DC

Preventing Adverse Events/Harm

Reduction/Overdose (9 states)

No Content (42 states)

Naloxone Content (7 states)

No Content (44 states)

Any Content (36 states)

No Content (15 states)

DC

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Quality Indicators

for State Boards of

Nursing Websites

�Definitions:

�An inherent or distinguishing characteristic; a property or attribute

�A personal trait, especially a character trait

� Essential character; nature

� Superiority of kind

�Degree or grade of excellence

�ISO 9000: Degree to which a set of inherent characteristics fulfills requirements

�A perceptual, conditional, and somewhat subjective attribute understood differently by different people

�Verifiable measures stated in either quantitative or qualitative terms that:

�Capture performance in terms of how something is being done relative to a standard or target

�Allow and encourage comparison

�Support the goals and objectives of the organization

�Performance metrics (i.e., Indicators) often represent how far a metric is above or below a specified target

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�The link to the (PDMP) in each state needs

to be readily accessible by nurses and

especially advanced practice registered

nurses (APRNs)

�E-newsletters should be an option for nursing professionals from their SBN

�Requiring course regarding opioid prescribing, abuse and/or diversion

�Facebook posts – provides licensees with useful information

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�Separate page/link for APRNs

�Separate page/link for pain management

�Separate page/link for public/professional

Header

Navigation Links

Local

Navigation

Links

Main Content Page Right

Column

Footer

Exemplars

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�All websites should have content for licensees related to addressing prescription medication abuse/diversion

� Links to external resources

� NCSBN could encourage such content

�Content should be easily searchable (e.g., 1 page)

�Other topics could be addressed

� Prescription form security/tamper-resistant forms

� Prescription series

� E-prescribing

� Coordinated care/integrative care

PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry

(AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American

Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM),

American Academy of Pediatrics (AAP), American College of Physicians (ACP),

American Dental Association (ADA), American Medical Association (AMA), American

Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric

Association (APA), American Society for Pain Management Nursing (ASPMN),

International Nurses Society on Addictions (IntNSA), and Southeast Consortium for

Substance Abuse Training (SECSAT).

For more information visit: www.pcss-o.orgFor questions email: pcss-o@aaap.org

Twitter: @PCSSProjectsFunding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor

does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.