____________________________ Responsibilities and Requirements of Prescribing Schedule II Opioid Drugs
• Loss of control over alcohol use • Using illegal drugs or non-prescribed controlled substances • Recurrent episodes of: ‒ Prescription loss or theft ‒ Obtaining opioids from other providers in violation of a treatment agreement ‒ Unsanctioned dose escalation ‒ Running out of medication and requesting early refills Behaviors with a lower level of evidence for their association with opioid misuse include [45; 47; 48]: • Aggressive demands for more drug • Asking for specific medications • Stockpiling medications during times when pain is less severe • Using pain medications to treat other symptoms • Reluctance to decrease opioid dosing once stable • In the earlier stages of treatment: ‒ Increasing medication dosing without provider permission ‒ Obtaining prescriptions from sources other than the pain provider ‒ Sharing or borrowing similar medications from friends/family INTERVENTIONS FOR SUSPECTED OR KNOWN ADDICTION OR DRUG DIVERSION There are a number of actions that prescribers and dispensers can take to prevent or intervene in cases of drug diversion. These actions can be generally categorized based on the various mechanisms of drug diversion. Prevention is the best approach to addressing drug diversion. As noted, the most common source of nonmedical use of prescribed opioids is from a family member or friend, through sharing, buying, or stealing. To avoid drug sharing among patients, healthcare professionals should educate patients on the dangers of sharing opioids and stress that “doing prescrip- tion drugs” is the same as “using street drugs” [49]. In addition, patients should be aware of the many options available to treat chronic pain aside from opioids. To prevent theft, patients should be advised to keep medications in a private place and to refrain from telling others about the medications being used. Communication among providers and pharmacies can help to avoid inappropriate attainment of prescription drugs through “doctor shopping.” Prescribers should keep complete and up-to- date records for all controlled substance prescribing. When pos- sible, electronic medical records should be integrated between pharmacies, hospitals, and managed care organizations [49]. If
inadequate analgesia, lack of improvement in quality of life despite dose titration, deteriorating function, or significant aberrant medication use [1; 10]. Clinicians should provide patients physically dependent on opioids with a safely structured tapering protocol. Withdrawal is managed by the prescribing physician or referral to an addiction specialist. Patients should be reassured that opioid discontinuation is not the end of treatment; continuation of pain management will be undertaken with other modalities through direct care or referral. As a side note, cannabis use by patients with chronic pain receiving opioid therapy has traditionally been viewed as a treatment agreement violation that is grounds for termination of opioid therapy. However, some now argue against cannabis use as a rationale for termination or substantial treatment and monitoring changes, especially considering the increasing legalization of medical use at the state level [48].
DENTAL OFFICE PROCEDURES FOR MANAGING VULNERABLE OR SUBSTANCE USE DISORDER PATIENTS
IDENTIFICATION OF DRUG DIVERSION/SEEKING BEHAVIORS
Research has more closely defined the location of prescribed opioid diversion into illicit use in the supply chain from the manufacturer to the distributor, retailer, and the end user (the pain patient). This information carries with it substantial public policy and regulatory implications. The 2019 National Survey on Drug Use and Health asked non-medical users of prescription opioids how they obtained their most recently used drugs [51]. Among persons 12 years of age or older, 38.6% obtained their prescription opioids from a friend or relative for free, 34.7% got them through a prescription from one doctor (vs. 17.3% in 2009–2010), 9.5% bought them from a friend or relative, and 3.2% took them from a friend or relative without asking [51]. Less frequent sources included a drug dealer or other stranger (6.5%); multiple doctors (2.0%); and theft from a doctor’s office, clinic, hospital, or pharmacy (0.9%) (vs. 0.2% in 2009–2010) [51]. There are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [45; 47; 48]: • Selling medications • Prescription forgery or alteration • Injecting medications meant for oral use • Obtaining medications from nonmedical sources • Resisting medication change despite worsening function or significant negative effects
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