Prescription Drug Misuse and Addiction, Part II: Strategies to Address the Problem

My previous article reviewed data on trends in use, misuse, and addiction to prescription opioids, tranquilizers, seda-tives, and stimulants; signs of misuse and addiction; reasons for use, and the effects of drug problems on individu-als and families. This article discusses strategies to reduce prescription drug misuse and addiction, and help indi-viduals and families. These are based on reports published by the US government (SAMHSA, 2017; Baker et al., 2017), the Centers for Disease Control and Prevention (CDC, 2016), academic institutions, other organizations, and my extensive experience in clinical care, research, and teaching. A range of education, prevention, early interven-tion, treatment, and recovery interventions are needed to address this significant public health and safety problem affecting millions of people in the US, their families, and our communities.

Education
Providers, patients, families, and communities need education about potential benefits and harms, and alternatives to med-ications with addictive potential so more informed decisions about treatment can be made. For example, there are nonaddic-tive medications and nonmedication treatments for pain or anxiety that can help patients manage their conditions.
Medical providers need education and training on screening and assessing patients for substance use disorders (SUD), evi-dence-based interventions for SUDs, and treatment and recovery resources in the community for patients and families. Screening, brief intervention, and referral to treatment (SBIRT) and motivational interviewing (MI) are two strategies that can enhance providers’ ability to identify patients with SUDs, provide brief interventions for less severe problems, or link patients with more severe SUDs to addiction treatment.
My surveys and discussions with medical providers show that there is a need for an increase in their knowledge base, skills, and comfort level in working with patients with substance problems. This can help reduce stigma, improve empathy of provid-ers, and lead to better patient care. Medical providers can partner with addiction specialists to implement training programs and design treatment services. Access to ongoing consultation on clinical cases and procedures to develop services such as medication-assisted treatment (MAT) programs in medical settings can also benefit medical staff.

Prevention of Drug Misuse or Addiction
Reducing the number of prescriptions written is one way to reduce the number of individuals who transfer their addiction to illicit street drugs like heroin or fentanyl.
SAMHSA and the CDC published clinical guidelines for drug prescribing and pain management. The CDC recommends not using opioids as the first-line therapy for patients with common chronic pain conditions such as low back pain, migraines, neu-ropathic pain, osteoarthritis, and fibromyalgia (CDC, 2016). Unless patients have active cancer, need palliative care, or are in end-of-life care, nonopioid medications or nonmedication treatments are recommended. Nonopioid drugs used depend on the specific medical condition and include acetaminophen, NSAIDs, gabapentin/pregabalin, select antidepressants, and topical agents such as lidocaine or capsaicin. Nonmedication treatments include exercise, weight loss, patient education, self-care, cognitive behavioral therapy, physical therapy, and interdisciplinary rehabilitation.
Individuals prescribed opioids by physicians and dentists can be advised on ways to safely store medications since individu-als with drug problems may find or steal medications from relatives or friends. Individuals who stop taking opioids and family members can be instructed to dispose of unused drugs at take-back locations to reduce access to these drugs by others.

Prevention of Overdose
Given the significant increase in deaths from drug overdose, there is a need for patients, families, concerned others, first responders to emergencies in the community, and medical providers to have access to overdose education and naloxone formulations. For example, hospital patients receiving opioids or with opioid use disorders (OUDs) can be given naloxone prior to hospital discharge and instructed (with or without their family) on how to use this medication. Many overdoses are reversed by drug users helping each other and by first responders. A challenge for first responders is overcoming negative reactions to addicted patients who refuse treatment after an overdose or receive naloxone multiple times for their overdoses.

Pharmacy and Drug Monitoring
Formulary and drug utilization strategies include requiring a prior authorization for opioids, quantity limits, and prospective drug utilization reviews that examine patient use of medications with addictive potential. Drug utilization reviews can identify patients on high morphine equivalent dosages or MEDs (usually 90 or 120 mg or more MEDs), those taking multiple opioids or receiving prescriptions from more than one provider, length of time taking opioids, or using opioids and concurrent benzodi-azepines and/or muscle relaxants. Some reports suggest improving formulary coverage and reimbursement for nonpharmaco-logic treatments as well as multidisciplinary and comprehensive pain management (NASEM, 2017).

Prescription Drug Monitoring Program (PDMP)
Prescriber registration and use of the PDMP is another helpful tool to monitor drug use and intervene with patients who evidence a problem that may otherwise not be identified (Wunch, Gonzalez, Hopper, McMasters, & Boyd, 2014). Other strate-gies to take advantage of the PDMP include better integration into electronic health records (EHRs) of patients; enhancing ac-cess of PDMP across state lines, since some patients will seek opioids from multiple providers in more than one state; and third-party payer access to PDMP data providing there are proper protections of patient confidentiality. To reduce fraud among providers, there needs to be policies to investigate those who are considered high risk.

Physician Benchmarking
This can be used to compare doctors or practices on opioid prescribing to peer averages within the same medical specialty for nonmalignant, nonterminal conditions. Metrics compared may include prescriptions written per thousand members, aver-age daily MEDs, and percent of total prescriptions written for opioids. Feedback to physicians can help them improve their management and oversight of individuals prescribed opioids for chronic noncancer pain.

Interventions in Medical Systems
Medical providers can screen patients for drug use during clinic visits. Positive screens can lead to a more extensive evalua-tion at the clinic or with an addiction provider. On-site education, support, brief interventions for drug misuse or mild forms of a drug use disorder, and linkage to specialized treatment for more serious drug use disorders can be provided. Given the low rates of treatment entry for individuals with SUDs, identification and early intervention in medical settings is needed for more patients with drug problems to receive care and improve their functioning.

Medication-Assisted Treatment (MAT)
More providers are needed to offer MAT to patients with addiction to prescription opioids. Licensed addiction residential programs can address this problem by implementing MAT with patients prior to discharge to the community. Inpatient medical hospital units, emergency departments, consultation and liaison services, and other specialty medical programs need to in-crease medical staff with waivers to provide buprenorphine. Incentives to initiate MAT during hospital stays or at ED or primary care visits could increase the number of addicted patients who receive MAT. Access to methadone maintenance or bupren-orphine with a “warm handoff” to a community provider is essential to get patients engaged in treatment beyond the acute phase of care. Medical systems have to own the problem of SUDs among their patients and use multiple strategies to assess, provide treatment, and/or link them to addiction care or community recovery resources.

Treatment and Recovery for Drug Addiction
There are many treatment and recovery resources for individuals with prescription drug misuse or a SUD and their family members. Information about treatment can be accessed at SAMHSA’s Behavioral Health Treatment Services Locator by enter-ing an address, city, or zip code, or by calling 1-800-662-4357 to receive confidential information in English or Spanish about treatment programs. Most states also have treatment locators, and health plans have care management services to help facili-tate identification of treatment services for members in need of treatment for a SUD.
Employees with access to an employee assistance program (EAP) can seek help for their own or a family member’s drug problem. EAPs may offer counseling to help people assess drug problems, decide what to do about them, or help families deal with the stress associated with addicted family members. EAPs can also link addicted people or family members to treatment or recovery resources in the community.
Medical treatment for physical addiction may include detoxification in a hospital, rehabilitation program, or outpatient clinic. Once individuals are tapered off addictive drugs and their condition stabilizes, they can be connected to ongoing treatment. Methadone (taken daily), buprenorphine (daily pills, sublingual film, or extended release shot given monthly), and buprenor-phine combined with naloxone are effective treatments for patients with opioid addiction who comply with their prescriptions and engage in other forms of treatment and/or recovery.
Short and long-term residential, partial hospital, intensive outpatient, and outpatient programs can be used based on the type and severity of the drug problem. Treatment programs aim to get people to accept their problems, stop misusing or be-come abstinent from addictive drugs, and learn ways to meet the challenges of recovery. These include managing cravings, resisting social pressures to use, refuting “addictive thinking,” getting the family involved, finding alternative ways to manage stress, catching early signs of relapse, and developing a support system so that recovery becomes a “we” and not an “I” pro-cess.
People who actively engage in mutual support programs such as Narcotics Anonymous (NA) often do better than those who do not use these programs (Donovan, Ingalsbe, Benbow, & Daley, 2013). Long-term recovery is one of the best antidotes to addiction. Mutual support programs such as Nar-Anon are also available to help family members or friends affected by a loved ones’ addictions. Other local mutual support programs for family members are available in some areas.
Support from peers in recovery can also help individuals with drug problems. Peers may include paid professionals such as peer navigators (PN), peer specialists, recovery coaches, or volunteers who provide services to individuals and in some in-stances their families. In the medical system in which I am associated, PNs are used in numerous hospitals and ambulatory pro-grams to screen, assess, refer, and provide brief interventions. This led to more patients engaging in treatment and/or commu-nity mutual support programs. PNs have also educated medical staff about treatment and recovery resources in the communi-ty.

Harm Reduction
Supervised consumption spaces and needle and syringe programs are used in some communities. While these can help ad-dicted individuals reduce the risk of acquiring or transmitting infectious diseases, or eventually engage in addiction treatment, they are controversial and not accepted by all professionals or others as viable strategies to reduce drug misuse or addiction.

Final Thoughts
Clearly, multiple educational, prevention, treatment, and recovery strategies are needed to address prescription drug mis-use and addiction, and the many adverse effects of these problems on individuals and families. Since individuals with prescrip-tion drug problems are likely to seek medical care for other reasons, providers who implement evidence-based assessment and treatment and referral strategies can influence patients to address their problems. In my current role in an integrated de-livery and finance system, I can attest to many positive outcomes from collaborations between addiction and medical profes-sionals. This has led to increased provider education, training and consultation; increased screening and interventions with medical patients with SUDs; reduction in opioid prescriptions; more providers offering MAT in primary care practices; financial support to first responders and families for overdose education and intervention with naloxone; and better coordination of care for medical patients with SUDs. c

About the Author
Dennis C. Daley, PhD, served for fourteen years as the chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. Dr. Daley has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research.

References
Baker, C., Bondi, P., Christie, C., Cooper, R., Kennedy, P. J., & Madras, B. (2017). The President’s Commission on Combating Drug Addiction and the Opioid Crisis. Retrieved from https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf
Centers for Disease Control and Prevention (CDC). (2016). Nonopioid treatments for chronic pain: Principles of chronic pain treatment. Retrieved from https://www.cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf
Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). Twelve step interventions and mutual support programs for substance use disorders: An overview. Social Work in Public Health, 28(3–4), 313–32.
National Academies of Sciences, Engineering, and Medicine (NASEM). (2017). Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use. Washington, DC: The National Academies Press.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm
Wunsch, M. J., Gonzalez, P. K., Hopper, J. A., McMasters, M. G., & Boyd, C. J. (2014). Nonmedical use, misuse, and abuse of prescription medications. In R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), The ASAM principles of addiction medicine (5th ed.) (pp. 513–23). New York, NY: Wolters Kluwer Health.