How to Discuss Drug Issues with a Patient

1. How to Discuss Drug Issues with a Patient Greg L. Jones, MD Medical Director Kentucky Physicians Health Foundation

2. Faculty Disclosure • Dr. Jones has no financial relationships to disclose • Dr. Jones is a full time employee of the Kentucky Physicians Health Foundation • Dr. Jones will not be speaking about “off label” uses of drugs or devices

3. Educational Need/Practice Gap Many Healthcare Professionals are uncomfortable discussing alcohol and drug use with their patients. Optimal healthcare requires this information for good clinical decisions. We all need to improve our comfort and skill set in having these discussions. And in recognition of pertinent findings.

4. Objectives Upon completion of this educational activity, you will be able to: • Discuss tolerance to drugs with patients competently • Ask the right questions for Addiction risk assessment • Learn ways patients can con and manipulate prescribers

5. Expected Outcome • Obtain better histories so care is most effective • Identify problem behaviors or attitudes before prescribing controlled substances • Utilize KASPER Reports effectively • Have a better understanding of the Disease Model of Addiction

7. Why bother? The patient is the one With the problem

8. Usual Way of Discussing Addiction Issues • Never ask- Probably most common way • Do you have a drinking or drug Problem? • Or You don’t have a drinking or drug problem do you? • How much do you drink? • How much drug do you use?

9. “I’ve never had a problem with drugs. I’ve had problems with the police.” Keith Richards

10. Dr. J’s 1st law of Addiction Medicine The level of Denial is proportional to the obvious and measurable damage done by their drinking or drug use. *Corollary- Denial increases if confronted with the evidence

11. Dr. J’s 2nd law of Addiction Medicine There is an inverse and proportional relationship between the degree of conviction a patient has in their dx and the likelihood it exists

12. “One of the first duties of the physician is to educate the masses not to take medicine.” Sir William Osler, Aphorisms from his Bedside Teachings

13. So what on Earth am I supposed to do! • Ask the questions • And in the course of your usual Hx taking • Any hint of judgmental or disapproving attitude and the useful conversation is over

14. How to Ask It • Don’t make a Big Deal out of it. It is very important, but so are many things we routinely discuss with our patients. • Include it as part of the overall conversation. • Make sure the person understands you are not judging you just need accurate information to care for them.

15. Which drugs are we talking about? • Tobacco • Alcohol • Opiates • Benzodiazepines/ Z-drugs • Cannabis • Cocaine • Amphetamines (includes Rx’d and other stimulants like Ritalin) (Tramadol, Pregabalin, Mondafinil…)

16. Willingway Drug Rule When old drugs become addictive, they are replaced with new non-addictive drugs. When the new drugs become addictive and are replace by new non-addictive drugs. Adapted from the Recovery Book

17. What to Ask • Ask do you drink? Or use drugs? • Ask when was the last time you …. • Are you concerned about your drinking or drug use? • Have you considered doing something different with your drinking or drug use? • Ever have times you drank or used more than you intended too?

18. Then…. • Do you recall how old you were when you first used alcohol or another drug? • Do you recall any of your family members having issues with alcohol or other drugs? • “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men, 4 for women • Used to get high?

19. What if they complain of Pain? • Ask what is the pain prevents them from doing? Not – How bad is the pain? • Pain scales are not helpful. • Ask about things they are able to do. • Ask how they first came to have the pain. • Ask how long the pain has been present. • Ask about prior evaluations. • Ask about prior treatment.

20. All the Studies that show Opiates to be safe and effective for chronic non-cancer pain • Zero

21. Opiates sold per capita

22. Opiate OD Deaths per capita

23. Closer to Home

24. NAS rates in KY, a frieghtful legacy

25. Red Flags • The “Call Brand” • Anytime they mention or ask for a specific drug by name… • Having more than one doctor. • Having more than one pharmacy. • Being on more than one class of controlled substance. • They brought their films. • Work or disability related.

26. Get A KASPER! • How many classes of drugs • How many prescribers • Overlapping? • How many Pharmacies? • Amount and frequency?

27. KASPER Case Study 3 (Page 1) - Male Patient –

28. KASPER Case Study 3 (Page 2) - Male Patient –

29. KASPER Case Study 3 (Page 3) - Male Patient –

30. KASPER Case Study 3 Notes • Male Patient – • Report date range 01/28/2010 to 01/27/2011 • Doctor shopper • Prosecution pending by Commonwealth’s Attorney

31. So you are fixin’ to Rx a controlled substance

32. What about Tolerance? • “Well doc I just have a big tolerance, that’s why my dose has gotten so big.” • Ask how long they have been on the drug. • Get an overview of the rate of titration up. • Who was determining how the adjustments were made. • Our natural instinct is to be helpful. Don’t let that get in the way of good care.

33. Opioid Induced Hyperalgesia

34. The Other Guy Did It

35. “Patient interview” Case study