Substance Abuse Education for Delaware Nurses
Drug Diversion Training and Best-Practice Prescribing

LEARNING OUTCOME AND OBJECTIVES :  Upon completion of this continuing education course, you will be prepared to help prevent prescription drug misuse and diversion. Specific learning objectives to address potential knowledge gaps include:

• Describe components of responsible opioid prescribing.
• Summarize the CDC and Delaware guidelines for safe prescribing of opioids.
• Explain strategies designed to prevent prescription drug misuse and diversion.
• Identify considerations for the use of the opioid antagonist naloxone.
• Discuss chemical dependency and impairment in the workplace

SCOPE OF THE PROBLEM

Millions of Americans suffer from pain and are often prescribed opioids to treat their conditions. However, the dangers of prescription misuse, opioid use disorder, and overdose have been a growing problem throughout the United States.

Since the 1990s, when the amount of opioids prescribed to patients began to grow, the number of overdoses and deaths from prescription opioids has also increased. Even as the amount of opioids prescribed and sold for pain has increased, the amount of pain that Americans report has not similarly changed (CDC, 2022).

From 1999 to 2020, more than 263,000 people died in the United States from overdoses involving prescription opioids. Overdose deaths involving prescription opioids increased by nearly five times from 1999 to 2020. In 2020, an average of 44 people died each day from overdoses involving prescription opioids, totaling more than 16,000 deaths (CDC, 2021a). Prescription opioids were involved in nearly 24% of all opioid overdose deaths in 2020, a 16% increase in prescription opioid-involved deaths from 2019 to 2020. (In order to account for increases in illicitly manufactured fentanyl, CDC Injury Center separates synthetic opioids, other than methadone, from prescription opioid death calculations.)

Delaware, like many other states, has been hit hard by the opioid epidemic. In 2021, the Delaware Division of Forensic Science (DFS) reported 515 overdose deaths, an increase of more than 50% over 2020, with more than 80% involving the use of fentanyl, a synthetic opioid (Delaware.gov).

One of the biggest challenges in healthcare practice is providing safe and appropriate pain care without contributing to this epidemic of prescription drug misuse, drug diversion, and drug overdose deaths. Nurses in particular are in a unique position to address this problem since they care for more patients than any other health profession. Nurses who understand the risks associated with prescription drug abuse will be better prepared to identify and intervene with patients and colleagues who may be at risk.

RESPONSIBLE OPIOID PRESCRIBING

Responsible prescribing involves individual prescribers following best practices and taking action to balance the risks and benefits of opioid pain management for each patient. Three important components to responsible prescribing include

• Thorough patient assessment
• Treatment plan design
• Periodic monitoring

Both the Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain and the state of Delaware provide recommendations for prescribing opioid pain medications (see below).

Patient Assessment

A thorough patient assessment is critical prior to prescribing opioid medication for chronic pain. It is important to properly diagnose the condition to determine if opioid medication is an appropriate treatment. A well-documented patient history that includes past medical history, medication history, social history, family history, and psychosocial history is critical. Assessing and documenting a personal or family history of substance misuse is also important.

ASSESSING PAIN

Proper diagnosis of the painful condition helps to assure that opioid medication is an appropriate treatment. It can be challenging, however, since pain is subjective and multidimensional. The patient’s self-report of pain is the most reliable indicator, recognizing that perceptions of pain are influenced by culture, environment, emotional state, sleep patterns, and habits.

Any provider must conduct a pain assessment before they can determine what type of pain management is needed. Assessment of pain should include:

• Context (How did the pain begin?)
• Location (Where is the pain felt?)
• Severity (How does the pain rate on a 0–10 scale?)
• Quality (Is the pain sharp, stabbing, dull, pulsating, etc.?)
• Timing (How often does the pain occur?)
• Duration (How long has the pain been persisting?)
• Modifying factors (What makes the pain better or worse?)
• Chronic illness status (What conditions might impact or worsen the pain?)
• Associated signs and symptoms (What else occurs with the pain?)

ASSESSING RISK

When clinicians assess patients with chronic pain, it is important to recognize two categories of risk due to opioid therapy: medical conditions that increase their risk for adverse events (e.g., respiratory depression) and risk of misuse, abuse, or addiction.

Risk of Adverse Events

Risk due to medical conditions are assessed and documented as part of the patient’s history and physical examination and the treatment plan adjusted accordingly to reduce risk of adverse events with opioid therapy. Older adults may be at higher risk because of cognitive decline and increased potential for falls. Patients with impaired renal or hepatic function, cardiopulmonary disease, mental health conditions, obesity, and sleep apnea are also at higher risk for adverse consequences when prescribed opioid medications.

Risk for Misuse, Abuse, and Addiction

Variables that have been associated with a higher risk for misuse, abuse, and addiction include history of addiction in biological parents, current drug addiction in the family, regular contact with high-risk groups or activities, and personal history of illicit drug use or alcohol addiction. (See also “Recognizing Aberrant Drug-Related Behaviors” later in this course.)

The use of screening tools is recommended, and multiple tools are available that can help healthcare providers to assess these risks. The specific tool to be used is determined based on:

• The type of substance of risk (or whether the patient is at a generalized risk to misuse numerous substances)
• The age of the patient (as certain tools are specific to children or adolescents)
• Whether it is preferred to have the patient self-administer the screening or to have a healthcare professional do so

Examples of screening tools include:

• Opioid Risk Tool: Administered at initial visit prior to beginning opioid therapy; questions address age, family, and personal history of substance abuse, history of preadolescent sexual abuse, and psychological diseases
• Screening to Brief Intervention (S2BI): A series of questions regarding frequency-of-use in adolescent patients of substances most commonly used
• Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS): A combined screening and brief assessment that addresses use-related behaviors and generates a risk level for each substance class

(See also “Resources” at the end of this course.)

Treatment Plan

Responsible opioid prescribing requires clinicians to develop treatment plans that focus on patient-centered outcomes that improve quality of life. A function-based treatment strategy that aims to maximize the patient’s quality of life and minimize the burden of their pain includes a mutual understanding between prescriber and patient covering the following principles:

• Complete elimination of all pain is often not possible.
• The goal of treatment is to successfully manage pain and not exclusively to reduce a pain scale score.
• Functional goals will be collaboratively set, with the aim of improving quality of life; these goals must be realistic, achievable, verifiable, and meaningful.
• Risks, benefits, side effects, and potential adverse consequences of opioid use will be fully disclosed.
• Education about safe use, storage, and disposal of opioid medication will be provided.

This treatment plan must be documented, together with informed consent and patient education.

Periodic Monitoring

It is critical to regularly reevaluate the appropriateness of continuing opioid therapy due to changes in pain etiology, health condition, progress toward functional goals, and addiction risk. To corroborate self-reports, review of data within the prescription drug monitoring program should be conducted at each visit (see “Delaware Prescription Drug Monitoring Program” later in this course). Periodic monitoring should also include urine tests and pill counts when appropriate.

Clinicians must utilize screening and monitoring for all patients on chronic opioid therapy to document patient outcomes and progress toward functional goals. The Pain Assessment and Documentation Tool (PADT) is a practical tool that clinicians can use at each patient visit and incorporate into electronic records (see “Resources” at the end of this course). It offers a simple checklist to monitor the “Five As” of pain management.

THE FIVE As OF PAIN MANAGEMENT

(Bazzo et al., 2019)
A nalgesia	A reduction in pain
A ctivities of daily living	Improvement in level of function
A ffect	Changes in mood
A dverse effects	Falls, decreased cognitive function, constipation, etc.
A DRBs	Aberrant drug-related behaviors

Periodic monitoring timing will vary with each patient. The CDC (n.d.-a) recommends checking monitoring every three months at the minimum, and before refilling an opioid prescription at any time. State requirements may vary.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain

In 2022, the CDC updated its guidelines for prescribing opioids for the treatment of pain. Whereas the 2016 guideline focused on recommendations for primary care physicians, the newer guideline expands the scope to additional clinicians whose scope of practice includes prescribing opioids (e.g., physicians, nurse practitioners and other advanced-practice registered nurses, physician assistants, and oral health practitioners). The 2022 guidelines address four main issues, including:

• Making a determination about whether or not to initiate opioids for pain
• Selecting the appropriate opioid and determining the dosage
• Deciding the duration of the initial opioid prescription and conducting follow-up
• Assessing the risk and addressing the potential harms of opioid use with the patient

The recommendations in the 2022 guidelines aim to improve communication between clinicians and patients about the risks and effectiveness of pain treatment; improve pain, function, and quality of life for persons with pain; and reduce the risks associated with opioid pain treatment (including opioid use disorder, overdose, and death) as well as with other pain treatment.

The practice guidelines include 12 recommendations for clinicians who are prescribing opioids for outpatients ages 18 years and older with pain that is acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months), excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.

1. Nonopioid therapies are at least as effective as opioids for many common types of pain. Maximize the use of nonpharmacologic and nonopioid pharmacologic therapies appropriate for the condition and the patient, and only consider opioid therapy for acute pain if benefits are expected to outweigh risks to the patient. Discuss benefits and risks with the patient prior to prescribing opioid therapy.
2. Nonopioid therapies are preferred for subacute and chronic pain. Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient. Consider opioid therapy if expected benefits are anticipated to outweigh risks, and work with the patient to establish treatment goals for pain and function. Consider how opioid therapy will be discontinued if benefits do not outweigh risks.
3. When starting opioid therapy for acute, subacute, or chronic pain, prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
4. When opioids are initiated for opioid-naive patients with acute, subacute, or chronic pain, prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, prescribe the lowest effective dosage. Avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks.
5. For those patients already receiving opioid therapy, carefully weigh benefits and risks and exercise care when changing opioid dosages. Work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risk of continued opioid therapy, optimize other therapies and work closely with patients to gradually taper to lower dosages, or appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.
6. When opioids are needed for acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
7. Evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Regularly re-evaluate benefits and risks of continued opioid therapy with patients.
8. Before starting and periodically during continuation of opioid therapy, evaluate risks for opioid-related harms and discuss risks with patients. Work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
9. When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
10. When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
11. Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
12. Offer or arrange treatment with evidence-based medications for patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended because of increased risks for resuming drug use, overdose, and overdose death.

(Dowell et al., 2022)

Delaware Guidelines for Use of Controlled Substances for Treatment of Pain

The Medical Society of Delaware (MSD) works closely with the Division of Public Health and other stakeholders to assure adequate pain care while reducing the potential for abuse and diversion of prescription medication. From these efforts, MSD developed the “Guidelines for the Use of Controlled Substance for the Treatment of Pain.” These clinical practice guidelines are tailored to relevant individual practice types that routinely deal with the management of various types of pain, including acute/subacute, chronic, emergency medicine, and hospice pain management.

In April 2017, Delaware issued regulations for safer opioid prescribing and better pain management practices, supporting the CDC Guideline for Prescribing Opioids for Chronic Pain, 2016 (DDPH, 2023). (See above for the 2022 update to the CDC guidelines.)

These regulations are aimed at stopping addiction before it starts by controlling the amount of opiates given to new patients and aggressively monitoring their treatment. These Delaware opioid prescribing rules stipulate that first-time opiate prescriptions are not to exceed a one-week supply . If further opiate prescriptions are deemed necessary, then further action must be taken by the prescriber, to include a query of the statewide Prescription Monitoring Program database and a physical exam with discussion of relevant patient history and the risks of opiates (DDOS, 2017a).

KEY ELEMENTS OF DELAWARE PRESCRIBING RULES

For an acute episode (injury or procedure):

• A first-time prescription to an adult patient for an acute episode cannot exceed a 7-day supply.
• No prescription to a minor can exceed a 7-day supply at any time.
• If professional judgment dictates more than a 7-day supply is necessary:
• Document the condition triggering the prescription.
• Query the Prescription Monitoring Program to obtain a prescription history.
• Indicate that a nonopiate alternative was not appropriate.
• Obtain informed consent, which must include information on:
  • The drug’s potential for addiction, abuse, and misuse
  • The risks of life-threatening respiratory depression associated with the drug
  • The potential for fatal overdose as a result of accidental exposure, especially in children
  • Neonatal opioid withdrawal symptoms
  • The potential for fatal overdose when interacting with alcohol
  • Other potentially fatal drug interactions, such as with benzodiazepines
• Administer a fluid drug screen, at the discretion of the provider.
• Conduct a physical examination, which must include a documented discussion to elicit relevant history, explain risks/benefits of opioid analgesics and possible alternatives, and establish other treatments tried or considered.
• Schedule periodic follow-up visits and evaluations to monitor progress, whether there is an available alternative to opiate use, and whether to refer the patient for a pain management or substance abuse consultation.

For chronic, long-term treatment with an opiate:

• Document the condition triggering the prescription, indicating that a nonopiate alternative was considered but not appropriate, obtain informed consent, and follow up with evaluations to monitor progress toward treatment goals.
• Query the Prescription Monitoring Program:
• At least every six months and more frequently if clinically indicated
• Whenever the patient is also being prescribed a benzodiazepine
• Whenever the patient is assessed to potentially be at risk for substance abuse or misuse
• Whenever the patient demonstrates loss of prescriptions, requests for early refills, or similar behavior
• Administer fluid drug screens at least every six months.
• Obtain a signed treatment agreement, which must include:
• The patient’s agreement to take medications at the dose and frequency prescribed, with a specific protocol for lost prescriptions and early refills
• Reasons for which medication therapy may be re-evaluated, tapered, or discontinued, including but not limited to violation of the treatment agreement or lack of effectiveness
• The requirement that all chronic pain management prescriptions are provided by a single practitioner or a limited, agreed-upon group of practitioners
• The patient’s agreement to not abuse alcohol or use other medically unauthorized substances or medications
• Acknowledgment that a violation of the agreement may result in action as deemed appropriate by the prescribing practitioner such as a change in the treatment plan, a referral to a pain specialist, or referral to an addiction treatment program
• The requirement that fluid drug screens be performed at random intervals at the practitioner’s discretion, but no less than every six months
(DDPH, 2017)

PREVENTING PRESCRIPTON DRUG MISUSE AND DIVERSION

Various actions by healthcare providers can help prevent prescription drug misuse and diversion. These include:

• Educating patients on safe use, storage, and disposal of medications
• Understanding which drugs are commonly misused and/or diverted
• Recognizing aberrant drug-related behaviors (ADRB) (behaviors that may be associated with misuse of prescription opioids)
• Detecting and responding to drug diversion in the workplace

Institutional measures are also an important part of addressing the opioid epidemic, such as:

• Delaware prescription monitoring program (PMP)
• Medication formulation and abuse-deterrent formulations

Teaching Safe Use, Storage, and Disposal of Prescription Medications

Educating patients on safe use, storage, and disposal of medications is an essential part of addressing the opioid and drug diversion epidemic. Nurses and prescribers can address the following points with patients who have been prescribed opioids:

SAFE USE

• Before you are prescribed opioids, tell your healthcare provider about all other medications and supplements you are taking.
• Tell your healthcare provider if you or your family has a history of alcohol or drug addiction. There are other pain treatment options that are equally as effective as (or more effective than) opioids and don’t carry the same risks for addiction and overdose.
• Only take opioids prescribed to you and as directed by your healthcare provider.
• Never accept opioids from anyone else.
• Don’t share your medications with others, because they may cause harm to someone else.
• Store prescription opioids in a locked container and out of children’s reach (see below).
• Safely dispose of any unused medication when you are not longer using the medication (see below).
• If you’ve been prescribed opioids, talk to your healthcare provider about your risk for overdose.
• Tell your healthcare provider if you experience changes in your mood, balance, sleep, or pain level, and if you find it difficult to stop or decrease opioid use.
• Discuss with your healthcare provider alternative ways to manage your pain.
  (VA, 2020)

SAFE STORAGE

Opioids are controlled substances, and their possession and use is regulated by state and federal laws. More than 70% of people who misuse prescription opioids obtain them from family and friends. Therefore, it is important that patients safely store their prescription medications. The CDC also recommends that prescribers discuss risks to household members and other individuals if opioids are intentionally or unintentionally shared with others for whom they are not prescribed, including the possibility that others might experience overdose at the same or at lower dosage than prescribed for the patient.

• Store opioids in their original packaging inside a locked cabinet, a lockbox, or other secure location.
• Do not store opioids in obvious places like bathroom cabinets or on kitchen counters where others might find them.
• Note when and how much medication you take in order to keep track of the amount left.
  (AAFP, 2021; Dowell et al., 2022; SAMHSA, 2020)

SAFE MEDICATION DISPOSAL

Prescribers and/or pharmacists often provide specific disposal instructions for unused or expired medicines, and patients are educated to follow those instructions. There are a variety of ways to dispose of medications. The FDA (2020a) outlines three options for drug disposal according to the type of drug: a take-back site, the flush list, or household trash.

Delaware currently has 21 permanent medication collection boxes across the state. This program is anonymous; no questions or requests for identification are made by law enforcement personnel present. Expired, unused, or unwanted medication can be dropped off at these locations to ensure proper disposal. Drugs must be in a container such as a pill bottle, box, blister pack, or zip-lock bag. Liquid medications should be left in their original containers. No needles, aerosols, biohazard materials, medical equipment, batteries, syringes, or other biohazard waste may be deposited into the drop-off boxes (DDPH, n.d.).

Flushing Disposal

If a drug take-back option or DEA-authorized collector is not available and a medication is on the FDA flush list (see table below), the FDA recommends safely flushing such approved medications down the toilet. The medicines on the flush list are those sought after for their misuse and abuse potential or those that can result in death from one dose if inappropriately taken. For these reasons, FDA recommends that patients flush them down the toilet to immediately and permanently remove these risks from their home.

The FDA believes that the risk of harm from accidental exposure to these few select medicines far outweighs any potential risk to the environment that may come from disposal by flushing (Khan et al., 2017).

FDA’s FLUSH LIST

Drug Name	Examples
(U.S. FDA, 2020b)
Drugs That Contain Opioids
Any drug that contains the word buprenorphine	Belbuca, Buavail, Butrans, Suboxone, Subutex, Zubsolv
Any drug that contains the word fentanyl	Abstral, Actiq, Duragesic, Fentora, Onsolis
Any drug that contains the words hydrocodoneor benzhydrocodone	Apadaz, Hysingla ER, Norco, Reprexain, Vicodin, Vicodin ES, Vicodin HP, Vicoprofen, Zohydro ER
Any drug that contains the word hydromorphone	Exalgo
Any drug that contains the word meperidine	Demerol
Any drug that contains the word methadone	Dolophine, Methadose
Any drug that contains the word morphine	Arymo Er, Avinza, Embeda, Kadian, Morphabond ER, MS Contin, Oramorph SR
Any drug that contains the word oxycodone	Codoxy, Combunox, Oxadydo (formerly Oxecta), Oxycet, Oxycontin, Percocet, Percodan, Roxicet, Roxicodone, Roxilox, Roxybond, Targiniq ER, Troxyca ER, Tylox, Xartemis XR, Xtampza ER
Any drug that contains the word oxymorphone	Opana, Opana ER
Any drug that contains the word tapentadol	Nucynta, Nucynta ER
Drugs That Do Not Contain Opioids
Any drug that contains the term sodium oxybate or sodium oxybates	Xyrem, Xywav
Diazepam rectal gel	Diastat, Diastat Acudial
Methylphenidate transdermal system	Daytrana

Household Trash Disposal

If a drug take-back program is not available and a medication is not on the flush list, the FDA (2018) provides the following guidance on how to dispose of drugs via household trash:

• Mix medicines (liquid or pills; do not crush tablets or capsules) with an unappealing substance such as dirt, cat litter, or used coffee grounds.
• Place the mixture in a container such as a sealed plastic bag.
• Throw away the container in the household trash.
• Delete all personal information on the prescription label of empty medicine bottles or medicine packaging, then trash or recycle the empty bottle or packaging.

Even after fentanyl patches have been used, a degree of medication remains. These patches should be folded over so the adhesive sticks together and no exposed area that contains the drug remains. It should then be flushed or disposed of per the household trash disposal guidelines.

Since inhalers are dangerous if punctured or if they come in contact with fire, they must be treated with care. Local trash and recycling facilities typically provide information on how to properly dispose of inhalers in their area.

Understanding Commonly Abused/Misused Drugs

The U.S. Drug Enforcement Administration (2020a) recognizes five classes of drugs that are frequently abused: opioids/narcotics, depressants, hallucinogens, stimulants, and anabolic steroids, with opioids being the most commonly misused. The extent to which the drug is reliably capable of producing intensely pleasurable feelings (euphoria) increases the likelihood of that substance being abused.

Three specific classes are most commonly abused and thus most susceptible to diversion for nonmedical use:

• Pain medications/narcotics. Opioid pain relievers (narcotics) are the most commonly diverted controlled prescription drugs. Opioid medications are effective for the treatment of pain and have been used appropriately to manage pain for millions of people, however increased rates of abuse and overdose deaths have raised concerns about proper use of these medications in the treatment of chronic pain.
• Central nervous system (CNS) depressants/sedatives/hypnotics. CNS depressants slow brain activity and are useful for treating anxiety and sleep disorders. Since many patients with pain also experience anxiety or sleep disturbances, increased prescribing of sedative hypnotics has paralleled the increase in prescribing of opioids. Clinicians who add sedative hypnotics to the treatment plan for chronic pain patients may potentiate the risk for patients who are also prescribed opioid medication.
• Stimulants. Stimulants are prescribed primarily for treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy. They may also be used as an adjunct medication in the treatment of depression. When taken nonmedically, stimulants can induce a feeling of euphoria and thus have a high potential for abuse and diversion. They also have a cognitive enhancement effect that has contributed to non-medical use by professionals, athletes, and other individuals who rely on productivity. Nonmedical use of stimulants poses serious health consequences, including addiction, cardiovascular events, and psychosis.
  (NIDA, 2020)

PRESCRIPTION DRUGS WITH HIGH POTENTIAL FOR DIVERSION/ABUSE

Category	Drugs
(NIDA, 2020)
Opioids	Codeine Fentanyl Hydrocodone or dihydrocodeinone Hydromorphone Meperidine Methadone Morphine Nalbuphine Oxycodone Oxymorphone
CNS depressants	Barbiturates: pentobarbital Benzodiazepines: alprazolam, chlordiazepoxide, diazepam, lorazepam, triazolam Sleep medications (hypnotics): eszopiclone, zaleplon, zolpidem Ketamine (can be classified as an analgesic, centrally acting nonopioid, anesthetic, or antidepressant depending on how it is used; when used appropriately, its primary purpose is sedation)
Stimulants	Amphetamines Methylphenidate

Recognizing Aberrant Drug-Related Behaviors

Some patients who are prescribed opioid pain medication are at increased risk for opioid misuse and diversion. These patients may demonstrate certain misuse behaviors that can provide clues to the clinician. By recognizing what are called aberrant drug-related behaviors (ADRBs), nurses can respond appropriately and help patients to remain safe.

ADRBs may occur because a patient is experiencing poor pain control or has a fear of uncontrolled pain, which can lead to hoarding of medication. The behaviors may also be attributed to elective use of opioid medication for the euphoric effect or for non-pain-related symptoms such as anxiety, depression, insomnia, and stress.

ADRBs in patients who are prescribed opioids should trigger clinicians to the possibility of addiction. Current literature suggests a range of aberrant drug-related behaviors, with some more predictive of addiction than others. Being aware of the behaviors described in the following box can help guide clinicians who are treating and monitoring patients who are receiving prescription opioid therapy for long-term pain management.

The presence of aberrant behaviors, however, may indicate a range of problems other than misuse or diversion, and the clinician must explore a differential diagnosis. Possible etiologies include addiction, pseudo-addiction, another psychiatric disorder, personality disorder, chronic boredom, mild encephalopathy, withdrawal states, and genuine undertreatment of pain. Therefore, it is important to monitor, document, and communicate any aberrant behaviors using objective means and in a team-based fashion over the patient’s entire course of care. This process will also remove any bias on the part of a single provider.

In the hospital setting, monitoring and responding to ADRBs is important in order to:

• Determine the success or failure of treatment
• Help prevent the transition of chronic pain to opioid dependence and SUD
• Help prevent psychiatric disorders such as anxiety and depression
• Identify undiagnosed SUD
• Identify patients at high risk for diversion
• Identify possible complications of opioid therapy
  (Maumus et al., 2020)

Drug Diversion in the Workplace

The opportunity for diversion of controlled substances from the workplace exists, and diversion of opioids is seen across all clinical disciplines and all levels of an organization, from management to frontline staff.

Despite a lack of comprehensive studies on the topic, one 2020 analysis of publicly reported diversion incidents involving healthcare workers found that diversion occurred in various settings: hospital/medical center/clinic (32%), practice (26%), long-term care (20%), pharmacy (17%), ambulance services (5%), and other (1%). Data on the diverter’s role found doctors to be the most common diverters (36%), followed by nurses (31%), pharmacist/pharmacy tech (13%), executive/owner/operator (9%), paramedic/emergency services (6%), and other (2.5%) (Protenus, 2021). Nurses may be at increased risk for misuse or diversion of prescription medications due to working in environments where frequent and easy access to controlled substances is part of their daily work routine (TJC, 2019; Mumba, 2018).

Diversion may occur with opened or unopened vials, partially used doses of medication that are not wasted, and medication that has been disposed of and left in sharps containers. The drugs most commonly diverted from healthcare settings are opioids, but there is no precise data that defines the extent of drug diversion.

Every nurse plays an important role in drug diversion prevention and should be able to recognize patterns, trends, and behaviors associated with drug diversion in the workplace. These may include:

• Consistently arriving early, staying late, or frequently volunteering for overtime
• Frequent breaks or trips to bathroom
• Heavy wastage of drugs
• Drugs and syringes in pockets
• Anesthesia record does not reconcile with drug dispensed and administered to patient
• Patient has unusually significant or uncontrolled pain after anesthesia
• Higher pain score as compared to other anesthesia providers
• Times of cases do not correlate when provider dispenses drug from automated dispenser
• Inappropriate drug choices and doses for patients
• Missing medications or prescription pads
• Drugs, syringes, needles improperly stored
• Signs of medication tampering, including broken vials returned to pharmacy
• Compromised product containers
• Frequent medication losses, spills, or wasting
• Controlled substances removed without a doctor’s order
• Controlled substances removed on recently discharged or transferred patient
• Controlled substances removed for a patient not assigned to the nurse
• Medication documented as given but not administered to the patient
• Frequent reports of ineffective pain relief from patients
• Frequent unexplained disappearances from the unit
• Incorrect controlled substance counts
• Consistently documenting administration of more controlled substances than other nurses
• Large amounts of narcotic wastage
• Numerous corrections on medication records
• Offers to medicate coworkers’ patients for pain
• Saving extra controlled substances for administration at a later time
• Altered verbal or phone medication orders
• Variations in controlled substance discrepancies among shifts or days of the week
  (NCSBN, 2018; AANA, 2021; U.S. DEA, 2021c; Brummond et al., 2017)

Essential organizational steps to address drug diversion in the workplace include:

• Prevention. Healthcare facilities must have systems in place to guard against theft and diversion of controlled substances. It is important that all staff understand and comply with these protocols, and act in ways to minimize unauthorized access or opportunities for tampering and misuse.
• Detection. Systems can include video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, and training staff to be aware of and alert for behaviors and other signs of potential diversion activity.
• Response. Appropriate responses include establishing a just culture in which reporting drug diversion is encouraged, assessing harm to patients, consulting with public health officials when tampering with injectable medication is suspected, and promptly reporting to enforcement agencies.
  (TJC, 2019)

Institutional Measures to Prevent Prescription Drug Misuse

Institutional measures are also an important part of addressing the opioid epidemic. Several such measures are discussed below.

DELAWARE PRESCRIPTION MONITORING PROGRAM (PMP)

The Delaware Prescription Monitoring Act (16 Del. C.§ 4798) authorizes the Office of Controlled Substances (OCS) in the Delaware Division of Professional Regulation to establish, maintain, and monitor the PMP. The purpose of the PMP is to reduce misuse of controlled substances in Delaware and to promote improved professional practice and patient care.

The PMP is a system that collects information on all controlled substance (schedules II–V) prescriptions. Using the PMP website, Delaware-licensed pharmacies and prescribers who dispense controlled substances report prescription data to the PMP daily. Prescribers and dispensers registered with the PMP can obtain immediate access to an online report of their current or prospective patient’s controlled substance prescription history. This PMP website is available 24/7 and is to be used for healthcare purposes only (DDPR, n.d.-a).

PMP capabilities include:

• Timesaving “NARX Score,” a three-digit score that corresponds to overall overdose risk; automatically calculated and displaying, at a glance, a patient’s current level of risk based on prescription history, without having to drill down to details
• Generation of multiple patients’ reports in one click
• Prescriber reports to compare a prescriber’s rates with other prescribers in the same specialty, emailed quarterly
• “My Rx” reports, which detail a prescriber’s prescribing data for any specific time period and can be run at any time
• Data sharing with many other states (new states added regularly)
• Integration into practice flow within the prescriber’s electronic health record system, using a single sign-on
• Morphine milligram equivalent (MME) automatically calculated for patient reports
• CDC resources, including helpful fact sheets about prescription drug monitoring programs

(See also “Resources” at the end of this course.)

MEDICATION FORMULATION

Manufacturers of prescription drugs continue to work on new formulations of opioid medications, known as abuse-deterrent formulations (ADFs) , which include technologies designed to prevent people from misusing them by snorting or injection. Abuse-deterrent formulations have been shown to decrease the illicit value of drugs. Several ADF opioids are on the market, and the FDA has called for the development of ADF stimulants.

Abuse deterrent strategies currently being used include:

• Physical or chemical barriers that prevent the crushing, grinding, or dissolving of drugs
• Agonist/antagonist combinations that cause an antagonist (which will counteract the effect of the drug) to be released if the product is manipulated
• Aversive substances that are added to create unpleasant sensations if the drug is taken in a way other than directed
• Delivery systems such as long-acting injections or implants that slowly release the drug over time
• New molecular entities or prodrugs that attach a chemical extension to a drug that renders it inactive unless taken orally

The development of effective, nonaddicting pain medications is also a public health priority. Researchers are exploring alternative treatment approaches that target other signaling systems in the body, such as the endocannabinoid system, which is also involved in pain (NIDA, 2020).

PRESCRIBING AND ADMINISTERING OPIOID ANTAGONISTS (NALOXONE)

Nearly 50,000 people died of opioid-related overdose in 2019 alone, and provisional data indicate a likely increase in that number for 2021 (NIDA, 2021). The availability of the opioid overdose-reversal drug naloxone has been shown to reduce the rate of these overdose deaths, and laws have been enacted in all U.S. states, including Delaware, to expand access to this life-saving medication.

Prescribing Naloxone

Naloxone is an opioid antagonist that blocks opioid receptors. The drug comes in intravenous, intramuscular, and intranasal formulations and is FDA-approved for use in an opioid overdose and for the reversal of respiratory depression associated with opioid use. The CDC guidelines recommend that naloxone be coprescribed to any individual who is prescribed high-dose opioid therapy (≥50 MME per day) or any combination of opioids and benzodiazepines. Recommendations also call for overdose prevention education to both patient and household members.

Candidates for naloxone are those who:

• Take high doses of opioids for long-term management of chronic pain
• Receive rotating opioid medication regimens
• Have been discharged from emergency medical care following opioid poisoning or intoxication
• Take certain extended-release or long-acting opioid medication
• Have had a period of abstinence from opioids, including those recently released from incarceration

Pregnant women can be safely given naloxone in limited doses under the supervision of a doctor (SAMHSA, 2021b).

Patient Education regarding Naloxone Administration

Patient education includes showing patients, their family members, or caregivers how to administer naloxone. The medication can be given by intranasal spray or intramuscular, subcutaneous, or intravenous injection.

Patients given an automatic injection device or nasal spray should keep the item available at all times. The medication must be replaced when the expiration date passes and if exposed to temperatures below 39 °F or above 104 °F.

Naloxone is effective if opioids are misused in combination with other sedatives or stimulants. It is not effective in treating overdoses of benzodiazepines or stimulant overdoses involving cocaine and amphetamines (SAMHSA, 2021b).

Side effects of naloxone may include an allergic reaction from naloxone, such as hives or swelling in the face, lips, or throat, for which medical help should be sought immediately. Use of naloxone also causes symptoms of opioid withdrawal. Opioid withdrawal symptoms include:

• Feeling nervous, restless, or irritable
• Body aches
• Dizziness or weakness
• Diarrhea, stomach pain, or nausea
• Fever, chills, or goose bumps
• Sneezing or runny nose in the absence of a cold

Since naloxone is a temporary treatment and its effects will wear off, medical assistance must be obtained as soon as possible after administering/receiving naloxone (SAMHSA, 2021b).

Expanding Access to Naloxone

Recommendations regarding increased access to naloxone include:

• Allowing providers to prescribe naloxone to third parties who may witness an overdose (i.e., family and friends of people who use opioids)
• Removing the need for individual prescriptions by allowing naloxone to be dispensed without a patient-specific prescription
• Allowing and equipping law enforcement officers to carry and administer naloxone
• Providing naloxone to people at risk of overdose who are leaving hospital, treatment, or corrections settings
• Permitting local agencies and organizations to distribute naloxone to community members who may be likely to witness an overdose
• Enacting “Good Samaritan” laws that provide immunity to people who experience or witness an overdose to encourage them to call 911 for help without fear of arrest (see below)
• Reducing costs for individuals and state governments by mandating public and private insurance coverage and negotiating with manufacturers for lower-cost bulk purchases
  (PEW, 2020)

Delaware’s Good Samaritan Law

Delaware has had increasing legislative support in curbing the prescription drug epidemic. Two Delaware laws, known as Good Samaritan laws, offer criminal and civil protection for individuals acting in good faith to assist someone who has overdosed from drugs or alcohol.

• Title 16, 4769, protects individuals who request medical assistance for someone who is overdosing. The law encourages witnesses to call 9-1-1 or seek medical attention for individuals at risk of dying from an overdose or other life-threatening emergency. It also protects both the witness and the person they’re assisting from being prosecuted for possession of an illegal substance.
• Title 16, 6801, protects individuals who administer naloxone to an individual who is overdosing from opioids such as heroin, fentanyl, or oxycodone. Naloxone is a lifesaving medication that can reverse an opioid overdose. Under the law, individuals who provide emergency care in good faith are immune from civil damages. That means you can’t be held responsible in civil court for administering naloxone to someone who is overdosing.

(HelpIsHereDE, 2023b)

CHEMICAL DEPENDENCY AND IMPAIRMENT IN THE WORKPLACE

Impairment from substance abuse, drug diversion, or other physical or psychological causes has far-reaching impact. It not only threatens the health and safety of patients but also creates serious consequences for the impaired professional, colleagues, and the healthcare facility that employs the impaired clinician.

The Nurse Worklife and Wellness Study found that in the year prior to the study illicit drug use among nurses was 5.7% and misuse of prescription drugs was 9.9% (Trinkoff et al., 2022). The exact number of nurses afflicted is unknown, but the prevalence of addiction among nurses is believed to mirror the general population. In 2020, an estimated 37.3 million Americans aged 12 or older were current illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 13.5% of the general population aged 12 or older (SAMHSA, 2021c).

Risk Factors for Substance Abuse

Healthcare professionals may be at increased risk for abuse of prescription-type medication due to the added risk of working in environments where frequent and easy access to controlled substances is part of their daily work routine. For instance, evidence suggests the types of drugs abused by nurses may depend on what drugs are most accessible in their individual work environments. The most common prescription drugs abused by nurses are benzodiazepines and opioid analgesics. Nurses who abuse prescription drugs are those who have the greatest access, such as nurse anesthetists (American Addiction Centers, 2022).

Signs of Substance Abuse and Impaired Practice

Impairment renders a clinician unsafe to provide patient care. Physical, psychosocial, and behavioral clues, however, can be subtle and easily overlooked. Colleagues may notice clues but seek other explanations and avoid suggesting substance abuse as a possible cause.

Generally, disruptions in family, personal health, and social life manifest long before an individual shows evidence of impairment at work. Thus, all indicators, no matter how subtle, appearing in the workplace must be taken seriously. Any of the following may be signs of impairment in the workplace, and patterns of such behavior and a combination of these signs are cause for increased suspicion.

COMMON SIGNS OF IMPAIRMENT

Type	Signs
(Nyhus, 2021; AANA, n.d.; Toney-Butler & Siela, 2020)
Physical	Progressive deterioration in personal appearance Wearing long sleeves when inappropriate Diminished alertness, confusion, or memory lapses Frequent runny nose Dilated or constricted pupils Bloodshot or glassy eyes Unsteady gait Slurred speech Diaphoresis Frequent nausea, vomiting, or diarrhea Tremors or shakes, restlessness Weight gain or loss
Psychosocial	Increasing isolation or withdrawal from colleagues Personal relationship problems Dishonesty with self and others Intoxication at social functions Defensiveness (e.g., denial, rationalization) Inappropriate verbal or emotional responses Mood swings, overreaction to criticism, overexcitement Personality change (mood swings, anxiety, panic attacks, depression, lack of impulse control, suicidal thoughts or gestures, feelings of impending doom, paranoid ideation) Feelings of shame, guilt, loneliness, sadness
Behavioral	Absenteeism (absences without notification, excessive use of sick days, excessive tardiness) Confusion, memory loss, and difficulty concentrating or recalling details and instructions Ordinary tasks requiring greater effort and consuming more time Frequent complaints of vague illness, injury, pain Insomnia Rarely admitting errors or accepting blame for errors or oversight Unreliability in keeping appointments and meeting deadlines Work performance that alternates between periods of high and low productivity Working excessive amounts and showing up on days not scheduled Making mistakes due to inattention, poor judgment, bad decision-making Sleeping on the job Elaborate, implausible excuses for behavior

Intervening and Reporting Impaired Practice in a Colleague

When planning to intervene in a case of suspected impairment, the first step is knowing state laws and rules pertaining to substance abuse and impairment in the workplace. It is also important to be familiar with and to follow the organization’s policies and procedures relating to substance abuse and impairment.

Healthcare professionals can follow these steps when they begin to notice possible impaired practice in a colleague:

• Observe job performance; be aware of signs and symptoms of impairment that are common in the workplace.
• Look for patterns of behavior indicating possible impairment that are consistent over a period of time.
• Document (date, time, place, witnesses) any inappropriate behavior; be concise and include objective, clear, and factual information:
• What happened?
• Who was involved?
• When did the incident occur?
• How was it discovered?
• Where did it occur?
• Were there any witnesses?

Supervisors should be involved in planning an intervention and taking steps to respond to concerns about impairment in the workplace.

• Planning and participating in an intervention is a critical responsibility of the manager, and it should never be implemented alone.
• It is important to develop a careful plan of action before implementing an intervention and also important to secure help.
• Interventions should focus on documented facts.
• The primary objective of an intervention is to request the clinician refrain from practice until a fitness-to-practice evaluation has been completed (IPN, 2023).
• To assure safety, a clinician who is impaired should never be left alone and should not be permitted to drive.

Delaware-licensed healthcare providers and certain other entities have a mandatory duty to report Delaware-licensed medical practitioners or other healthcare providers when they reasonably believe that the practitioner is (or may be) guilty of unprofessional conduct or unfit to practice. For example, under their board’s Rules and Regulations, Delaware-licensed nurses must report unsafe nursing practices or conditions. Delaware law allows the Division of Professional Regulation (DPR) to keep the identity of the person who makes the report confidential, when appropriate, and affords immunity from civil or criminal prosecution for good faith reporting (DDPR, n.d.-b).

CONCLUSION

Currently, there is an epidemic of prescription drug abuse, diversion, and overdose deaths not only in Delaware but also across the country. The complexity of this crisis creates challenges for federal, state, and local governments as well as nongovernmental partners who must confront the growing impacts on the community.

Overprescribing opioids for more than a decade has contributed to prescription opioid addiction and led to a sharp increase in opioid addiction, which is associated with a significant increase in heroin abuse, health compromise, and overdose deaths. A multifaceted public health approach is necessary in order to effectively reduce opioid-related morbidity and mortality.

The opioid epidemic in this country has evolved and escalated along with an epidemic of chronic pain. With current evidence affirming that less-risky pain alternatives are just as effective as opioids for managing chronic pain, it is clear that there must be a cultural shift away from treating chronic pain with opioid medication.

Healthcare professionals are in a unique position to address this dual epidemic with the right clinical skills and knowledge in assessment and management of addiction risk and best practices for safe opioid prescribing. A comprehensive approach that supports safe and effective pain management without increasing patient risk for addiction must be priority in every clinical practice setting.