Prescription drug abuse is an epidemic in the Appalachian region that is impacting public health, education, economic development and family life. This talk will examine epidemiologic factors associated with prescription and over-the-counter drug misuse. Commonly abused prescription and over-the-counter drugs will be discussed and safe patient and prescriber factors that can increase the risk of prescription drug abuse will be compared. The strengths and limitations of prescription-drug monitoring programs will be explained. Session participants will discuss actions they have taken in their community to fight prescription drug abuse.

1. VRHA/VFC Annual Conference 2009
Prescription and Over-the-Counter
Drug Misuse and Abuse
Risk Factors, Red Flags, and Prevention Strategies
Sarah T. Melton, PharmD,BCPP,CGP
2009 VRHA/VAFC Joint Meeting
The Homestead Resort
November 17, 2009
“The nonmedical use or abuse of prescription drugs is a
serious and growing public health problem in this country.
The elderly are among those most vulnerable to prescription
drug abuse or misuse because they are prescribed more
medications than their younger counterparts. Most people
take prescription medications responsibly; however, an
estimated 48 million people (ages 12 and older) have used
prescription drugs for nonmedical reasons in their lifetimes.
This represents approximately 20 percent of the U.S.
population.”
Nora Volkow, MD. Director, National Institute on Drug Abuse
2
Objectives
At the completion of this presentation, the participant will be able to:
1. Examine epidemiologic factors associated with
prescription and over-the-counter drug misuse and
abuse in Virginia and Central Appalachia.
2. Discuss commonly abused prescription and over-the-
counter drugs.
3. Compare and contrast safe patient and prescriber
factors that can increase the risk of prescription drug
abuse and describe prescribing practices that can limit
abuse.
4. Explain the strengths and limitations of prescription-
drug monitoring programs.
Sarah T. Melton, PharmD,BCPP,CGP 1

2. VRHA/VFC Annual Conference 2009
Prescription drug misuse: A concerning trend
While most people take prescription medications
responsibly for the reasons in which the medications
were prescribed, there has been an increasing trend
in non-medical use of pharmaceuticals.
Video and images of prescription drugs misuse and
abuse are increasing as the media reporting on the
popularizing of pharmaceuticals intensifies.
Increase in Controlled Substance Abuse
(1992-2003)
Scope of the Problem
6.4 million (2.6%) of people aged 12 or older
used prescription psychotherapeutic drugs for
nonmedical reasons in the past month
4.7 million used pain relievers
1.8 million used tranquilizer
1.1 million used stimulants
Nonmedical use of pain relievers and marijuana
account for the largest number of first-time
abuse
Sarah T. Melton, PharmD,BCPP,CGP 2

3. VRHA/VFC Annual Conference 2009
Scope of the Problem
(Substance Abuse and Mental Health Services Administration [SAMHSA], 2007)
Scope of the problem
Source?
56.5% reported obtained free from friend or
relative
18.1% reported obtained from one or more
doctors
4.1% purchased from a drug dealer or
stranger
0.5% bought from the internet
http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.pdf
Drug abuse related ED visits
Drug abuse related emergency department visits involving narcotic analgesics and benzodiazepines (data from
2003 not available). Source: DAWN data.
Sarah T. Melton, PharmD,BCPP,CGP 3

4. VRHA/VFC Annual Conference 2009
Drug/Poison Caused Death Rates by
City/County of Residence, 2007
Office of the Chief Medical Examiner Annual Report, 2007.
Prescription Drug Abuse in Appalachia
Admission rates for the primary abuse of opiates
and synthetic are higher in Appalachia than in the
rest of the nation.
Rates are rising across the nation and in
Appalachia, the rate of increase in Appalachia is
greater; particularly in Appalachian coal mining
areas.
National Opinion Research Center (NORC) at the University of Chicago and East Tennessee State University. An
Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian
Region Final Report August 2008
Prescription Drug Abuse in Appalachia
Appalachian adolescents demonstrate similar use
patterns for cocaine, marijuana and
methamphetamine
Non-medical use of psychotherapeutics
Cigarettes Higher compared
with rest of US
Heavy alcohol use
Highest rate of non-medical use of psychotherapeutics
Distressed, at-risk Appalachian counties
10.6% in Appalachia, 8.7% outside Appalachia
National Opinion Research Center (NORC) at the University of Chicago and East Tennessee State University. An
Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian
Region Final Report August 2008
Sarah T. Melton, PharmD,BCPP,CGP 4

5. VRHA/VFC Annual Conference 2009
Adolescents in Appalachia
Past year nonmedical use of psychotherapeutics
Painkillers Use in Past Year
Coal Mining Status of Patient Location
Sarah T. Melton, PharmD,BCPP,CGP 5

6. VRHA/VFC Annual Conference 2009
Trends in Use
People use potentially addicting prescription
or OTC medications in the following manner:
For legitimate medical treatment
As a substitute when drug of choice (DOC) is not
available
As a booster for a more intense high
As an alternative when DOC has been eliminated
from use by drug testing
As an alternative addictive drug prescribed by
physicians
Lessenger JE, Feinberg SD. Abuse of prescription and over-the counter medications. J Am Board Fam Med
over-
2008;21:45-54.
2008;21:45-
Defining Abuse
Appropriate use
Use of controlled substance as prescribed for defined
condition with no signs of misuse or abuse.
Misuse/inappropriate use
Use of controlled substance for reason other than that
for which it was prescribed or in dosage different than
that prescribed
Abuse
Use of controlled substance outside normally
accepted standards of use, resulting in disability
and/or dysfunction.
Dependence and Tolerance
Physical dependence does not equal abuse
Dependence: abrupt cessation of intake of
a substance leads to characteristic
withdrawal symptoms
Tolerance: state in which escalating doses
must be ingested to attain the same effect
Sarah T. Melton, PharmD,BCPP,CGP 6

7. VRHA/VFC Annual Conference 2009
Dependence, Addiction, and Pseudo-addiction
Dependence
Addiction
Pseudo-addiction
Person engages in drug-seeking behavior
simply to obtain therapeutic and effective
dosage of medication
Pharmacologic Properties of Medications
Likely to be Abused
Rapid onset of action
High degree of potency or intensity
Brief duration of action
High purity and water solubility
High volatility
Parran T. Prescription drug abuse: a question of balance. Med Clin North Am 1997;(81(4): 967-978.
Characteristics of Abusers
White
Younger (stimulants)
Tend to use opiates
Tend to be women (sedatives)
Tend to mix medications with alcohol
Tend to use prescription and OTC meds in
combination with alcohol to attempt suicide
Obtain prescriptions from physicians or dentists,
from friends, or purchase on the black market
Lessenger JE, Feinberg SD. Abuse of prescription and over-the counter medications. J Am Board Fam Med
over-
2008;21:45-54.
2008;21:45-
Sarah T. Melton, PharmD,BCPP,CGP 7

8. VRHA/VFC Annual Conference 2009
Lucrative Black Market
Quality and potency are guaranteed
Obtaining from health professional less
than cost on the street
Oral products perceived to be “safer”
Drugs can be traded on the street for
other drugs of choice
Values for Commonly Prescribed Substances
Hydromorphone (Dilaudid) $30/tab
Morphine (MSIR, Roxanol) $20/tab
Meperidine (Demerol) $15/tab
Oxycodone (Percocet, Tylox) $7-10/tab
Methadone (Dolophone, Methadose) $9/tab
Diazepam (Valium) $8/tab
Methylphenidate (Ritalin) $6/tab
Hydrocodone (Vicodin, Lortab) $3-6/tab
Oxycodone ER (Oxycontin) $1/mg
State Police Drug Diversion Unit for average prices, 2005
Opioids
Hydrocodone is the most commonly prescribed drug
in the United States
Opioids are second most commonly abused drug,
falling after marijuana and before cocaine
20-40% of patients taking opioids for chronic pain
have UDS positive for marijuana, alcohol or
unprescribed controlled substance
Estimated number of ED visits involving narcotic
abuse rose 117% from 1994 to 2002
Drug Abuse Warning Network Report
Sarah T. Melton, PharmD,BCPP,CGP 8

9. VRHA/VFC Annual Conference 2009
Opioids
More people died from drug overdoses in
Western Virginia in 2006 than from
homicides, house fires and alcohol-related
automobile accidents combined.
The region had 264 fatal drug overdoses
in 2006
22 percent increase from 2005
294 percent increase from a decade ago.
Methadone (combined with benzodiazepines)
most fatal drug
Where pain relievers are obtained
www.oas.samhsa.gov/nsduh/2k6nsduh/2k6results.pdf
Opiate Use (1997-2006)
Source: Based on data from US Drug Enforcement Administration. Automation of Reports and Consolidated
Orders System (ARCOS); www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html
Sarah T. Melton, PharmD,BCPP,CGP 9

10. VRHA/VFC Annual Conference 2009
Opioids : Increased Risk of Abuse
Significantly more dramatic, euphoric
reaction the first time they use them
Tobacco use
Criminal record
Presence of mood disorder
History of emotional, physical, sexual
abuse
Wilson J. Strategies to stop abuse of prescribed opioid drugs. Ann Int Med 2007;146(12):897-900.
Retail Sales of Opioid Medications (grams)
Source: http:www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.htmo
Opioid Risk Stratification Tools
Screening Instrument for Substance Abuse
Potential (SISAP)
Opioid Risk Tool
The Screener and Opioid Assessment for Patients
with Pain (SOAPP)
www.painedu.org
Drug Abuse Screening Test (DAST)
The Current Opioid Misuse Measure (COMM)
Prescription Opioid Misuse Index
Sarah T. Melton, PharmD,BCPP,CGP 10

11. VRHA/VFC Annual Conference 2009
Stimulants
Misuse most frequently involves immediate-
release methylphenidate and dextroamphetamine
Past year use is more prevalent among person
aged 25 years or younger
Peak use in mid-1990s, annual prevalence of
amphetamine use has fallen in all age categories
since that time
2.8% percent of all 12th graders reported they
had used Adderall®.
Amphetamines rank fourth among 12th graders
for past-year illicit drug use.
Kroutil LA, Van Brunt DL, Herman-Stahl MA, et al. Nonmedical use of prescription stimulants in the
Herman- the
United States. Drug and Alcohol Dependence 2006;84: 135-143.
135-
Stimulant abuse
545 subjects (89.2% with ADHD)
14.3% abused stimulants
79.8% abused short-acting agents
17.2% abused long-acting agents
2% abused both
1% abused other agents
Adderall® 40%
Adderall® XR 14.2%
Ritalin® 15%
Most common method of abuse was crushing pills
and snorting (75%)
Bright GM. Abuse of medications employed for the treatment of ADHD: results from a large-scale
ADHD: large-
community survey. Medscape J Med 2008;10(5):111.
Benzodiazepines
Rarely sole or preferred drug of abuse
High doses used to enhance the euphoria
effects of opioids; boost methadone or
heroin fixes; temper cocaine highs;
augment the effects of alcohol; ease the
effect of withdrawal from other drugs
Sarah T. Melton, PharmD,BCPP,CGP 11

12. VRHA/VFC Annual Conference 2009
Benzodiazepines
Benzodiazepine use, abuse and dependence
higher in psychiatric treatment
settings/substance-abuse populations
Short-acting BZs are preferred
Diazepam (lipophilic, crosses BBB quickly)
Lorazepam, alprazolam (more potent and
reinforcing)
Less reinforcing effects
Oxazepam, clorazepate, chlordiazepoxide
Muscle relaxants
Soma® (Carisoprodol)
Centrally acting
Active metabolite is meprobamate (C IV)
Higher doses cause euphoria, impaired hand-
eye coordination and balance
Tolerance exists
Withdrawal syndrome
Atypical Drugs of Abuse
Seroquel® (quetiapine)
Quell, Suzie Q, baby heroin, Q-ball (with cocaine)
Abused intranasally
Abuse is related to sedating effects
Problematic in prisons
Neurontin® (gabapentin)
Sedating effects with a “high” similar to marijuana
Reduces cravings for alcohol
Can cause withdrawal
Sarah T. Melton, PharmD,BCPP,CGP 12

13. VRHA/VFC Annual Conference 2009
Antiretroviral agents
Norvir® (ritonovir)
Booster for other protease inhibitors
Unintended effect of heightening effects of
illicit drugs
Methamphetamine
Ecstasy
PCP
Diazepam
Inciardi JA, Surmatt Hl, Kurtz SP, et al. Mechanisms of prescription drug diversion among drug-involved club- and
drug- club-
street-based populations. Pain Medicine 2007;8(2):171-183.
street- 2007;8(2):171-
Medications for Erectile Dysfunction
Viagra® (Sildenafil)
Drug seeking behavior in homosexual and
heterosexual men and women
Often mixed with recreational drugs
Now recognized as a “club drug”
Increasingly popular among ecstasy users
Prescription Drug Abuse in the Elderly
Overall prevalence of prescription abuse is difficult to
estimate
11% of older women misuse/abuse (Simona-Wastila, 2006)
As baby boom cohort ages, extent of alcohol and
medication misuse is predicted to significantly increase
Factors associated with drug abuse in older adults
Female gender
Social isolation
History of substance abuse
History of mental illness
Medical exposure to prescription drugs with abuse potential
Culberton JW, Ziska M. Prescription drug misuse/abuse in the elderly. Geriatrics 2008; 53(9):
2008;
22-26, 31.
22-
Sarah T. Melton, PharmD,BCPP,CGP 13

14. VRHA/VFC Annual Conference 2009
OTC Substance Abuse
Intentional use of a commercially available
substance to experience its psychoactive
effects instead of use of that product for its
intended purpose.
Legal, inexpensive, easily concealed,
convenient, uncontrolled availability
1 in 10 American teens has abused OTC
medications
Antihistamines/sleep aids, caffeine, NRT, DXM
Dextromethorphan
Dex, DXM, Robo, Skittles, Triple-C, Tussin
Semisynthetic morphine derivitive
Drug of choice is Coricidin HBP®
30 mg of DXM, comes in tablet form
Plateaus of response
8 tablets – euphoria
16 tablets- dissociation
Abuse has increased 300% from 2000-2003 in
13-19 year olds
Effects begin within 30 minutes after ingestion,
and persist 6 hours
Dextromethorphan
Clinical presentation
Mood changes, giggling, euphoria, dissociation, dreamlike
experience, warm feelings for others
Tachycardia, hypertension, diaphoresis, vomiting, mydriasis,
altered tactile sensations,
Hallucinations, “zombie,” ataxic gait
Withdrawal is manifested by a profound depression
Combination with other ingredients
Guaifenesin – intense nausea and vomiting
Acetaminophen – hepatic injury
Chlorpheniramine – classic anticholinergic symptoms
Pseudoephedrine – diaphoresis, hypertension
Lab testing
Useful to identify concomitant ingestion
Can ask specifically for testing for DXM
http://www.dxmstories.com/watch.html
Sarah T. Melton, PharmD,BCPP,CGP 14

15. VRHA/VFC Annual Conference 2009
Antihistamines and Sleep Aids
Doxylamine, cyclizine, chlorpheniramine,
dimenhydrinate
Most ingestions are intentional
Used to induce hallucinations and euphoria
Tachycardia; warm, dry, flushed skin; dry
mucosa; mydriasis; delirium; urinary
retention; arrhythmias
Dimenhydrinate/diphenhydramine
OTC anti-emetic compound of diphenhydramine
and 9-chlorotheophylline
Acute effects of euphoria and hallucinations
Psychiatric patients abuse because of anti-anxiety
effects
Tachycardia, anticholinergic syndrome, agitation,
tremor, hallucinations, convulsions, delirium,
coma
Withdrawal results in sedation and memory
impairment
Caffeine
Psychoactive methylxanthine alkaloid
Widely available in beverages, analgesics,
weight loss supplements, stimulants
Children are vulnerable to caffeine effects
Dependence and withdrawal
Intentionally abused in up to 23% of children
and teens
Doses > 200 mg
Anxiety, nervousness, GI upset
Sarah T. Melton, PharmD,BCPP,CGP 15

16. VRHA/VFC Annual Conference 2009
Nicotine Replacement Therapy
Up to 5% of adolescents report trying or
using nicotine gum or patches
2% of students who have never smoked
admit to having tried NRT
Lower abuse potential than tobacco
containing products
Cost
Side effects
IV epinephrine
19 year-old male who injected 1.1 mg
epinephrine
Removed the drug from an OTC
bronchodilator used for asthma
History of IV cocaine and amphetamine
abuse
Headache, nausea, numbness of
hands/feet, chest pain, palpitations
Hall AH, Kulid KW, Rumak BH. Intravenous ephinephrine abuse. Am J Emerg Med. 1987 Jan;5(1):64- 65.
Jan;5(1):64-
Preventing prescription drug abuse/misuse
Prescription drug abuse prevention is
a is an important part of patient care.
Nearly 70 percent of Americans (191
million people) - visit a health care
provider, such as a primary care
physician, at least once every 2 years.
Accurate screening and increases in
medication should be careful
monitored by physicians as well as the
patient receiving the medication.
(National Institute on Drug Abuse [NIDA], 2001)
Sarah T. Melton, PharmD,BCPP,CGP 16

17. VRHA/VFC Annual Conference 2009
Assessing Prescription Drug Abuse:
Four Simple Questions
Have you ever felt the need to Cut down on
your use of prescription drugs?
Have you ever felt Annoyed by remarks
your friends or loved ones made about your
use of prescription drugs?
Have you ever felt Guilty of remorseful
about your use of prescription drugs?
Have you Ever used prescription drugs as a
way to “get going” or to “calm down?”
Adapted from Ewing, JA. “Detecting Alcoholism: The CAGE Questionnaire.” JAMA 252(14):1905-1907, 1884.
Questionnaire.” 252(14):1905-
Red Flags for Drug-Seeking Behavior
More concerned about the drug than the
problem
Report multiple medication sensitivities
Say they cannot take generic drugs
Refuse diagnostic workup or consultation
Sophisticated knowledge of drugs
“You are the only one who can help me”
“Lost” prescriptions
Patterns of Use Indicating Risk
Escalating use of a substance without
consultation with a physician
Use of a substance for effects independent
of a defined medical condition
Continued use of a substance despite
negative consequences
Preoccupation with obtaining the
substance
Using opioids to relieve anxiety
Abnormal results from a urine drug screen
Sarah T. Melton, PharmD,BCPP,CGP 17

18. VRHA/VFC Annual Conference 2009
Patterns of Use Indicating Risk
Unauthorized emergency department
visits
Resisting changes in therapy or use of
alternative therapies
Having been discharged from another
clinician’s practice for noncompliance
Prescription forgery Injecting oral formulations
Overdose Altering route of administration
Common Scams
Spilled the bottle…
Lost the prescription…
It is the only thing that works…
Stolen from my home…
But you filled it before…
Prescription stealing or altering…
Washed the prescription in the laundry…
“We have met the enemy…”
Editorial by Dr. Ron Pawl, published in May 2008 in
Surgical Neurology
Discusses the dramatic rising prescription rates of
opioids for non-disease based pain
Emphasizes the lack of evidence supporting use of
narcotics to treat psychological-based chronic pain
“…part of our medical leadership in pain medicine, some
of the practitioners of pain medicine and the
pharmaceutical industry all have contributed to the
increased use of narcotic medications and
unprecedented rise in narcotic drug abuse. We have
met the enemy and they are ourselves.”
Sarah T. Melton, PharmD,BCPP,CGP 18

19. VRHA/VFC Annual Conference 2009
4 D’s and Other Physician/Pharmacist Factors
Dated
Duped
Dishonest
Disabled
“Medication mania”
“Hypertrophied enabling”
“Confrontation phobia”
Strategies to Prevent Prescription Drug Abuse
Screen for alcohol and drug abuse before
prescribing controlled substances
Be knowledgeable about controlled substances
Be familiar with anxiety, depression, and pain
syndromes
Document all prescription drugs in medical
record
Adopt safe prescribing practices
Strategies to Prevent Prescription Drug Abuse
Use controlled-substance contracts
Learn “antiscam” techniques
Just say no
Turn the tables
Collaboration between pharmacists -
prescribers
Clarify cross-coverage policies
Sarah T. Melton, PharmD,BCPP,CGP 19

20. VRHA/VFC Annual Conference 2009
Safe Prescribing Practices
Use EMR and fax/electronically send prescriptions
If handwriting prescriptions, keep blanks in secure location
Use watermark paper or prescription pads
Choose long-acting opioids and opioids of lesser street
value
Limit quantity to no more than 30-day supply
No refills
Use letters and numbers to document quantity and
strength
Allow only the patient to pick-up prescriptions
Office Practice Standards
Office-wide controlled substance policy
Office visit documentation templates
Opioid risk tools
Controlled Substance Agreement
Monitoring tools
Office visits for periodic reassessment
Prescription drug monitoring program data
Pharmacy records
Urine drug screens
Pill counts
Safe Prescribing Practices
Perform a thorough physical examination and
document the results
Document the questions asked of the patient and
his or her responses
Request identification and social security number.
Photocopy these documents and include them in
the patient’s record
Confirm a telephone number at which the patient
can be contacted
During each visit, confirm the patient’s current
address
Sarah T. Melton, PharmD,BCPP,CGP 20

21. VRHA/VFC Annual Conference 2009
Safe Prescribing Practices
Ensure that there is clear clinical indication for
the drug
Define the therapeutic end point
Do not prescribe controlled substances on the
first visit
Obtain all medical records and review before
prescribing any controlled substance
State your refill policy up front
Avoid prescribing multiple substances
Avoid giving multiple refills without office visits
Train staff to respond to suspicious phone calls
Safe Prescribing Practices
Never telephone prescriptions for an unfamiliar
patient; insist the patient make an appointment
to be seen.
Trust your instincts! Take precautions when you
are suspicious.
Never prescribe drugs simply to get rid of a drug-
seeking patient.
Ensure that all prescribing and dispensing of
controlled substances are conducted within the
scope of practice and part of a valid practitioner-
patient relationship.
Characteristics of Fraudulent Prescriptions
Prescription looks “too good”
Quantities, directions or dosages differ
from the usual medical usage
Appears to be “textbook” prescriptions
Prescription appears to be photocopied
Directions written in full without
abbreviations
Prescriptions written in different color inks
or in different handwriting
Sarah T. Melton, PharmD,BCPP,CGP 21

22. VRHA/VFC Annual Conference 2009
Types of Fraudulent Prescriptions
Legitimate prescription pads stolen from
physician office and written for fictitious
patients.
Alteration of the physician’s prescription.
Change call-back number on prescription
Computers used to create prescriptions
from nonexistent prescribers or to copy
legitimate prescriptions.
Types of Fraudulent Prescriptions:
? Legitimate Use
Prescriber writes significantly more prescriptions
(or larger quantities) compared with other
prescribers in the area.
Patient appears to be returning too frequently.
Prescription written for antagonistic drugs
(uppers and downers) at the same time.
Prescriptions written in the names of other
people.
A number of people appear simultaneously, or
within a short time, all bearing similar
prescriptions from the same physician.
Prevention Techniques
Know the prescriber and his/her signature;
Know the prescriber’s DEA registration
number;
Know the patient, and;
Check the date on the prescription order.
With any question: CALL THE PRESCRIBER!
Request proper identification.
Sarah T. Melton, PharmD,BCPP,CGP 22

23. VRHA/VFC Annual Conference 2009
Prevention Techniques
If you believe you have a forged, altered
or counterfeit prescription --- don’t
dispense it!
If you have discovered a pattern of
prescription abuses, contact the State
Board of Pharmacy or your local DEA
office.
Disposal of Medications
Patients may have
hundreds of tablets on
hand
Take unused, unneeded
or expired drugs out of
their original containers
and throw in trash, but
first….
Mix with coffee grounds
or kitty litter and put in
impermeable cans or
bags will ensure the
drugs are not diverted
Prescription Monitoring Programs (PMPs)
Education and Information
Public Health Initiatives
Intervention and prevention
Investigation and law enforcement
Protection and confidentiality
Mission: To promote the appropriate use of
controlled substances for legitimate medical
purposes while deterring the misuse, abuse, and
diversion of controlled substances.
Sarah T. Melton, PharmD,BCPP,CGP 23

24. VRHA/VFC Annual Conference 2009
Prescription Monitoring Programs
Prescription Monitoring Programs
Electronic data base of controlled substances
dispensed in pharmacies
Used to track individual patients
Allows healthcare providers to feel more
comfortable prescribing and dispensing controlled
substances
Better able to identify patients at risk for abuse
Intervene in problematic cases to minimize risk
Katz N, Housel B, Fernandez KC, et al. Update on prescription monitoring in clinical practice: a survey study of
prescription monitoring program administrators. Pain Med 2008;9(5): 587-594.
NASPER
National All Schedules Prescription Electronic
(NASPER) Act of 2005 (through Health and
Human Services)
Provides for establishment of controlled substance
monitoring program in each state
Communication between state programs
Goals
Physician/pharmacist access to monitoring
programs
Monitoring of Schedule II – IV drugs
Information sharing across state lines
Sarah T. Melton, PharmD,BCPP,CGP 24

25. VRHA/VFC Annual Conference 2009
Case One: In the Clinic
A 46 YO female is seen in clinic for
the first time for evaluation of
chronic migraine headaches. She
states she has just moved to the
area and she does not provide any
old medical records. While getting
her history, you discover she has
a long history of generalized
anxiety and depression. She
reports adverse effects to valproic
acid, codeine, propoxyphene,
tramadol, and sumitriptan. She
states that a neurologist saw her
years ago but that “he did not help
her at all.” After completing your
physical exam, the patient
requests prescriptions for a
month’s supply of Lortab 10/500
mg tablets QID and diazepam 5
mg TID because “those are the
only things that work.”
Case One: In the Clinic
Discuss red flags that alert you to the
possibility of prescription drug abuse.
Describe strategies you could employ to
prevent prescription drug abuse.
Case Two: In the Pharmacy
A disheveled appearing man
approaches the pharmacy
counter ten minutes before
closing time and presents a
prescription to the technician.
He is speaking in a loud voice
and demands immediate
attention. The prescription is
from a physician in a town
approximately 45 minutes
away. The prescription is
written for Vicodin, 1 tab po
Q6h prn pain #30 with 4 refills.
It is dated one month ago. He
tells the technician that he
must have the brand name
Vicodin and that he does not
“do well” with the generic. He
states he has no insurance
and then he proceeds to pace
in front of the pharmacy.
Sarah T. Melton, PharmD,BCPP,CGP 25

26. VRHA/VFC Annual Conference 2009
Case Two: In the Pharmacy
What are some red flags that alert you to
possible diversion?
How would you handle this situation?
What are precautions you should use on a
regular basis in the pharmacy?
Conclusion
Statistics show that prescription drug abuse
is escalating, especially in Appalachia, with
increasing ED visits and unintentional
deaths due to prescription controlled
substances.
Several patient and physician factors
increase risk for prescription drug abuse.
Recognition of these factors and
implementation of prevention strategies can
allow physicians to prescribe controlled
substances in a safe, effective manner and
pharmacists to limit diversion in the
pharmacy.
QUESTIONS?
Sarah T. Melton, PharmD,BCPP,CGP 26