CONTROLLED SUBSTANCES AND OPIOIDS
CONTROLLED SUBSTANCES AND OPIOIDS 2
Opioids are used extensively for chronic pain management in the United States. These substances interact with receptors on nerve cells in the body and brain. Opioid pain receptors are safer when taken in short-term as prescribed by the doctor. An opioid is said to be misused when used in larger quantities than prescribed, or when taken without a doctor’s prescription. Long-term use of this product creates a dependence that leads to overdoses that can cause death. Devastating consequences of the opioid epidemic include increased misuse and related overdoses. Measures to control the epidemics are needed to control opioid prescription by establishing regulations and creating awareness on the impacts of opioid overdose. This paper has researched state regulations guiding prescriptive practice related to education, prescribing controlled substances, and obtaining an advanced practice license. The research has been done by choosing Pennsylvania and West Virginia cities and comparing their respective regulations. The paper has defined controlled substances and opioids and highlighted how they are misused and abused. Opioid epidemic and state regulations are discussed, and a conclusion given.
Controlled Substance and Opioids
A controlled substance is an illegal drug with detrimental effects on human’s health and welfare. The state and federal governments regulate these substances, and people caught in their possession can be fined and imprisoned by local, federal, or state law enforcement. Opioids are a drug classification including heroin, synthetic opioids like fentanyl, and pain-relieving drugs that are legal by prescription. They are natural drugs derives from poppy, and help relieve pain, by altering brain response to pain. A variety of prescribed opioids are used to provide relief from toothaches, dental procedures, surgeries, chronic conditions such as cancer, and injuries. Opioids are safe to use when used correctly by following doctor’s instructions.
Opioid Misuse and Abuse
Opioid misuse is taking the substances in different ways or larger quantities than prescribed by doctors, or taking without doctors’ prescription. Regular use of opioids even with doctors’ prescriptions can lead to dependence, and when misused, these opioids pain relievers lead to overdoses that can cause death incidents. People easily misuse these substances because they produce euphoria in addition to pain relief.
The Euphoria created by opiates is unlike any naturally occurring rush of endorphin, and this propels users to use the drug repeatedly to experience the feeling. Regular use of the substance makes the brain to stop creating endorphin and dopamine, limiting individuals to experience the feelings unless they use opiates (Pinkerton & Hardy, 2017). People crave for higher doses of opiates to experience the continued pleasure that fails to occur naturally and end up being addicts. They typically abuse the production order to lessen their pain and have a continued euphoric feeling on demand.
People who become dependent on these controlled substances may experience withdrawal symptoms when they stop taking them. Dependence is coupled with tolerance, meaning users need to take more doses of the same effects. Opioid addicts may switch to heroin because it is less expensive than prescription drugs.
Long-term misuse of opiates changes normal brain functioning leading to physical and psychological reliance. Opiate withdrawal symptoms exist from mild to severe, depending on dependence although they are different between individuals. Early withdrawal symptoms include tearing up, agitation, anxiety, and fever among others. Late withdrawal symptoms include diarrhea, depression, nausea, and drug cravings. Some psychological withdrawal symptoms and craving for drugs may prolong for days. Psychological support and therapy are provided to victims by mental health professionals as part of a substance abuse program.
The current problem with opioids in the world is their increased misuse and relative overdoses. There are incidences of newborns experiencing withdrawal syndromes because of pregnant mothers using and misusing opioids during pregnancy. The crisis was brought by efforts to increase prescribing for the pain to get it to zero in the 1900s. Pharmaceutical companies developed stronger and long-lasting opioids, with aggressive marketing to physicians while limiting potential risks. Users realized that short-term opioids and the long-acting ones resulted in enhanced euphoria and had additive nature. Physicians used to prescribe higher doses because of lack of education and experience, and never realized the dangers that existed.
Deaths and Violence Associated with Opioids
The total number of overuse fell by 8.3% in 2017 as compared to 2016 in America, estimating the number to be 1,977 down from 2,155 (J, 2017). The number was still greater with more than 200 deaths compared to the 2015 toll. The provisional data released by the Centers for Disease Control and Prevention showed a decline in opioids overdose deaths in 14 states during the one year period that ended July 2017. The decline is a hopeful indicator that policies are working to curb death tolls.
In the year 2016, the total number of opioid overdoses accounted for more than 42,000 deaths (Ruhm, 2018). A 40% estimate of these overdose deaths resulted from a prescribed opioid. More than 115 people in America die daily because of opioid overdose. Overdose rates began to increase in 2015, with more than 33,000 American deaths because of opioid overdose, including prescribed type, illicit fentanyl, and heroine. Two million people were estimated to suffer from the substance use disorder as a result of prescribed pain relievers, and another half a million individuals suffering from heroin use disorder in 2015. Between 2000 and 2014, the rate of overdose deaths in America increased by 200%, and by 14% between 2013 and 2014 alone.
Opioid overdose is a risk to both genders, although men are at higher risks of overdose-related deaths. Toxicology reports show the increased likelihood of finding heroin males system, and higher chances of finding prescription opioids in female’s system at the time of death. Women mostly use the healthcare system, increasing risks of using multiple prescriptions for opioids which is a risk factor (Druid, 2016).
Illegal drugs epidemics are a battle to protect future generations. Opioid overdose-related deaths for all group shows the young generation is at higher risks of these deaths. Opioids resulted in more than 25% of all fatalities in the 18 to 24 age-groups in Massachusetts. More than 33% deaths were realized for 25 to 34 age groups rising to more than 40% for men in the group. Approximately two out of every three individual deaths that were related to opioids were younger than 45.
Opioid use and crime are associated and develop together amongst opioid using criminals. America’s murder cases rose tremendously in 2015, 2016, and the first half of 2017. According to Massey, (2017), arrests for sale and possession of opioids fell by 9.2% from 2010 to 2013, even as drug use rates were rising. In 2015, arrests rose by 12.5%, the latest year for which data is available (Rana, MD & Braithwaite, MD, 2016). The timing of the drug arrests coincide with the national rise in homicides, with drug-related killings accounting for
Medical Emergencies Related to Opioid Use
Visits to an emergency department for opioid overdoses provide an important marker of acute morbidity (Elixhauser, 2017). Hospitalizations related to opioid misuse and overdoses have increased dramatically, with the rate of adults under impatient program per 100,000 people rising by 200% between 2000 and 2012. The national hospital ambulatory medical care survey between 1993 and 2010 identified emergency department for opioid overdose and outcomes addressed. The outcome measures were national emergency department visit rates for the individual with opioid overdose per a 100 thousand U.S population and 100 thousand emergency department visits. There were approximately 731 thousand emergency department visits for opioid overdose between 1993 and 2010. They represented an overall rate of 14 visits per 100 thousand population and 37 visits per 100 thousand emergency department visits. 41% were for prescription opioid overdose. The national visitation rates increased from 7 to 27 per 100 thousand individuals between 1993 and 2010, and from 19 to 63 per 100 thousand visits.
The results showed an upward trend across multiple demographic groups in the U.S after a stratified analysis of the visit rates per population. The analysis of the visitation rate per a 100 thousand emergency department visits showed an increased rate significantly across several groups above 20 years. The nationally represented U.S database of emergency visits found that emergency visit rate for opioid overdose quadrupled significantly between 1993 and 2010. The finding suggested previous prevention measures were inadequate.
Opioid Regulation in the US
Opioid use in The United States is regulated by the federal and state governments to curb the effects of controlled substances overdose. The Centers for Disease Control and Prevention are responsible for releasing guidelines related to r chronic stress opioid prescriptions. The Food and Drug Administration (FDA) is mandated to approving reliable and efficient formulations of opioids to provide immediate and long-lasting medication. The FDA can order pharmaceutical agencies to halt or stop drug manufacturing
Drug Enforcement Agency (DEA) works in collaboration with other agencies like departments of justice to enforce powers that put to prosecution pill mills for doctors who prescribe illegally. The DEA implement prescription drug use monitoring programs (PDMPs) that are provided at state levels and application of electronic prescribing for Schedule I and II medications.
State agencies conduct an important role in reducing controlled substances and deaths related to overdoses, protecting public safety, and promoting effective medical pain remedies. They assume the role of regulating practices of medicine and insurance companies within their border. The state utilizes the agencies to train physicians about the impacts of opioids and encourages their licensure depending on registration and application of PDMPs anytime they are prescribing a controlled substance. They encourage the flow of information within states and share prescriptive information that aims at improving the efficiency of controlling overdoses, and also promoting innovations that intervene in reducing impacts associated with illegal prescriptions.
Purpose of this Paper
The paper aims to research state regulations which guide prescriptive practice related to education, prescribing controlled substances, particularly opioids, and obtaining an advanced practical license. This will be done by choosing two different states (Pennsylvania and West Virginia) and comparing and/ contrasting their perspective governing regulations.
Information to providers
Healthcare providers require appropriate knowledge, skills and professional judgment to prescribe drugs. They need to know state regulations that guide prescriptive practice to improve patient safety when prescribing because the policies set out all requirements for prescribing drugs.
Prescribing of controlled substances is regulated by legislative frameworks with policies that health practitioners must put into considerations and obey rules set in prescription laws. Following the policies and having awareness of practice will help prevent history from repeating itself. The medical community was assured by pharmaceutical companies that prescriptive opiates were not addictive to pain relievers in the late 1990s. Medical practitioners prescribed the substance at greater rates subsequently leading to increased misuse and diverse use before the side effects were realized. Drug deaths have been steadily climbing every year globally since the 1990s.
The state regulations define key values of professionalism that form the basis for the expectations set out in policies. Physicians embody the values of compassion, altruism, service, and trustworthiness to act in patient’s best interests, demonstrate professional competence, and maintain their patients’ confidentialities. The practitioners must ensure maximum collaboration, communication, and should not be driven by their advantages.
The Act 124 was put in place to provide a prescription drug monitoring program. The revision of the previous Act 124 aims to amend laws by expounding some other provisions. The prescribers doubt the PDMP systems when individuals are prescribed opioid drug products. Queries are not required when patients have been admitted to licensed healthcare facilities, or in an observation status in the same facilities after initial query, provided they remain admitted or in observation.
Bodies in charge of licensing require people applying for initial licenses or certificate authorizing them to be dispensers or prescribers to submit educational documents. The submission should not be later than one year after obtaining an initial license and must show their completion of at least two hours education program in pain management, and addiction identification. They must also show completion of several hours’ education program pertaining prescription or opioid dispensing. The licensing board requires prescribers applying for license renewal to provide completion of two hours of continuing education program related to managing pain and stress, addiction identification, or practice of prescribing opioids. The education is part of the overall requirement, and do not apply to those exempted from the drug enforcement administration necessities for a registration number.
The act 124 entails prescribing opioids to minors. The subscribers are required by law to limit opioid prescription numbers to minors by ensuring a not more than a week supply unless they determine needs to stabilize the minor’s acute medical conditions. The law requires practitioners to do a thorough assessment of whether the minors have taken or they are under prescription for substance use disorder at that time before prescribing any opioids. They have to discuss with the minor’s parents or guardians the risks of addictions and overdoses that commonly occur with use of controlled substances. Prescribers are required to get written consent for prescribing opioids to minors.
The Pennsylvanian Act 126 requires a safe opioid education and patient directives. The licensing board implemented curricula that address safer prescriptions of opioids. The curriculum is provided in all medical schools and training facilities. The act also requires patient voluntary non-opioid directive. Patients are allowed to practice this form of a directive to deny the administration of controlled substance containing an opioid.
Opioid Regulation in Pennsylvania
Opioid-related overdose deaths have dramatically increased in Pennsylvania and across the nation. Pennsylvania declared heroin and opioid addiction crisis a statewide emergency to combat overdose harm in 2016. Governor Wolf has taken significant steps to improve doctor’s prescribing practices. The Department of Drug and Alcohol Programs ensures a safe and effective prescribing task force. The task force members include a variety of state agencies, medical association representatives, provider advocates, and the community members. They collectively established and applied measures for them medical fields to safely and efficiently use controlled substances in relieving pain. The developed law significantly impact medical practitioners nationwide, because some took effect moments after they were signed.
Pennsylvania has an Act 122 that restricts opioids limits to practitioners in emergency situations. The components of the act significantly affect practitioners in situations demanding urgent care and in-hospital emergencies. The act restricts a not more than one week opioid supply. There are extensions for physicians when it comes to treating individuals with acute illness, as they require a more than one week opioid supply. Chronic cancer treatment and palliative care exempt the requirements of Act 122, but physicians have to monitor the patients closely. Under these exceptions, physicians must document patients’ medical record that a non-opioid alternative was inappropriate under the circumstances.
The act prohibits refills, providing that regardless of the amount prescribed, physicians should not in any way write prescriptions to refill controlled substances. Medical practitioners in these situations should refer patients for treatment if they exhibit signs of abusing controlled substances. Physicians are required to make queries on prescription drug monitoring program system to discover chances of these patients being under treatment with opioid drug products by other providers. Queries do not apply to medications provided to patients in need of treatments in urgent care facilities. Any medical practitioner who violates Act 122 has their license sanctioned by the state’s board. Following the law to the latter means the medical practitioner at all time act in good faith and has immunity in civil actions.
The legislature in Pennsylvania has determined that there should be an increased role for physicians in preventing and mitigating heroine and opioid epidemic. The intentions seem noble, and the burden lies to physicians in treating patients with increased leisure sanctions and liability if they fail to comply with the regulations. They are required to familiarize themselves with the new laws and implement their requirements to curb illegal use of controlled substances (Huber, Robinson, Noe & Van Ness, 2016).
Opioid Regulation in West Virginia
Western Virginia has the highest rate of opioid-related overdose deaths, and drug overdose is the top mortality causal for people under the age of 45 (writer, 2018). Experts and policymakers are struggling to cobalt the nationwide opioid crisis which was declared a public health emergency, with increased efforts to control their prescriptions. In West Virginia, the poster child for the epidemic new research shows that prescription drug regulations have not affected by a decrease in opioid-related hospitalizations. The nation has experienced a reduced opioid prescription dispensed since 2012 legislations authorized the use of a prescription drug monitoring program. The overall rates of opioid poisonings are relatively constant, with poisonings from heroin and illegal opioids increasing by more than 200%. Regulations on controlled substances were made under the board’s emergency authority given that state commissioner declared opioid addiction a national crisis as a public health emergency.
The bill requires health care prescribers to obey the state’s prescription drug monitoring programs, and also established the licensing and regulation of chronic pain guidelines. The guidelines provide additional regulations for opioid treatment centers and require a consisted continued education for administrators (Lund, 2017).
Studies in Western Virginia examining opioid poisoning rates from 2008 to 2015 reveal complexities of the crisis and how it is a challenge to provide a solution to the problem Smith, MD, Kirsh, Ph.D. & Passik, Ph.D., 2018). Despite having prescriptions decrease, the crisis is still rampant because people are having alternative sources of controlled substances, cheaper and more widely available in the streets.
The Western Virginia Department of Health and Human Resources established an Opioid Response Plan in 2017 through public involvement and expert input. The board of medicine was authorized to be more aggressive in disciplining overprescribing physicians. The plan emphasized the importance of having efforts addressing excessive prescribing not go too far, and develop targeted investigations to assess prescribing, and professional boards recognize the importance of individualized care and clinical judgment. The judgment should support patients with severe pain and where an inappropriate prescription is found, the care providers should support tapering of medication rather than rapid withdrawal. The patient care plan is adopted even after provider’s prescribing certification is terminated, to support appropriate treatment for patients.
Western Virginia encourages insurers to adopt evidence-based guidelines on reimbursement for opioid prescribing before filling co-prescriptions of benzodiazepines and opioids. Non-pharmaceutical coverage approaches are supported to manage pain and improve medical education on pain prescription and treating of substance use disorders. The state is considering developing cross-agency strategies for primary prevention, to include targeted economic development, and expanded use of mentoring. An evidence-based curriculum will be put in place to identify resources for youths at highest risks based on adverse childhood experiences, and expanded primary prevention through education in schools.
West Virginia addresses the issue of opioid overdose-related deaths by putting into practice legislation to be followed by all prescribers. The legislation has a code 16-47-4 that requires good Samaritans to alert the authorities of any cases of controlled substance abuse through 911. The witnesses are protected by the legislation from arrests. The state also uses the West Virginia Code 16-46-31, to allow pharmacist distribute awareness and provide education to the public on the impacts of naloxone. The HB 2195 legislation emphasizes on implementing opioid implementation strategies to prevent their impacts and create awareness into all school curricula. HB 4347 legislation has priority over substance abuse treatment for expectant women.
The West Virginia codes 16-46-31 and 16-47-4, collectively have been linked with more 911 emergency alerts on overdose and reduced deaths. The legislature is considering other bills that will effectively help fight the opioid epidemic.
West Virginia applied for a medical waiver to specifically address substance abuse disorders. The state decided to use a considerable share of its stake with opioid distributors to expand the availability of treatment for people struggling with addiction (Webster & Grabois, 2015).
Huntington has been the heart of opioid epidemic. The city’s overdose death rate is tenfold that of the national rate, prompting the city to make several changes to combat the crisis and reduce its harmful effects. The Huntington city established Office of Drug Control Policy and coordinated with; a coalition of law enforcement, public health leaders, first responders, and local groups to mitigate opioids. The city has emphasized on reducing opioid harm by opening the first needle exchange in the state, a center for weaning babies off drugs, and school programs with students and parents who have been caught in possession of drugs. The drug users are trained on how to administer naloxone to curb deaths on overdose.
Huntington is implementing the measure of sending drug users to treatment care instead of taking them to jail. The city has a Recovery point, a facility with a 100 beds to provide long-term recovery program with a 68% sobriety rate for graduates after a one year program.
Pennsylvania and West Virginia
The most effective solutions applied by states are to increase utilization of advanced practices of certified and registered medical practitioners. Advanced practices ensure the safety of patients is maintained because unqualified physicians prescribe doses with side effects. The lawmakers in both states have responded well to the opioid epidemics by planning legislatures that limit how much pain medicine practitioners prescribe to their patients. Doctors in both cities are required by their legislation to counsel new patients, who pick up a prescription for opioids, about the risks of taking controlled substances. All practitioners are required to assess patients being treated for acute conditions, to prevent risks of addiction and ensure compliance with rules and regulations.
Pharmacists who fail to follow the legislation to the latter lose their certification. The departments of Justice, DEA, and local agencies have gained supporters in both cities as a result of their efforts to combat the growing crisis. The consequences of diversion use of controlled substances include societal, clinical, and economic impacts. The high profile legislative activities force pharmacists to turn away patients who exceed their monthly dispensing limits. All wholesalers are inspected to ensure appropriate dispensing and hesitancy by suppliers and other regulatory agencies in guiding address gray areas.
In response to the ongoing prescription drug overdose epidemics, the cities have put in place prescribing guidelines, continuing education, federal, state, and international measures to deal with the epidemic. All licensed practitioners are required to prescribe opioids to acute pain patients and provide them with information. They are required to apply their skills and reinforce healthy behavior, identify problematic drug and alcohol use early, and reduce substance misuse.
Physicians and health systems reduce their exposure to investigations and prosecution by adhering to best practices and standards of care. They are bound by medical and legal regulations in prescribing opioids. Substantial compliance with opioid prescribing guidelines is the accepted standards of care and satisfies adherence to the many states and federal laws (Pardo, 2017).
Abuse of controlled substances has considerable impacts on the society providing both economic and clinical burdens. Overdoses result to more than 830,000 years potentially before the age of 65, similar to years lost through road accidents. The increase in deaths is attributed to unintentional overdoses because of failure to understand the risks associated with the use of controlled substances. Organizations should work in collaboration to curb abuse and misuse of opioids and use it for intended purposes only. Drug monitoring programs should aim at providing insight into current opioid trends, and minimize fraud prescriptions and related doctor shipping. Pharmacies mostly utilized by prescribed patients should be closely monitored to reduce potential misuse, and health bodies to come up with alternative tamper resistant with multiple mechanisms to reduce the likelihood of opioid abuse.
Pharmacies should be in the forefront in making efforts that prevent and minimize opioid abuse. Policies should be put in place requiring pharmacists to contact prescribing physicians to ensure diagnosis, and previously tried and tested, and expected lengths of therapies are accurate in verifying prescriptions for opioids.
Healthcare career has a vital responsibility to help reverse the exponential curve in opioid-related morbidity and mortality rates by improving prescribing practices. Healthcare providers should work to establish community-wide approach needed to address the opioid crisis effectively. The coordinated approach at local, regional, and state level will simultaneously address multiple parts of the complexities of opioid misuse, dependence, addiction, and recovery.
Raising awareness about chronic pain and pain management will increase knowledge about opioid abuse. Physicians should routinely take SCOPE of pain, free online training where they will learn safe and responsible opioid prescription within their first years of practice. Before providing prescriptions, practitioners should first identify patients with opioid use disorder earlier and should learn various ways of recognizing substance use disorder. The greatest measure to help minimize opioid overdoses is to demonstrate the safety of advanced practice registered nurses, and ensure they have the right skills to handle prescriptions
Druid, H. (2016). Toxicological and pathological findings in opioid-related deaths. Toxicology Letters, 258, S36. http://dx.doi.org/10.1016/j.toxlet.2016.06.1235
Elixhauser, A. (2017). Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009- 2014 #219. Hcup-us.ahrq.gov. Retrieved 3 March 2018, from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb219-Opioid-Hospital-Stays-ED- Visits-by-State.jsp
Huber, E., Robinson, R., Noe, C., & Van Ness, O. (2016). Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk. Healthcare, 4(4), 29. http://dx.doi.org/10.3390/healthcare4020029
J, F. (2017). Mass. deaths by opioid overdose fell 8.3 percent last year – The Boston Globe. BostonGlobe.com. Retrieved 3 March 2018, from https://www.bostonglobe.com/metro/2018/02/14/mass-deaths-opioid-overdose-fell-percent-lastyear/ov2g3vtfS50NrzCMFI9GcK/story.html
Lund, E. (2017). Preventing, Detecting, and Addressing Opioid Overprescribing. Journal Of Nursing Regulation, 8(2), 5-9. http://dx.doi.org/10.1016/s2155-8256(17)30092-3
Massey, B. (2017). Battling the Opiate Crisis: Translating the Latest Advances in Addiction Biology into Novel Treatment Strategies. Pharmacy & Pharmacology International Journal, 5(4). http://dx.doi.org/10.15406/ppij.2017.05.00131
Pardo, B. (2017). Do more robust prescription drug monitoring programs reduce prescription opioid overdose?. Addiction, 112(10), 1773-1783. http://dx.doi.org/10.1111/add.13741
Pinkerton, R., & Hardy, J. (2017). Opioid addiction and misuse in adult and adolescent patients with cancer. Internal Medicine Journal, 47(6), 632-636. http://dx.doi.org/10.1111/imj.13449
Rana, MD, H., & Braithwaite, MD, B. (2016). Physician conviction for prescription-related deaths: How will this affect the opioid debate?. Journal Of Opioid Management, 12(4), 241. http://dx.doi.org/10.5055/jom.2016.0338
Ruhm, C. (2018). Corrected US opioid-involved drug poisoning deaths and mortality rates, 1999-2015. Addiction. http://dx.doi.org/10.1111/add.14144
Smith, MD, H., Kirsh, Ph.D., K., & Passik, Ph.D., S. (2018). Chronic opioid therapy issues associated with opioid abuse potential. Journal Of Opioid Management, 5(5), 287. http://dx.doi.org/10.5055/jom.2009.0029
Webster, L., & Grabois, M. (2015). Current Regulations Related to Opioid Prescribing. PM&R, 7(11), S236-S247. http://dx.doi.org/10.1016/j.pmrj.2015.08.011
Writer, E. (2018). WV lawmakers seek to limit opioid prescribing. Charleston Gazette-Mail. Retrieved 3 March 2018, from https://www.wvgazettemail.com/news/health/wv_drug_abuse/wv-lawmakers-seek-to-limit-opioid-prescribing/article_1b088ea7-de2c-55c8-98de-a293bece51f4.html