Bhrs Medication Policy
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>> Brian Greenberg, Ph.D.: Prescription medications,
use and abuse in behavioral health settings.
The focus of this presentation is prescription medications
that are vulnerable to abuse and their use
in behavioral health settings.
>> Lea Goldstein, Ph.D.: San Mateo County Behavioral Health
and Recovery Services implemented a new medication policy.
We will be reviewing the policy in the presentation
and discussing its implications.
The policy states that consumers are not to be denied services
because they are taking prescribed medication regardless of type.
Client treatment plans will address treatment needs of persons
on prescription medications.
Treatment staff will consult
with prescribing physicians whenever possible.
There are some notations important about the medication policy.
Any perceived problems with prescribed medications are
to be dealt with as a clinical issue
and done in a clinical manner.
The prescribing physician should be involved whenever possible.
Each treatment provider shall develop procedures to ensure
that the policy is adhered to.
>> Brian Greenberg, Ph.D.: It's helpful for programs
to adopt operational procedures to implement the guidelines.
These procedures may include policies and guidelines
that are non-discriminatory
and that address all clients treated regardless
of their prescription medications.
The procedures may further include how
to physically handle prescription medication
in a safe and responsible manner.
There are obvious differences in AOD providers
that may only store medications and mental health providers
that may have different regulations concerning the handling
of prescription medications.
The procedures should also include how to engage clients
around prescription medications and how to create an accepting culture
to ensure the minimization
of any stigma concerning prescription medications.
>> Lea Goldstein, Ph.D.: There are perhaps special challenges
in compliance with the policy in substance abuse recovery programs.
Some of these challenges include
that non-behavioral health recovery service physicians' training
and understanding of addiction may be different.
Also that non-behavioral health and recovery services physicians,
their willingness to discuss issues with their patients, your clients.
Non-behavioral health and recovery services physicians' willingness
to partner with treatment staff.
The abuse potential of prescription medications,
and the milieu issues involved in a treatment program.
To further discuss the challenges working with physicians
who may be prescribing these medications,
there have been several surveys done of physicians, and they reveal
that many feel it is difficult to discuss prescription drug abuse
and addiction with their patients.
This may present unique challenges in working
with these prescribing physicians.
When staff find that physicians are difficult to engage,
things that providers may do are to consult
with the administrative leadership of BHRS, to consult with behavioral
and recovery services consultants, to utilize staff with personal
or professional relationships to the contact, attempt different ways
to contact the physician, and refer for a second opinion.
>> Brian Greenberg, Ph.D.: Of course,
prescription drug abuse if widespread.
More than 2.4 million Americans reported current use
of prescription drugs for non-medical purposes in 2010.
We're going to be discussing three classes of prescription drugs
that are especially vulnerable to abuse.
These include opiates prescribed to treat pain, stimulants prescribed
to treat attention deficit hyperactivity disorder
and narcolepsy, and CNS depressants prescribed both
to treat anxiety and insomnia.
>> Lea Goldstein, Ph.D.: While these drugs can be abused,
they also may serve as an important clinical tool.
Many persons with co-occurring disorders benefit
from psychotropic medications.
Some, but not all, of these medications do have
abuse potential.
Treatment outcomes are improved when collaboration between primary
and behavioral health care providers is ongoing.
>> Brian Greenberg, Ph.D.: It is important to be aware of the limits
of our scope of practice for each professional in the field.
Addiction to prescribed medication is common but recovery
and mental health services staff must refer and defer
for medical decisions to medical practitioners.
Furthermore, recovery and mental health services staff must refer
or defer to physicians for medical advice.
>> Lea Goldstein, Ph.D.: There are certain clients that seem
to be more vulnerable to abuse of prescription medication.
There are over-represented groups in treatment programs.
More women than men abuse and are addicted to prescribed medications,
especially tranquilizers and sedatives.
More adolescent girls, one in ten, than adolescent boys, one in 13,
are abusing prescription medications.
A significant cause for concern is older people who are in recovery.
Older people are more vulnerable
because they receive many more prescriptions.
And the misuse/abuse
of prescription drugs is the most common form
of drug abuse among the elderly.
>> Brian Greenberg, Ph.D.: There are red flags for abuse.
A common aphorism in the field is
that no one ever loses a prescription
for high blood pressure medication.
This speaks to the manipulation for drugs that are vulnerable to abuse.
Multiple physicians prescribing medications
for a single patient is also a red flag, as is an over-reliance
on emergency rooms for prescriptions.
Persons in mental health
or substance abuse treatment programs may have real
and almost disabling pain.
When pain is not addressed and drug-seeking behavior occurs
in the pursuit of legitimate pain relief,
this is often referred to as pseudoaddiction.
So when severe pain is not addressed with enough
or appropriate medication, pseudoaddiction may occur.
Drugs that alleviate pain and that can be abused are generally the
prescription narcotics.
So pseudoaddiction was first described in 1989
to describe an iatrogenic condition in people with severe pain.
An iatrogenic illness is
when adverse health effects result from medical treatment.
It's caused by the insufficient treatment of real pain,
and it can be present in persons
with a true addictive disorder or not.
It can be difficult to distinguish between drug-seeking behavior
for legitimate pain relief and drug-seeking behavior for abuse.
Many signs or symptoms are or may be identical.
These include moaning or other demonstrations of pain,
pain complaints that seem excessive, clock watching
for the next dose, or repeated requests for medication.
All of these can be either addiction-related behavior
or pain-related behavior or pain-alleving related behavior.
Of course, there are differences over time.
Distinguishing between seeking pain relief
and drug-seeking behavior is difficult, but in pseudoaddiction,
the condition improves with the provision of adequate pain relief.
In addiction, the condition rarely improves.
There is almost never enough medication.
And in pseudoaddiction,
the client's painful condition is not believed but interpreted
as addictive or as drug-seeking behavior associated with addiction.
>> Lea Goldstein, Ph.D.: Many individuals
in behavioral health services have histories of abuse and trauma.
Repeated trauma in the face
of powerlessness is devastating to the human condition.
There is a high correlation between addiction and trauma,
and these individuals may benefit from medication.
The consequences of trauma can be debilitating and may result
in psychological disorders that are treatable with medication.
>> Brian Greenberg, Ph.D.:
Drugs that treat attention deficit disorder are generally the
stimulants, and attention deficit hyperactivity disorder does not
always go away when people transition from child to adulthood.
The National Institute of Mental Health estimates that three
to five percent of children are thought to have the disorder,
and that a third to half of adults retain the symptoms
and diagnosis in adulthood.
Adult treatment for ADHD frequently parallels childhood treatment,
and prescription medication assists in helping
to focus the concentration and energy
of adults as it does in children.
There are no medical withdrawal risks
with drugs used to treat ADHD.
>> Lea Goldstein, Ph.D.: Medications used
to treat anxiety are also vulnerable to abuse and dependence.
There is potential for abuse.
So some physicians will prefer
to treat anxiety in the milieu setting.
These medications are used to treat anxiety disorders
and are also used for detoxification.
They are physically addictive.
Clients cannot stop the use of these medications
without a taper schedule.
>> Brian Greenberg, Ph.D.:
The culture of a behavioral health treatment program concerning the
use of prescription drugs is critical to client success.
It's very important to create a culture of acceptance.
Persons who use anti-psychotic drugs or major tranquilizers
for thought disorders or anti-depressants
for depression are only now being fully accepted in recovery culture
and recovery communities.
And persons on prescribed drugs susceptible to abuse continue
to be stigmatized in substance abuse recovery
and treatment settings.
Stigma associated with prescription medication can unnecessarily
interfere with recovery.
Stigma ignored represents a treatment opportunity lost.
Furthermore, each co-occurring disorder may need
to be treated independently,
and so multiple prescriptions may need to be prescribed.
It's important to develop an acknowledgment
that there is nothing contradictory about being in recovery
or recovery services and being on a medication with abuse potential.
Peers in treatment and especially
in recovery programs should not be allowed to stigmatize persons
on prescribed medications.
Furthermore, staff must be comfortable
in role modeling non-stigmatizing and accepting attitudes.
It's critical that staff understand that treatment is individualized
for each client or patient in treatment and convey this
to the client-peer group.
However, of course, we want to be aware of how clients are doing
with their prescribed medications, and we want to remain aware
of potentially dangerous behaviors or conditions
in the client population.
>> Lea Goldstein, Ph.D.: There are several issues
that deserve special consideration regarding medication
in behavioral health treatment programs.
These include the abuse of medication, the sale of medication,
sharing of medication between clients,
and missing medication in a treatment program.
A primary concern then is responsibility among the
treatment staff.
Staff must make certain that the right medication gets
to the right person, and also be certain
that the doctor's orders are followed.
>> Brian Greenberg, Ph.D.: Storing controlled medications requires
extra precaution.
Each program may need to decide whether all controlled medications
are counted during each shift change.
Although time consuming, it may serve to protect staff
from both temptation as well as false allegations of impropriety.
So controlled medications are best treated like cash.
Persons receiving or assuming responsibility
for controlled medications want
to be certain what they are taking responsibility for,
and there must be procedures for ensuring accountability
and these procedures must be site or program specific.
>> Lea Goldstein, Ph.D.: Programs implementing these policies need
to consider medication storage and chain of responsibility,
how to adapt the culture so as to eliminate stigma, the establishment
of processes for liaisoning with the prescribing physicians,
changing the culture of a treatment program, taking time,
and unanimous buy in, all the way from the top
of the leadership down to all line staff.
>> Brian Greenberg, Ph.D.: The keys to success, in summary,
are first that creating a positive culture and accepting culture
and non-stigmatizing culture in the treatment program.
>> Lea Goldstein, Ph.D.: Another key
to success is the knowledge base of the staff.
There are clear reasons for clients to be prescribed medication
with abuse potential, and this may occur even while these clients are
participating in a recovery treatment program.
Prescription medications are a clinical intervention
to treat specific conditions.
Prescription medications have the potential
to help clients be maintained in treatment.
>> Brian Greenberg, Ph.D.:
The prescribing physician should be a part
of the treatment team whenever necessary,
and the prescribing physician is able to problem solve with staff
and hear staff concerns.
>> Lea Goldstein, Ph.D.: We often have limited
and at times even wrong ideas about what works.
Diverse clients require a diverse bag of clinical tools.
Psychiatric diagnoses and pain may best be treated
with prescription medications.
We as providers have a responsibility
to help everyone succeed in behavioral health services.
