A necessary pain

In October 2013, the Texas Department of Public Safety officially began allowing physicians to electronically prescribe schedule II controlled substances. The practice of electronic prescription of controlled substances (EPCS) for schedule II drugs became more commonplace in March 2014, after DPS completed a small pilot program to test the accuracy of reporting schedule II drugs to the Texas Prescription Program. Sending prescription requests to a pharmacy through an electronic vendor helps reduce the risk of prescription fraud.

Disclosures to participate in State Prescription Drug Monitoring Programs. Final rule

This document adopts as final, without change, an interim final rule published in the Federal Register that amended the Department of Veterans Affairs' (VA) regulations concerning the sharing of certain patient information in order to implement VA's authority to participate in State Prescription Drug Monitoring Programs (PDMP).

Abuse of family physicians by patients seeking controlled substances

OBJECTIVE

To examine family physicians' career prevalence and monthly incidence of workplace abuse by controlled substance prescription seekers.

DESIGN

A 4-page cross-sectional survey.

SETTING

A family medicine continuing medical education event in Halifax, NS.

PARTICIPANTS

The survey was distributed to 316 family physicians attending the continuing medical education event.

MAIN OUTCOME MEASURES

Career prevalence and monthly incidence of workplace abuse related to the act of prescribing controlled substances.

RESULTS

Fifty-six percent (n = 178) of the 316 surveys were returned completed. Half the study participants were men (49%). Most study participants were in private practice and lived in Nova Scotia, and approximately half (51%) practised in urban settings. On average, the study participants had 20 years of practice experience. The career prevalence of abusive encounters related to controlled substance prescribing was divided into "minor," "major," and "severe" incidents. Overall, 95% of study participants reported having experienced at least 1 incident of minor abuse; 48% had experienced at least 1 incident of major abuse; and 17% had experienced at least 1 incident of severe abuse during their careers. Further, 30% reported having been abused in the past month; among those, the average number of abusive encounters was 3. Most (82%) of the abusers were male with a history of addiction (85%) and mental illness (39%). Opioids were the most frequently sought controlled substance.

CONCLUSION

Abuse of family physicians by patients seeking controlled substances is substantial. Family physicians who prescribe controlled substances are at risk of being subjected to minor, major, or even severe abuse. Opioids were the most often sought controlled substance. A national discussion to deal with this issue is needed.

Disclosure to participate in State Prescription Drug Monitoring Programs. Interim final rule

The Department of Veterans Affairs (VA) amends its regulations concerning the sharing of certain patient information in order to implement VA's authority to participate in State Prescription Drug Monitoring Programs (PDMPs). Participation in PDMPs will allow the VA patient population to benefit from the reduction in negative health outcomes.

Quantitative study of controlled substance bedside wasting, disposal and evaluation of potential ecologic effects

Drugs in wastewater arise from many sources. For health care, these include excretion and direct disposal (bedside wasting). The present study reports on the dispensing and wasting of 15 controlled substances (CS) at two health care facilities in Albany, NY over a nearly two year period. The study considered measures of ecotoxicity, drug metabolism, excretion and disposal of these CS. Potential alternatives to flushing of CS into wastewaters from healthcare facilities are discussed. Drug medication and waste collection records (12,345) included: numbers of drugs dispensed, returned and wasted. Overall, 8528 g of 15 CS were wasted. Three (midazolam, acetaminophen-codeine and fentanyl) accounted for 87.5% of the total wasted. Wasting varied by hospital, 14 CS at the academic medical center hospital and 8 at the surgical care center were wasted. Liquids were more frequently wasted than tablets or pills. Some combination drugs (acetaminophen (APAP)-codeine) were frequently (50% of drug dispensed) wasted while others were less wasted (APAP-hydrocodone-6.3%; APAP-oxycodone-1.3%). The 8 CS judged more hazardous to aquatic life were: APAP-codeine, APAP-hydrocodone, APAP-oxycodone, alprazolam, diazepam, fentanyl, midazolam, and testosterone. Ketamine, morphine, oxycodone and zolpidem were of lesser acute toxicity based on available LC50 values. These CS might provide a therapeutically equivalent alternative to the more environmentally harmful drugs. In health care facilities, professionals dispose of CS by bedside wasting into water or other receptacles. This can be avoided by returning CS to the hospital's pharmacy department, thence to a licensed distributor. Study of this process of drug wasting can identify opportunities for process improvements. We found 3 CS (APAP-codeine, midazolam and testosterone) where ½ to 1/3 of the drug was wasted and 5 others with 30 to 13% wasted. Knowledge of the adverse impacts from the release of highly toxic drugs into the environment might influence CS selection and disposal alternatives.

A systems-level approach to resolve tension between research misconduct and confidentiality

The author examines methods of resolving tensions between confidentiality and research conduct and methods of avoiding these tensions. He mentions universities are obligated to address misconduct allegations and considers how to do this while respecting confidentiality between patient and therapist. He comments an underlying aspect of research ethics is a core commitment to honesty and states students are obligated to self-report even when patient-therapist confidentiality restricts reporting.

Managing disclosure of research misconduct by a graduate student to a university mental health professional during a clinical counseling session

This case looks at the question of how to consider obligations of confidentiality by a mental health professional who works for an institution and learns that a student has been using a drug intended for an animal research project. Dr. Paul Appelbaum, MD, a psychiatrist at Columbia University, examines the issue of the limits of confidentiality. Nicholas Steneck, PhD, a scholar in research misconduct at the University of Michigan, explores the obligations to report research misconduct. Walter Limehouse, MD, an ethicist at the Medical University of South Carolina, considers the systems issues raised by this case and offers some suggestions that might change the institutional environment.

Minnesota's Prescription Monitoring Program: how to identify patients who may be abusing controlled substances

The Minnesota Prescription Monitoring Program, which was launched by the Minnesota Board of Pharmacy last year, is collecting data on prescriptionsof controlled substances. Reporting is required from in-state pharmacies and others including physicians who dispense medications as well as from out-of-state pharmacies that ship controlled substances to Minnesota residents. This article describes the program, how it works, and how it can benefit physicians.