Prescription drug abuse. A question of balance

Complexities of Perioperative Pain Management in Orthopedic Trauma

PURPOSE OF REVIEW

This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period.

RECENT FINDINGS

Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.

Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient

BACKGROUND AND OBJECTIVES

The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care.

METHODS

Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies.

RESULTS

Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times.

CONCLUSIONS

Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.

Care plans reduce ED visits in those with drug-seeking behavior

Patients with drug-seeking behavior can be both labor and resource intensive to the emergency department (ED).

OBJECTIVE

To determine the effectiveness of ED care plans for individuals at high risk for drug-seeking behavior on ED visits.

METHODS

A retrospective, cohort observational study.

LOCATION

A suburban teaching hospital with an annual census of 80,000 patients. The number of ED visits was determined 1 year before and 2 subsequent years following care plan initiation.

EXCLUSION CRITERIA

Unclaimed letter, incomplete data, and/or non-drug-seeking care plan.

STATISTICS

Two-tailed Wilcoxon signed-rank test with significance of P < .05.

RESULTS

Sixty patients were enrolled and 7 were excluded, leaving 53 patients for analysis. Mean annual visits before care plan initiation were 7.6 (95% confidence interval [CI], 6.3-9.1). One year following implementation, mean visits decreased to 2.3 (95% CI, 1.5-3.1) (P ≤ .0001). Two years following implementation, mean visits continued to decline to 1.5 (95% CI, 0.9-2.1) (P ≤ .0001). A significant reduction in visits occurred 1 and 2 years following care plan implementation.

CONCLUSIONS

Emergency department care plans are an effective method to reduce ED visits in those with drug-seeking behavior.

Prescription drug use and abuse

When a patient is in physical or emotional pain, prescribing controlled substances often appears to be the simplest and most efficient way to relieve suffering and distress. However, in a minority of cases, this approach leads to prescription drug abuse and patient harm. In this article, the authors review the epidemiologic factors of prescription drug abuse, legal policies designed to safeguard against it, risk factors and red flags, and practical ways to minimize the chances of misuse.

Racial disparities across provider specialties in opioid prescriptions dispensed to medicaid beneficiaries with chronic noncancer pain

OBJECTIVE

Chronic pain affects both psychological and physical functioning, and is responsible for more than $60 billion in lost productivity annually in the United States. Although previous studies have demonstrated racial disparities in opioid treatment, there is little evidence regarding disparities in treatment of chronic noncancer pain (CNCP) and the role played by physician specialty in these disparities.

DESIGN

A retrospective cohort study.

SETTING

We analyzed North Carolina Medicaid claims data, from July 1, 2009 to May 31, 2010, to examine disparities by different provider specialties in beneficiaries' dispensed prescriptions for opioids.

SUBJECTS

The population included white and black North Carolina Medicaid beneficiaries with CNCP (N = 75,458).

METHODS

We used bivariate statistics and logistic regression analysis to examine race-based discrepancies in opioid prescribing by physician specialty.

RESULTS

Compared with white beneficiaries with CNCP (N = 49,197), black beneficiaries (N = 26,261) were less likely (odds ratio [OR] 0.91 [confidence interval {CI}: 0.88-0.94]) to fill an opioid prescription. Our hypothesis was partially supported: we found that race-based differences in beneficiaries' dispensed opioid prescriptions were more prominent in certain specialties. In particular, these differences were most salient among patients of specialists in obstetrics and gynecology (OR 0.78 [CI: 0.67-0.89]) and internal medicine (OR 0.86 [CI: 0.79-0.92]), as well as general practitioners/family medicine physicians (OR 0.91 [CI: 0.85-0.97]).

CONCLUSIONS

Our findings suggest that, in our study population, black beneficiaries with CNCP are less likely than whites to fill prescriptions for opioid analgesics as a function of their provider's specialty. Although race-based differences in patients filling opioid prescriptions have been noted in previous studies, this is the first study that clearly demonstrates these disparities by provider specialty.

Prescribing in prison: minimizing psychotropic drug diversion in correctional practice

Correctional facilities are a major provider of mental health care throughout the United States. In spite of the numerous benefits of providing care in this setting, clinicians are sometimes concerned about entering into correctional care because of uncertainty in prescribing practices. This article provides an introduction to prescription drug use, abuse, and diversion in the correctional setting, including systems issues in prescribing, commonly abused prescription medications, motivation for and detection of prescription drug abuse, and the use of laboratory monitoring. By understanding the personal and systemic factors that affect prescribing habits, the clinician can develop a more rewarding correctional practice and improve care for inmates with mental illness.

Prescription opioid use among patients seeking treatment for opioid dependence

OBJECTIVE

This study was designed to assess non-medical prescription opioid use among a sample of opioid dependent participants.

METHODS

A cross-sectional survey was conducted with a convenience sample of patients hospitalized for medical management of opioid withdrawal. We collected data related to participant demographics, socio-economic characteristics, the age of first opioid use, types of opioids preferred, and routes of administration. We also asked participants to describe how they first began using opioids and how their use progressed over time.

RESULTS

Among the 75 participants, the mean age was 32 years (SD: +/- 11, range: 18-70), 49 (65%) were men, 58 (77%) considered themselves to be "white," 55 (74%) had a high school diploma or equivalent, and 39 (52%) were unemployed. All of these participants considered themselves to be "addicted." Thirty-one (41%) felt that their addiction began with "legitimate prescriptions," 24 (32%) with diverted prescription medications, and 20 (27%) with "street drugs" from illicit sources; however, 69 (92%) had reported purchasing opioids "off the street" at some point in time. Thirty-seven (49%) considered heroin to be their current preferred drug, and 43 (57%) had used drugs intravenously.

CONCLUSIONS

We found that many treatment-seeking opioid dependent patients first began using licit prescription drugs before obtaining opioids from illicit sources. Later, they purchased heroin, which they would come to prefer because it was less expensive and more effective than prescription drugs.

Preventing prescription drug misuse: field test of the SmartRx Web program

Purpose of the project was to test a Web-based program designed to prevent prescription drug misuse. Study sample consisted of 346 working women randomized into either an experimental or wait-list control condition. Analysis of covariance and logistic regression were used to compare responses. Women receiving the intervention had greater knowledge of drug facts and greater self-efficacy in medication adherence and ability to manage problems with medications compared with controls. Women receiving the intervention also had reduced symptoms reported on the CAGE for prescription medications. Findings suggest that multimedia Web-based programs can be a beneficial addition to substance misuse prevention services. The study's limitations are noted.

The Health Effect of Psychostimulants: A Literature Review

Prevalence of psychostimulant use is high, and raising in several countries. Nicotine is the legal stimulant causing the most important public health impact. Cocaine ranks among the most used illicit substances after cannabis. Stimulant medications are frequently misused. Psychostimulants can lead to addiction, have physical, psychological and social health consequences and can induce a great disease burden. The aim of the present article is to provide a literature review on the health effects of stimulants as potential drugs of abuse. It will cover essentially cocaine, amphetamines and its derivatives (including methamphetamines and 3-4-methylenedioxymethamphetamine, ecstasy), nicotine, caffeine and khat, and touch upon the issues of prescribed substances (anti-depressants, weight control medications, attention-deficit hyperactivity disorder medications, hypersomniac disorder). Their pharmacology, addictive potential, health consequences and treatment will be discussed. We used Medline for the literature review from 1990 to the date of this review, and mention the findings of human and animal studies (the latter only if they are of clinical relevance).

Addiction to prescription opioids: characteristics of the emerging epidemic and treatment with buprenorphine

Dependence on and abuse of prescription opioid drugs is now a major health problem, with initiation of prescription opioid abuse exceeding cocaine in young people. Coincident with the emergence of abuse and dependence on prescription opioids, there has been an increased emphasis on the treatment of pain. Pain is now the "5th vital sign" and physicians face disciplinary action for failure to adequately relieve pain. Thus, physicians are whipsawed between the imperative to treat pain with opioids and the fear of producing addiction in some patients. In this article, the authors characterize the emerging epidemic of prescription opioid abuse, discuss the utility of buprenorphine in the treatment of addiction to prescription opioids, and present illustrative case histories of successful treatment with buprenorphine.

Imported compounded diet pill use among Brazilian women immigrants in the United States

In Brazil, compounded diet pills that combine amphetamines, benzodiazepines, antidepressants, diuretics and laxatives are often prescribed. In 2006, the Food and Drug Administration banned their sale in the United States (US) citing substantial safety concerns. This study evaluates the prevalence of, and factors associated with, use of these pills among Brazilian immigrant women aged 18-50. Pill use was assessed at one clinic and two churches using an anonymous survey (n = 307). While living in the US, 18% of clinic respondents and 9% of church respondents reported using these diet pills. Nearly two thirds of pill users reported adverse effects. In multivariate logistic regression analysis, being unmarried, college educated, dissatisfied with current weight, and advised by a US physician to lose weight were associated with greater odds of imported diet pill use. To enhance care of Brazilian immigrants, US physicians should become familiar with the health consequences of imported diet pills from Brazil.

Changes in the prevalence of non-medical prescription drug use and drug use disorders in the United States: 1991-1992 and 2001-2002

OBJECTIVE

To examine changes in the prevalence of non-medical prescription drug use and DSM-IV non-medical prescription abuse and dependence in the United States between 1991-1992 and 2001-2002.

METHOD

Comparison of the prevalence of past-year non-medical prescription drug use and drug use disorders in the total sample and among lifetime non-medical users in two large national surveys conducted 10 years apart.

RESULTS

From 1991-1992 to 2001-2002, the prevalence of DSM-IV non-medical prescription drug use increased by 53%, from 1.5% to 2.3% (p<0.001), and the prevalence of drug use disorders increased by 67% from 0.3% to 0.5% (p<0.001). The conditional prevalence of a disorder among users increased numerically from 19.9% to 23.6%, but this increase was not statistically significant (p=0.15).

CONCLUSIONS

There have been substantial increases in the prevalence of prescription drug non-medical use and prescription drug use disorders in the United States. Given the clinical utility of prescription drugs, urgent action is needed to find approaches that balance the need for access to these medications among those who need them, against their potential for abuse and dependence in subgroups of vulnerable individuals.

Toxicology Screening in Orthopedic Trauma Patients Predicting Duration of Prescription Opioid Use

Following hospitalization for orthopedic trauma, some patients continue to use opioids following fracture healing. This retrospective cohort study of 50 patients with high-energy fractures was conducted to determine if toxicology screening tests upon admission can predict subsequent opioid use. Data were collected from clinical records and a statewide electronic database of prescription records. Six months following hospital discharge, those with positive toxicology used more Following hospitalization for orthopedic trauma, some patients continue to use opioids following fracture healing. This retrospective cohort study of 50 patients with high-energy fractures was conducted to determine if toxicology screening tests upon admission can predict subsequent opioid use. Data were collected from clinical records and a statewide electronic database of prescription records. Six months following hospital discharge, those with positive toxicology used more. Following hospitalization for orthopedic trauma, some patients continue to use opioids following fracture healing. This retrospective cohort study of 50 patients with high-energy fractures was conducted to determine if toxicology screening tests upon admission can predict subsequent opioid use. Data were collected from clinical records and a statewide electronic database of prescription records. Six months following hospital discharge, those with positive toxicology used more opioids (730 mg vs. 364 mg; P = .04) expressed as morphine equivalents than those with negative toxicology and were more likely to continue using opiates at the end of the 3rd, 4th, 5th, and 6th month after discharge. Patients hospitalized for high-energy fractures with positive admission toxicology are at risk for prolonged opiate use during the initial six months following discharge.

Preventing communication errors in telephone medicine

Errors in telephone communication can result in outcomes ranging from inconvenience and anxiety to serious compromises in patient safety. Although 25% of interactions between physicians and patients take place on the telephone, little has been written about telephone communication and medical mishaps. Similarly, training in telephone medicine skills is limited; only 6% of residency programs teach any aspect of telephone medicine. Increasing familiarity with common telephone challenges with patients may help physicians decrease the likelihood of negative outcomes. We use case vignettes to highlight communication errors in common telephone scenarios. These scenarios include giving sensitive test results, requests for narcotics, managing ill patients who are not sick enough for the emergency room, dealing with late-night calls, communicating with unintelligible patients, and handling calls from family members. We provide management strategies to minimize the occurrence of these errors.

The drug-seeking patient in the emergency room

Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that has not been appropriately managed. Opioids produce euphoria in some patients, providing the motivation for abuse, which can be detrimental even with occasional use. Even in the absence of overt euphoria, opioids are highly self-reinforcing and can be problematic in a large number of patients, requiring that acute care physicians exercise caution in whom they are administered. Habitual patient files, narcotic contracts, pain management letters, and patient tracking and management programs can be used for the benefit of both drug seeking-patients and chronic pain patients. For many patients, drug-seekers and chronic pain patients alike, withholding opioids may be an important part of their long-term management. For others, long-acting opioids such as long-acting morphine or methadone are a reasonable option.

Prescription opiate medications: medical uses and consequences, laws and controls

The proposed analysis and evaluation of the data elements in the OPP and other similar regulatory programs will support the following potential impact on the patients and physicians in Michigan and other states: Reduced rates of addictive use of prescriptions of Schedule II medications. Reduced rates of addictive patterns of prescribing of Schedule II medications. Improved the prescribing of Schedule II medication for pain disorders. Improved the prescribing of Schedule II medications in addictive disorders. Establish the need and direction for development of curriculum for Schedule II drugs for undergraduate medical education and continuing medical education. Establish the need and direction for development of curriculum for use of Schedule II medications in patients with addictive and pain disorders. Explore the need and direction for development of the monitoring system medical curriculum for Schedule III, IV, and V drugs. Demonstrate link between diversion and adverse effects on health caused by an addictive pattern of use and prescribing of Schedule II drugs

Variability in emergency physician decisionmaking about prescribing opioid analgesics

STUDY OBJECTIVE

The purpose of this study is to determine what factors influence emergency physicians' decisions to prescribe an opioid analgesic for 3 common, painful conditions.

METHODS

We developed items thought to influence the decision to prescribe an opioid analgesic through a review of the literature, expert consultation, and interviews with practicing emergency physicians. We developed a baseline vignette and items expected to influence the decision for each of the 3 conditions: migraine, back pain, and ankle fracture. We surveyed 650 physicians randomly selected from the American College of Emergency Physicians. The influence of individual items was explored through a univariate analysis of the response distribution. Patterns were assessed by analytically creating scales.

RESULTS

We received responses from 398 (63%) of the 634 eligible physicians. Physicians' likelihoods of prescribing an opioid showed marked variability, with at least 10% of physicians saying they were unlikely and 10% of physicians saying they were likely to prescribe for each condition. Physician responses to individual pieces of clinical information, such as the patient requesting "something strong" for the pain, were also highly variable, with at least 10% of physicians saying they would be negatively influenced by this request and at least 10% saying they would be positively influenced by it.

CONCLUSION

Even when faced with identical case scenarios, physicians' decisions to prescribe opioid analgesics are highly variable. Moreover, the same clinical information, such as a patient requesting a strong analgesic, changes the likelihood of prescribing opioids in opposite directions for different physicians.

Association between human mu-opioid receptor gene polymorphism, pain tolerance, and opioid addiction

Central to both pain responses and opioid addiction is activity at the micro -opioid receptor. To explore the role of the micro -opioid receptor gene (OPRM) in human pain tolerance and opioid addiction, we examined the relationships among OPRM genotype and experimental pain tolerance in opioid addicts in methadone treatment (n = 50) and healthy normal controls (n = 59). Pain phenotype (pain tolerant vs. pain intolerant) was operationalized as tolerance to a standardized noxious stimulus (either thermal or mechanical), and dichotomized based on distribution. One microsatellite and two single nucleotide polymorphisms, A118G and C17T, in exon 1 were typed to study the OPRM gene. Although the established relationship between the phenotypes of opioid addiction and pain intolerance was validated (P = 0.02), genotype differed neither between addict-affected vs. control, nor pain tolerant vs. intolerant subjects. The variant A118G was absent in all individuals and the C17T polymorphism appeared in only three African-American individuals (two addicts and one control). The absence of this polymorphism, the small sample size and the heterogeneous ethnic backgrounds of participants in the pilot study allow only tentative conclusions based on the results, thus the role of the opioid receptor in pain and opioid reward response remains uncertain.

Keeping lists and naming names: habitual patient files for suspected nontherapeutic drug-seeking patients

Emergency departments commonly keep files of patients who are suspected of frequently visiting them and fabricating symptoms to obtain prescription drugs, usually opioids, for nontherapeutic purposes. Such files have previously been given names such as "frequent flyer file," "repeater log," "kook-book," "problem patient file," "patient alert list," or "special needs file." Little has been written about the ethical, legal, and regulatory considerations that should be taken into account when establishing, maintaining, and using such files. This article explores these issues. The term "habitual patient files" is proposed because it is descriptive without being judgmental.

Alcohol use disorders in primary care: do gender-specific differences exist?

OBJECTIVE

To describe how alcohol use disorders (AUDs) affect women, focusing on gender-specific implications for primary care physicians (PCPs).

DESIGN

An overview of literature from 1966 to 2000 identified by a medline, PsychINFO and HealthSTAR/Ovid Healthstar database search using key words "women,""alcohol" and "alcoholism."

MEASUREMENTS AND MAIN RESULTS

Although the prevalence of AUDs is greater in men than in women, women with AUDs are more likely to seek help, but less likely to be identified by their physicians. Psychiatric comorbidities (especially depression and eating disorders) are more common in women with AUDs than in men with AUDs. A past history of sexual and/or physical abuse places a woman at increased risk for AUDs. Women have a greater sensitivity to alcohol, have an accelerated progression from alcohol toxicity, and have increased mortality at lower levels of consumption compared to men. Women and men who are light-to-moderate drinkers have lower coronary artery disease mortality than do abstainers or heavy drinkers. Risk of breast cancer is increased in women who drink >or=1 drinks daily. Common barriers to treatment include: fear of abandonment by partner; fear of loss of children; and financial dependency. Brief interventions have been shown to be effective in reduction of alcohol consumption in women with at-risk drinking. It is unclear if women-only treatment programs improve outcomes.

CONCLUSION

PCPs should be alert to gender-specific differences for women with AUDs.

Psychoactive substances in suicides. Comparison of toxicologic findings in two samples

The goal in this study was to assess if there is any constancy in detections of psychoactive substances in consecutive suicides. Toxicologic findings in 179 suicides in San Diego County, California, between 1981 and 1982, and 333 suicides in Mobile County, Alabama, between 1990 and 1998, were compared. Alcohol was detected in about 30% of suicides in both samples. Abusable prescription psychoactive substances, i.e., benzodiazepines and opiates, were detected in one fifth of cases in both locations. Nonabusable prescription psychoactive substances, mainly antidepressants, were found in more suicides in Mobile than in San Diego. Detection rates of different classes of psychoactive substances have not changed much in the past decade. Detection of alcohol, cocaine, or cannabis in about 40% of suicides supports the clinical practice of discouraging consumption of these substances in depressed patients. Another challenge is the low rate of detection of antidepressants in suicide, which suggests undertreatment of depression in suicides. Continued reporting of routine, comprehensive, toxicologic findings in suicides is useful to monitor patterns of use of psychoactive substances in this group and to guide suicide prevention in clinical practice and public health policy.

The role of disabled physicians in the diversion of controlled drugs

To test the assertion that disabled physicians are loose prescribers and clinically meaningful contributors to the diversion of controlled prescriptions, an anonymous survey of physicians in a confidential treatment program in Ohio was conducted to compare pre- and post-recovery: (1) self-reported number of controlled drug prescriptions written, and (2) self-rated appropriateness of prescribing practices. Forty (50%) of the surveyed physicians responded. Opioids alone showed a post recovery reduction in the number of prescriptions (-4.5; 95% CI: -9.5 to -0.5). The volume of prescribing in all controlled drug categories was small from both a law enforcement and clinical perspective. Respondent's self-assessment of prescribing practices indicated conservative pre-, and more conservative post-recovery prescribing, increasing from 2.0 in stimulants (CI: 1.0-4.0), to 3.5 in sedatives (CI: 1.0-6.0). Despite limitations, this initial data provides evidence to refute the assertion that disabled physicians are loose prescribers and meaningful contributors to the diversion of controlled prescriptions.

Pain responses in methadone-maintained opioid abusers

Providing pain management for known opioid abusers is a challenging clinical task, in part because little is known about their pain experience and analgesic requirements. This study was designed to describe pain tolerance and analgesic response in a sample of opioid addicts stabilized in methadone-maintenance (MM) treatment (n = 60) in comparison to matched nondependent control subjects (n = 60). By using a placebo-controlled, two-way factorial design, tolerance to cold-pressor (CP) pain was examined, both before and after oral administration of therapeutic doses of common opioid (hydromorphone 2 mg) and nonsteroidal anti-inflammatory (ketorolac 10 mg) analgesic agents. Results showed that MM individuals were significantly less tolerant of CP pain than control subjects, replicating previous work. Analgesic effects were significant neither for medication nor group. These data indicate that MM opioid abusers represent a pain-intolerant subset of clinical patients. Their complaints of pain should be evaluated seriously and managed aggressively.

Evaluation of the abuse liability of modafinil and other drugs for excessive daytime sleepiness associated with narcolepsy

Psychostimulants have been used routinely for the treatment of the disabling daytime sleepiness associated with narcolepsy. However, the perceived and real potential for abuse of amphetamine and amphetaminelike stimulants prompted a search for new wake-promoting compounds with lower dependency and abuse liabilities. Modafinil is a novel wake-promoting agent with a mechanism of action that differs markedly from that of amphetamine and amphetamine-like stimulants. In controlled clinical trials, modafinil has been shown to be an effective and well-tolerated treatment for excessive daytime sleepiness (EDS) in patients with narcolepsy. With a benzhydrylsulfinylacetamide structure, modafinil has a low level of solubility in water (< 1 mg/mL) and is unstable at temperatures > or = 180 degrees C, physicochemical properties that reduce the potential for its abuse via intravenous injection and smoking, respectively. Available preclinical and clinical data on the abuse liability of modafinil suggest a much lower potential for abuse and dependency than amphetaminelike stimulants commonly used for treating EDS in patients with narcolepsy. Therefore, modafinil represents a valuable therapeutic option for the treatment of EDS associated with narcolepsy.

What perioperative nurses need to know about substance abuse

Substance abuse can occur with legal drugs (e.g., alcohol, tobacco, prescription medications), illegal drugs that are purchased on the street, or prescription drugs used for reasons other than health. Alcohol is the most commonly used legal drug, and cocaine, heroin, and marijuana are the most commonly used illegal drugs. Each drug has specific effects on body systems. Some drugs can lead to acute and chronic problems; some even can cause death. Perioperative nurses may be among the few health care professionals who assess and care for substance abusers. As such, they should be prepared to recognize the symptoms of substance abuse and implement measures to support and help these individuals. This article provides perioperative nurses with information about the use and abuse of alcohol, prescription drugs, cocaine, heroin, and marijuana; the acute and chronic effects that these drugs have on various body systems; and guidelines and interventions that can be implemented when caring for substance abusers.