first two articles

I N J U R Y P R E V E N T I O N

Anna Valde Walden Un

For corresp C-NPT, 15 E-mail: ann

J Emerg Nu Available on 0099-1767 Copyright © All rights re http://dx.do

Septembe

RX FOR INJURY: ADOLESCENT PRESCRIPTION DRUG MISUSE

Authors: Anna Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT, and Tomi St. Mars, MSN, RN, CEN, FAEN, Minneapolis, MN, Phoenix, AZ

Section Editor: Anna Maria Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT

Earn Up to 9.0 CE Hours. See page 519.

n the past 2 decades, preventable injuries in children and adolescents have been on the decline.1 This

I decrease in injuries is a positive outcome of many years

of injury prevention activities; however, one area in which injury rates are on the rise is drug poisoning. In fact, the number of poisoning incidences in youth aged 15 to 19 years doubled between 2000 and 2009.2 This sharp increase in poisoning events has been attributed to a dramatic increase in the number of medications being prescribed and the misuse of those medications.3 Poisoning is now the leading cause of injury-related deaths in the United States, and drugs—most of which are prescription drugs—cause 90% of poisoning deaths.4

Frequency of Prescription Drug Misuse in Adolescents

Prescription drug misuse or “abuse” is the intentional use of a medication without a prescription or use of a medication in a way other than prescribed.5 Findings from the 2012 Partnership Attitude Tracking Study (PATS) indicated that 1 in 4 teens (25%) has misused a prescription drug in his or her lifetime and 20% of those teens had done so before the age of 14 years. This is an alarmingstatistic, buteven moreconcerning is the fact that prescription drug misuse by teens increased by 33% during the 5-year period between 2008 and 2012.6

The 2 prescription drugs that are most commonly misused by adolescents are stimulants and opioid analgesics.5

Approximately 12% of teens report having misused a prescription stimulant in their lifetime, and nearly as many have reported nonmedical use of opioid medications.6 A study

z, Member, San Francisco Chapter, is Contributing Faculty, iversity, Minneapolis, MN.

ondence, write: Anna Valdez, PhD, RN, CEN, CFRN, CNE, 01 Mendocino Ave, Santa Rosa, CA 95401; [email protected].

rs 2014;40:497-9. line 3 August 2014

2014 Emergency Nurses Association. Published by Elsevier Inc. served. i.org/10.1016/j.jen.2014.05.011

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conducted in the University of Michigan emergency department found that approximately 10% of teens treated in the emergency department reported nonmedical prescrip- tion opioid or sedative use.7 This upward trend in prescription drug misuse has been attributed to an unprecedented availability and perceptions by teens and their parents that prescription drug misuse is not a serious concern. The increase in stimulant misuse is attributed in part to a misconception by both teens and parents that stimulants can improve academic performance.

Availability and Access to Prescription Drugs

The number of medications being prescribed in the United States each year is staggering, and medications that are commonly abused are easily accessible by adolescents. Between 1991 and 2010, the number of prescriptions written for stimulants, such as Ritalin (Novartis Pharma- ceuticals; Basel, Switzerland) and Adderall (Shire Plc; Dublin, Ireland), increased from 5 million to almost 45 million. At the same time, prescriptions for opioid analgesics increased from 75.5 million to 209.5 million.5 Many teens have access to these medications in their own homes. A pilot study by Tanabe et al8 found that improper storage and disposal of prescription pain medications after discharge from an emergency department is a common occurrence. Patients often keep “leftover” medications, and these medications are rarely locked in a secure area. This is important because more than half (56%) of teens responding to the PATS survey indicated that it is easy to obtain prescription drugs from their parents’ medicine cabinets. In addition, many adolescents who reported using prescription medications for nonmedical purposes stated that they were given the medication by a friend or relative.5,9

Awareness and Attitude About Prescription Drug Misuse

One of the reasons that adolescents misuse prescription medications is that they incorrectly believe that using these

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medications is less risky than taking “street” or illicit drugs. The PATS survey found that 27% of teens and 16% of parents believed that prescription drugs were safer than street drugs.6 This misconception may contribute to the casual attitude that some parents and adolescents have about prescription drug use. Only 15% of teens reported having had a conversation with their parents about prescription drug misuse. When viewed in contrast to the 80% who reported having discussed the dangers of drinking alcohol and 81% who have discussed the risks of marijuana use, it is clear that there is a lack of understanding of the risks associated with prescription drug misuse.6 This is an area where emergency nurses can be instrumental in providing education.

Injury Prevention Strategies

There are several strategies that emergency nurses can use to minimize the risk of prescription drug misuse and prevent poisoning deaths. Emergency nurses should educate their patients on the risks associated with prescription drug use and misuse. By raising awareness about the hazards of misusing prescription drugs, emergency nurses can change the public perception that prescription drugs are safer to use than illicit drugs. In addition, emergency nurses should discuss proper storage and disposal of medications at discharge. This is particularly important for opioid medications, which are commonly prescribed in the emergency department and frequently misused.8

Emergency nurses should ensure that the prescription drug monitoring program (PDMP) is queried before prescriptions for controlled substances are written in the emergency department. The PDMP is a statewide electronic database that collects designated data on substances dispensed in the state. Currently, 48 states and 1 territory either have operating PDMPs or have passed legislation to implement them.10 The PDMP is housed by a specified statewide regulatory, administrative, or law enforcement agency. This agency is tasked to distribute data from the database to individuals who are authorized under state law to receive the information for purposes of their profession. This database serves as a valuable health care tool to identify previous controlled substances a patient may have received.

Emergency departments can also use controlled substance prescribing guidelines to minimize the risk of poisoning and prescription drug misuse. Early evidence suggests that prescribing guidelines can reduce the volume of prescriptions written, but the impact that this is having on morbidity and mortality rates is unknown.11 Prescribing

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guidelines focus on the prescriber’s practice of writing prescriptions and should not be confused with clinical treatment guidelines. Examples of prescribing guideline recommendations include checking the PDMP before writing prescriptions for controlled substances; not replac- ing controlled substances reported as being lost, stolen, or destroyed; not prescribing long-acting or controlled-released opioids in the emergency department; and performing screening, brief interventions, and treatment referrals for patients with suspected prescription abuse problems.12

Emergency nurses can participate in the development of controlled substance prescribing guidelines and encourage their prescribing colleagues to use them. Several states, including Arizona, Washington, and Ohio, have developed controlled substance prescribing guidelines that can be directly applied in the emergency department or used as a framework for developing department-specific guidelines.12,13 By using controlled substance prescribing guidelines, clinicians mini- mize inappropriate prescribing practices in the emergency department, which decreases access and abuse.

In the community, emergency nurses can engage in activities to increase public awareness and education efforts about prescription drug misuse. Education for children should begin before they enter adolescence. A study by the National Institutes of Health found that middle school students from small towns who participated in a community- based prevention program were less likely to abuse prescription medications in late adolescence and early adulthood.14 There are a number of excellent resources available to parents and emergency nurses, including the PEERx program from the National Institute on Drug Abuse15 and the “Not in my House” Web page from the Partnership for Drug-Free Kids.16

Conclusion

Emergency nurses play an important role in addressing the growing problem of prescription drug misuse and pediatric poisoning. Prevention begins at home but should also occur in the emergency department and within the community. In addition toengaginginprimary prevention strategiesfocused on access, availability, awareness, and attitudes,17 emergencynurses should be prepared to monitor for prescription drug misuse and offer referrals for treatment to teens and their parents when prescription drug misuse is identified.

REFERENCES 1. Valdez AM. Pediatric injury prevention: are we there yet? J Emerg Nurs.

2013;39(1):76-7.

2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Vital signs: unintentional injury deaths among

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persons aged 0–19 years—United States, 2000–2009. MMWR Morb Mortal Wkly Rep. 2012;61:270-6. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm61e0416a1.htm?s_cid=mm61e0416a1_w. Accessed March 22, 2014.

3. Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug Poisoning Deaths in the United States, 1980–2008. NCHS data brief, No. 81, National Center for Health Statistics; 2011. http://www.cdc.gov/nchs/data/databriefs/db81.pdf. Accessed March 23, 2014.

4. Trust for America’s Health. Prescription drug abuse: strategies to stop the epidemic 2013. http://healthyamericans.org/assets/files/ TFAH2013RxDrugAbuseRptFINAL.pdf. Accessed March 20, 2014.

5. National Institute on Drug Abuse. Prescription drug abuse – December 2011. Topics in brief. http://www.drugabuse.gov/sites/default/files/ prescription_1.pdf. Accessed March 23, 2014.

6. MetLife Foundation. 2012 Partnership attitude tracking study. Teens and parents. http://www.drugfree.org/wp-content/uploads/2013/04/ PATS-2012-FULL-REPORT2.pdf. Accessed March 23, 2014.

7. Whiteside LK, Walton MA, Bohnert AS. Nonmedical prescription opioid and sedative use among adolescents in the emergency department. Pediatrics. 2013;132(5):825-32.

8. Tanabe P, Paice JA, Stanacti J, Fleming M. How do emergency department patients store and dispose of opioids after discharge? A pilot study J Emerg Nurs. 2012;38(3):273-9.

9. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11–4658, Substance Abuse and Mental Health Services Administration; 2011.

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10. Alliance for States with Prescription Monitoring Programs. http:// pmpalliance.org/about-the-aspmp/. Accessed May 17, 2014.

11. Kilaru A, Gadsden S, Perrone J, et al. How do physicians adopt and apply opioid prescription guidelines in the emergency department? A qualitative study [published online ahead of print April 14, 2014]. Ann Emerg Med. http://dx.doi.org/10.1016/j.annemergmed.2014.03.015. Accessed March 29, 2014

12. Arizona College of Emergency Physicians. Arizona guidelines for emergency department controlled substance prescribing. http://www. azdhs.gov/phs/owch/pdf/injuryprevention/az-prescription-prescribing- guidelines.pdf. Accessed March 23, 2014.

13. Ohio Department of Health. Ohio emergency and acute care facility opioids and other controlled substances (OOCS) prescribing guidelines. http://www. healthy.ohio.gov/ed/guidelines.aspx. Accessed March 23, 2014.

14. National Institutes of Health. Prevention efforts focused on youth reduce prescription abuse into adulthood. http://www.nih.gov/news/ health/feb2013/nida-14.htm. Accessed March 23, 2014.

15. National Institute on Drug Abuse. PEERx. Teen prescription drug abuse prevention. http://teens.drugabuse.gov/peerx. Accessed March 29, 2014.

16. Partnership for Drug-Free kids. Not in my house. http://notinmyhouse. drugfree.org/default.aspx. Accessed March 29, 2014.

17. Iowa Governor’s Office of Drug Control Policy. Talking to kids about prescription drug abuse. http://www.iowa.gov/odcp/images/pdf/ Parentskids.pdf. Accessed March 29, 2014.

Submissions to this column are encouraged and may be sent to Anna Maria Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT [email protected]

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.