Drug Diversion Training and Best Practice Prescribing for West Virginia Nurses (1 CH)
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Course Availability: Expires October 2, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Medical Disclaimer Legal Disclaimer Disclosures
This course fulfills the requirement of 1 hour of continuing education for West Virginia nurses in drug diversion training and best practice prescribing of controlled substances after the first 3-hour CE is completed. Looking for the 3-hour course?
Drug Diversion Training and Best Practice Prescribing for West Virginia Nurses (1 CH)
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare nurses to prevent prescription drug abuse and diversion through dissemination and implementation of evidence-based information about the current prescription drug abuse epidemic and best practices for prescribing controlled substances.
Upon completion of this course, you will be able to:
- Discuss factors that have contributed to the increase in prescription drug abuse and diversion in the United States.
- Identify risk factors for potential misuse/abuse of prescribed pain medications.
- List the classes of drugs that are most commonly abused and/or diverted.
- Discuss behaviors suggestive of aberrant drug-taking behavior.
- Summarize key factors of a “Universal Precautions” approach to prescribing controlled substances.
TABLE OF CONTENTS
Prescription drug abuse is the fastest-growing drug problem in America. It affects every age, gender, ethnic group, and socioeconomic class and is contributing to the overall drug abuse epidemic in this country. Serious and deadly consequences that have occurred from non-medical use of prescription drugs have raised concern about their efficacy in the management of chronic pain. Reevaluation of chronic pain treatment and prescribing practices is necessary in order to halt this growing epidemic of prescription drug abuse and overdose deaths.
Nurses are in a unique position to address the problem of prescription drug abuse and diversion. They comprise the largest group of healthcare professionals and care for more patients than any other health profession. Nurses who understand the complex relationship between chronic pain and addiction risk associated with the prescription drugs often used to alleviate pain will be better prepared to identify and intervene with patients and colleagues who may be at risk.
Prescription opioid medications are the drugs most commonly abused, diverted, and associated with overdose deaths. Since they are also the drugs commonly prescribed for treating pain, nurses must be acutely aware of current challenges in managing chronic pain. An understanding of current guidelines for more responsible opioid prescribing will prepare nurses to provide better pain care while concurrently helping their patients avoid addiction risk.
West Virginia has been reported to have the highest drug overdose mortality rate in the nation, with 28.9/100,000 people dying from drug overdoses. Prescription drugs are involved in 90% of these drug fatalities, and opioid pain relievers such as oxycodone, hydrocodone, fentanyl, and hydromorphone are responsible for 75% of the prescription drug overdose deaths (CDC, 2014).
As part of a comprehensive effort to address this problem in West Virginia, the Governor’s Substance Abuse Prevention Bill (SB437) was passed in March 2012. This bill established a requirement that all healthcare providers who prescribe, dispense, or administer controlled substances participate in continuing education related to prescription drug abuse and drug diversion. Nurses licensed in the state are required to obtain three CEUs initially and one CEU every year thereafter to satisfy this legislative requirement (WV RN Board, 2012).
DEFINITION OF TERMS
The following terms related to prescription drug abuse and diversion of controlled substances are used throughout this course.
Prescription drug misuse: Taking a legal prescription medication for a purpose other than the reason for which it is prescribed (NIDA, 2011b)
Prescription drug abuse and non-medical use: Used synonymously and broadly defined as the use of a medication without a prescription, in a way other than as prescribed, or for the experience or feelings elicited (NIDA, 2011b)
Prescription drug diversion: Diverting prescription drugs from legal and medically necessary purposes toward use that is illegal and typically not authorized or medically necessary (HHS, 2012)
Illicit drug use: Illegal use of drugs, including the non-medical use of prescription drugs (SAMHSA, 2013)
Substance abuse: A set of related conditions associated with the consumption of mind- and behavior-altering substances that have negative behavioral and health outcomes; may include alcohol, prescription drugs used non-medically, and illicit drugs (HHS, 2011)
Addiction: A chronic, relapsing disease characterized by compulsive drug seeking and use, despite serious adverse consequences, and by long-lasting changes in the brain (NIDA, 2011b)
PRESCRIPTION DRUG ABUSE AND DIVERSION: SCOPE OF THE PROBLEM
Prescription drug abuse and diversion is a nationwide problem that is contributing significantly to the overall drug epidemic in this country. A striking increase in drug overdose deaths in the past two decades has been directly associated with an increase in non-medical use of prescription drugs, particularly opioid medications. Prescription drugs are more available to a broader population, and because they are legal, many people perceive them to be safer and fail to recognize the dangers in using them (SAMHSA, 2013).
Prescription drugs commonly used for non-medical purposes fall into four categories: pain relievers, tranquilizers, stimulants, and sedatives. In 2012 these four categories of prescription drugs made up the second-highest illicit drug use category, with 6.8 million Americans reporting past-month non-medical use. Marijuana was the only drug category with higher past-month illicit use (18.9 million users) (SAMHSA, 2013).
In 2010, West Virginia was one of the top-ten states for past-year rates of non-medical pain reliever use among young adults ages 18 to 25. West Virginia was also one of the top-ten states for past-month use of illicit drugs among persons ages 12 years and older. Between 2000 and 2010, deaths from drug overdose and poisonings in West Virginia were higher than the national average (CDC, 2014).
Rates of drug overdose deaths have increased five-fold since 1990 largely due to prescription opioid painkillers, and treatment admissions involving the use of prescription pain relievers were seven times higher in 2010 than in 1999 (CDC, 2014).
In 2010, the highest rate of past-month illicit drug use including use of prescription drugs was among 18- to 20-year-olds (23.9%), and the second highest rate occurred among 21- to 25-year-olds (19.7%). Comparing past-month illicit use in 2010 to previous years, there was an increase in the 12–13, 18–20, and 30–34 year age groups.
These trends are important because youth are particularly vulnerable to addiction, and early use of prescription drugs for non-medical purposes has been associated with illicit use of other drugs. The rate of use of other illicit drugs is significantly higher among individuals who have abused prescription drugs (see graph below) (SAMHSA, 2013).
Percentage of individuals using illicit drugs according to whether they have abused prescription drugs. (Source: NIDA, 2011b.)
In West Virginia, death rates from drug-induced causes increased significantly between 1999 and 2010 (see table below). In 2011, drug overdose was the second-leading cause of accidental death in West Virginia, and the majority of these deaths were associated with prescription opioid medications (Gwilliam, 2013).
(per 100,000 population)
|Source: Gwilliam, 2013.|
There are a number of factors that have contributed to the alarming increase in prescription drug abuse, diversion, and overdose deaths over the past two decades.
MORE AGGRESSIVE PAIN MANAGEMENT PRACTICES
In the 1990s, “under-prescribing” for pain was the predominant concern because of the physiologic and psychological effects caused by unrelieved pain. Concerns about under-treatment of pain despite the availability of effective drugs led to a movement toward more aggressive pain management, which has been the driving force toward more liberal opioid prescribing. Support from the pharmaceutical industry to increase utilization of opioid analgesics as a preferred treatment for chronic pain may also have driven financial incentives aimed at more liberal prescribing practices.
The Joint Commission (TJC) supported the efforts to improve pain management in healthcare facilities across the country. In August 1997, a collaborative project was initiated to include pain assessment and management in TJC standards. By 2001, all organizations accredited by TJC, including hospitals, ambulatory care centers, behavioral health, and home care, were required to incorporate pain assessment and management into the treatment plan for all patients. Hospitals and other healthcare organizations were faced with the risk of receiving unsatisfactory accreditation visits if they did not have a formal process in place to proactively probe and properly treat acute and chronic pain (ASAM, 2012). Since opioids are one very effective treatment in the management of pain, more liberal prescribing practices evolved.
INCREASED PRESCRIBING OF CONTROLLED SUBSTANCES
Increased controlled substance prescribing has contributed to the increase in prescription drug abuse and diversion. Sales of opioid medication has drastically increased since the 1990s—from 76 million prescriptions in 1991 to 210 million subscriptions in 2010—creating a significant increase in the environmental availability of opioids and making them more accessible for non-medical use (NIDA, 2011a, 2011b).
PATIENT PERCEPTION AND LACK OF KNOWLEDGE
Patients’ perceptions about the safety and use of prescription drugs also played a role in the widespread use and availability of controlled substances. Patients with false perceptions that prescription drugs are safer and less addictive believe it is acceptable to share prescription medication with friends or family members. These perceptions account for more widespread distribution of controlled substances to individuals for non-medical use. In addition, lack of education about proper storage and disposal of controlled substances has left many unused prescriptions in medicine cabinets for months or even years, where these powerful drugs may be a target for non-medical use and diversion.
The culture we live in today has also contributed to the abuse and diversion of controlled substances. Our culture has evolved to one that demands instant gratification, and taking a pill for any ailment has become acceptable. Direct-to-consumer marketing by the pharmaceutical industry has increased patient demand for prescription drugs by making patients more comfortable about asking their physicians for the drugs they feel they need. The proliferation of drug information on the Internet has also contributed by increasing access to legitimate as well as illegitimate prescription drug information.
COMMONLY DIVERTED/ABUSED DRUGS
There are many types of prescription drugs that have high potential for abuse (see table below). Three specific classes are most commonly abused and thus most susceptible to diversion for non-medical use:
- Pain medications/narcotics. Opioid pain relievers (narcotics) are the most commonly diverted controlled prescription drugs (SAMHSA, 2013). Opioid medications are effective for the treatment of pain and have been used appropriately to manage pain for millions of people. Increased rates of abuse and overdose deaths related to opioid pain relievers in the past decade have raised concerns about proper use of these medications in the treatment of chronic pain.
- Central nervous system (CNS) depressants/sedatives/hypnotics. CNS depressants slow brain activity and are useful for treating anxiety and sleep disorders. Since many patients with pain also experience anxiety or sleep disturbances, increased prescribing of sedative hypnotics has paralleled the increase in prescribing of opioid medication. Clinicians who add sedative hypnotics to the treatment plan for chronic pain patients may potentiate the risk for patients who are also prescribed opioid medication.
- Stimulants. Stimulants are prescribed primarily for treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy. They may also be used as an adjunct medication in the treatment of depression. When taken non-medically, stimulants can induce a feeling of euphoria and thus have a high potential for abuse and diversion. They also have a cognitive enhancement effect that has contributed to non-medical use by professionals, athletes, and older individuals. Non-medical use of stimulants poses serious health consequences, including addiction, cardiovascular events, and psychosis (NIDA, 2011b).
The table below lists three categories of drugs that have the highest potential for abuse and diversion. Examples of drugs (including the generic name and brand names) that fall into each category are provided.
|Source: NIDA, 2011a.|
RISK FACTORS FOR DRUG ABUSE/DIVERSION
Recognizing and responding to risk indicators is an important nursing responsibility that can help reduce prescription drug abuse and diversion among patients and colleagues. To examine risk for substance abuse or drug diversion, it is important to look at general risk factors as well as specific population risk indicators. There are a number of physiologic, behavioral, and genetic risk factors that can predispose any person to abuse of opioid medication.
A personal or family history of alcohol or drug abuse accounts for as much as 60% of a person’s risk. It is also the one factor that is most strongly predictive of drug abuse and aberrant drug-related behaviors (Chou et al., 2009).
Patient Risk Factors
Some patients who are prescribed opioid pain medication are at increased risk for opioid abuse and diversion. These patients may demonstrate opioid misuse behaviors that can provide clues to the clinician. Aberrant drug-related behavior (ADRB) is the term commonly used to describe a set of behaviors that may be associated with misuse of prescription opioids.
ADRB may occur because a patient is experiencing poor pain control or has fear of uncontrolled pain, which can lead to hoarding of medication. The behaviors may also be attributed to elective use of opioid medication for the euphoric effect or for non-pain-related symptoms such as anxiety, depression, insomnia, and stress.
ADRB in patients who are prescribed opioids should trigger clinicians to the possibility of addiction. Current literature suggests a range of aberrant drug-related behaviors, with some more predictive of addiction than others.
|Source: Passik et al., 2006.|
|More predictive of addiction||
|Less predictive of addiction||
Healthcare Professional Risk Factors
Healthcare professionals, including nurses, are not immune to the physiologic, behavioral, and genetic risk factors that can predispose one to opioid abuse and diversion. In fact, healthcare professionals may be at higher risk because of frequent access and availability of drugs in the workplace.
While current literature suggests that prevalence rates of substance abuse among health professionals mirrors the general population, these professionals have higher rates of abuse with benzodiazepines and opiates. Nurses who work in high-stress environments with easy access to controlled substances may be particularly vulnerable. Specialties such as anesthesia, emergency medicine, and psychiatry also have an increased incidence (Baldisseri, 2007).
There are a number of warning signs that should raise concern that a healthcare professional may be at risk for drug addiction. There are also specific behaviors that may be associated with diversion of medication by healthcare professionals.
|Source: NCSBN, 2011.|
|Behaviors that are suspicious and may suggest high risk||
|Behaviors that may be associated with drug diversion||
SOURCES OF DRUG DIVERSION
Drug diversion can occur anywhere along the continuum: manufacturer, wholesale distributor, retail pharmacy, hospitals and other healthcare organizations, prescribers, healthcare professionals who administer the medication, or the patient for whom the medication is prescribed.
The National Survey on Drug Use and Health (NSDUH) examines various sources where users obtain drugs to better understand where prescription drugs are most likely to be diverted for non-medical use. Data collected in 2012 reveals that a primary source of drug diversion for non-medical use comes from friends and relatives, and users often obtain the drugs free of charge. The perception that prescription drugs are safe and that it is acceptable to share them with friends and family members has fueled this disturbing trend.
SOURCES WHERE DRUGS WERE OBTAINED FOR NON-MEDICAL USE
(Among past users age 12 or older, United States, 2011–12)
- 54.0%, free from friend/relative
- 19.7%, one doctor
- 14.9%, bought/took from friend/relative
- 4.3%, drug dealer/stranger
- 1.8%, more than one doctor
- 0.2%, bought on Internet
- 5.1%, other
Source: SAMHSA, 2013.
Patients may be involved in drug diversion simply by:
- Sharing medication with family members or friends to help alleviate their pain
- Selling prescription drugs they obtained legally
- Soliciting multiple physicians (“doctor shopping”) to obtain pain medication under false pretenses
- Purchasing prescription medication from rogue websites that exist under the guise of a legitimate pharmacy
Healthcare Provider Diversion
Physicians, nurses, and other healthcare providers may knowingly or unknowingly be involved in drug diversion by:
- Prescribing controlled substances to patients who have given false information
- Prescribing controlled substances to patients involved in “doctor shopping”
- Prescribing controlled substances to patients who are selling their prescription drugs
- Intentionally prescribing controlled substances for illegal purposes
- Diverting controlled substances for personal use or financial gain
CHRONIC PAIN AND PRESCRIPTION DRUG ABUSE
Chronic pain drives more people to seek medical care than any other health condition and is a primary reason people take medication. It is a complex and often debilitating condition that involves physical as well as psychological and environmental factors. It is often hard to diagnose and difficult to treat. Management of chronic pain is challenging for the clinician and the patient because it may manifest as physical symptoms but also encompass many other facets of human suffering.
More than 100 million Americans are affected by chronic pain. This is more than the total number of Americans with heart disease, cancer, and diabetes combined. Chronic pain costs our nation nearly $635 billion per year in medical treatment and lost productivity (IOM, 2011) and has been a primary reason for the increased quantity of opioids prescribed to a broader population.
Over the past two decades, lack of knowledge about the complex nature of chronic pain combined with liberal prescribing of opioid medication to treat chronic pain has contributed to the widespread problem of prescription drug abuse, diversion, and overdose deaths.
The competing responsibilities of balancing pain care and preventing prescription drug abuse create a challenge for the clinician. An understanding of current evidence-based treatment modalities and precautions in opioid prescribing can improve quality of life for those who suffer in pain while reducing adverse consequences that can result from addiction.
Management of Chronic Pain
Opioids are widely accepted in the treatment of chronic pain related to cancer or other end-of-life processes. However, there is much controversy about the efficacy of opioids for management of chronic non-cancer pain (Chou et al., 2009).
The American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) commissioned an expert panel to review evidence on the efficacy of chronic opioid therapy (COT) for treatment of chronic non-cancer pain. It was concluded that while COT can be an effective treatment for patients who are carefully selected and monitored, COT is also associated with potentially serious harm. Clinicians must have advanced clinical skills and knowledge about safe prescribing practices and risk assessment to provide safe and effective care to chronic pain patients (Chou et al., 2009).
Effective management of chronic pain requires a multimodal, interdisciplinary approach that addresses not just physical functioning but also psychological and social functioning. Chronic pain treatment goes beyond relieving the physical symptoms of pain and aims to:
- Improve quality of life
- Increase functional ability
- Relieve associated psychological stressors
- Minimize risk of addiction
Approaches that incorporate physical and psychological components of pain management and utilize the expertise of various healthcare specialties are most effective. Recognizing the complex biological and psychosocial aspects of chronic pain challenges clinicians to tailor pain care to each person’s experience of pain. It is important to incorporate pharmacologic as well as non-pharmacologic modalities of treatment and to promote self-management as much as possible.
UNIVERSAL PRECAUTIONS FOR PRESCRIBING OPIOID MEDICATION
A universal precautions approach when prescribing opiod medication for chronic pain recognizes that all patients who are prescribed opioid medication are at risk for addiction. The implementation of universal precautions came from the experience gained from infectious diseases, where it was recognized that the safest and most appropriate approach to help reduce the risk of transmitting potentially life-threatening infectious diseases was to apply a minimum level of precaution with all patients. In time, this became a standard of care for infectious disease.
Since opioid medications have the potential to lead to drug abuse, diversion, and addiction, it likewise makes sense to proceed with caution when prescribing these medications. An assessment of patient lifestyle, past history, and a tendency toward risky behavior can provide clues about a patient’s risk for addiction but cannot accurately predict the likelihood of a patient abusing or diverting these medications. Thus, using a universal precautions approach when prescribing opioid medications offers a similar level of precaution with all patients and can help balance the risks with the benefits of prescribing opioids.
A universal precautions approach when prescribing opioid medication for chronic pain is a cornerstone for responsible opioid prescribing and can be summarized in the following 10 steps:
- Make a diagnosis with an appropriate differential.
- Conduct a patient assessment, including risk for substance use disorders.
- Discuss the proposed treatment with the patient and obtain informed consent.
- Have a written treatment agreement that sets forth the expectations and obligations of both the patient and the treating physician.
- Initiate an appropriate trial of opioid therapy, with or without adjunctive medication.
- Perform regular assessments of pain and function.
- Reassess the patient’s pain score and level of function.
- Regularly evaluate outcomes of pain management.
- Periodically review the pain diagnosis and any comorbid conditions, including substance use disorders, and adjust the treatment regimen accordingly.
- Keep careful and complete records of the initial evaluation and each follow-up visit.
Source: Gourley & Almahrezi, 2005.
WEST VIRGINIA EVIDENCE-BASED GUIDELINES
The value of a universal precautions approach in pain care has led many states to implement guidelines for the use of controlled substances in the treatment of chronic pain. These guidelines can help clinicians make better decisions about managing pain and promote safer and more consistent prescribing practices that will improve patient outcomes.
In West Virginia, guidelines were adopted by the Board of Medicine in 2010 and include the following (WVBOM, 2010):
Identifying patients who are appropriate to receive opioid medications for chronic pain is necessary before prescribing any opioid medication. Patient evaluation includes a history and physical examination that documents the nature and intensity of pain, current and past treatments for pain, underlying or coexisting diseases, the effect of pain on physical and psychological function, and any history of substance abuse.
A written treatment plan must be utilized that focuses on patient-centered outcomes such as reduced pain and improved physical and psychosocial function. Specific objectives should be outlined to help evaluate treatment success. Other treatment modalities and further diagnostic evaluations should be included as part of the treatment plan.
Informed Consent and Treatment Agreements
The goal of the informed consent process is to assist patients in making appropriate medical decisions consistent with their values and preferences (Chou et al., 2009). The risks and benefits of using controlled substances must be discussed with the patient. A treatment agreement outlines patient responsibilities and helps patients be accountable. A risk assessment can help guide the treatment agreement and may include stipulations that the patient receive prescription pain medications from only one physician and one pharmacy, undergo urine drug screens when requested, and adhere to pill counts to determine that medications are being taken appropriately.
The continuation of opioid therapy or other controlled substances must be guided by the patients’ progress toward functional goals. Periodic reviews assess changing circumstances that may indicate a need for change in the treatment plan. Pain etiology, health condition, progress toward functional goals, and an ongoing risk assessment should be part of the periodic review.
Consultation and Referrals
Chronic pain is common in patients with psychosocial comorbidities such as depression and a history of substance abuse. Treating these patients with opioid medication is challenging because they are more vulnerable to drug abuse, addiction, and diversion. Referral to experts who can provide a higher level of surveillance and monitoring may be needed.
Compliance with Controlled Substance Monitoring Program
All clinicians in West Virginia who prescribe or dispense controlled substances for the treatment of nonmalignant pain are required to regularly access the controlled substance monitoring program (CSMP). They must access the CSMP upon initially prescribing or dispensing a pain-reducing controlled substance to any patient who is not suffering from a terminal illness. Clinicians are required to check the database annually thereafter, and failure to comply could result in disciplinary action by their licensing board.
Currently we are facing an epidemic of prescription drug abuse, diversion, and overdose deaths not only in West Virginia but also across the country. This nationwide problem has escalated along with the growing epidemic of chronic pain. A cultural shift toward balancing the risks and benefits of prescription opioids for chronic pain is necessary.
Nurses are in a unique position to address this dual epidemic, but they must gain clinical skills and knowledge in both the assessment and management of addiction risk and best practices for safe opioid prescribing. A comprehensive approach that supports safe and effective pain management without increasing patient risk for addiction must become a priority in every clinical practice setting.
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
American Society of Addiction Medicine (ASAM). (2012). Public policy statement on measures to counteract prescription drug diversion, misuse, and addiction. Retrieved from http://www.asam.org
Baldisseri MR. (2007). Impaired healthcare professional. Critical Care Medicine, 35(2), S106–16.
Centers for Disease Control and Prevention (CDC). (2014). Prevention status reports 2013: prescription drug overdose—West Virginia. Atlanta, GA: US Department of Health and Human Services. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2012). Summary health statistics for U.S. adults: national health interview survey, 2010. Retrieved from http://www.cdc.gov
Chou E, Fanciullo G, Fine P, Adler J, Ballantyne J, Davies P, Donovan M. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain, 10(2), 113–30.
Gourley DL & Almahrezi HA. (2005). A universal precautions approach in pain medicine: a rational approach to the treatment of chronic pain. Pain Med, 6(2), 107–12. Retrieved from http://dx.doi.org
Gwilliam M. (2013). West Virginia behavioral health epidemiological profile. Charleston, WV: West Virginia Department of Health and Human Resources, Bureau for Behavioral Health and Health Facilities, Division on Alcoholism and Drug Abuse. Retrieved from http://www.dhhr.wv.gov
Institute of Medicine (IOM). (2011). Relieving pain in America: a blueprint for transforming prevention, care, education, and research [report brief]. Retrieved from http://www.iom.edu
Manchikanti L & Singh A. (2008). Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician Journal, 11, 563–88.
National Council of State Boards of Nursing (NCSBN). (2011). Substance use disorder in nursing: a resource manual and guidelines for alternative and disciplinary monitoring programs. Chicago: Author. Retrieved from http://www.ncsbn.org
National Institute on Drug Abuse (NIDA). (2011a). Commonly abused prescription drugs chart. Retrieved from http://www.drugabuse.gov
National Institute on Drug Abuse (NIDA). (2011b). Prescription drugs: abuse and addiction (NIH Pub Number 11-4881). Retrieved from http://www.drugabuse.gov
Passik S, Kirsh K, Donaghy K, & Portenoy R. (2006). Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clin J Pain, 22, 173–81.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Results from the 2012 national survey on drug use and health: summary of national findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD. Retrieved from http://www.samhsa.gov
U.S. Attorney’s Office, Southern District of West Virginia. (2011). A WV summit on prescription drug abuse: report and recommendations. Retrieved from http://www.justice.gov
U.S. Department of Health and Human Services (HHS), Healthypeople.gov. (2011). Substance abuse. Retrieved from http://www.healthypeople.gov
West Virginia Board of Examiners for Registered Professional Nurses (WV RN Board). (2012). Senate bill 437: guidelines for required CE. Retrieved from http://www.wvrnboard.com
West Virginia Board of Medicine (WVBOM). (2010). Policy for the use of controlled substances for the treatment of pain. Retrieved from http://www.wvbom.wv.gov