Preventing Drug Overdoses in Oklahoma
Drug overdose deaths in Oklahoma have risen sharply during the past decade,
according to Oklahoma City Addiction Medicine physicians Hal Vorse, MD, and Billy Stout, MD.
Between 2002 and 2010, the Oklahoma Bureau of Narcotics and Dangerous
Drugs Control (OBN) reports the number of overdose deaths in the state rose from 470 to 814 per year. Preliminary data indicates there were at least 795 drug overdose deaths in Oklahoma in 2011. Seventy-seven percent of the deaths were due to the use of prescription drugs in combination with other prescription drugs or alcohol.
Drug overdose deaths now annually outnumber automobile accident fatalities
in the Sooner State.
Many physicians consider such drugs. relatively harmless when used alone.
Many physicians consider such drugs as benzodiazepines, hydrocodone and
carisoprodol relatively harmless when used alone. When used in combination, however, they can become very lethal. All drugs which depress the central nervous system become synergistic in their toxicity when used together.
The Oklahoma State Medical Examiner's Office reported the following drug
overdose death statistics for 2009:
• 351 single agent deaths.
• 441 two or more agent deaths.
• Benzodiazepines (Xanax, Valium), 10 single agent deaths; 181 deaths with
one or more other agents.
• Carisoprodol (Soma), 2 single agent deaths; 46 deaths with one or more
• Tramadol (Ultram, Ultracet), 5 single agent deaths; 14 deaths with one or
Board of Medical
more other agents.
• Hydrocodone (Lortab, Vicodin, Norco), 20 single agent deaths; 124 deaths
with one or more other agents.
101 N.E. 51st Street
Since the Drug Enforcement Agency (DEA) classifies hydrocodone as
Oklahoma City, OK
a Schedule III rather than a more tightly controlled Schedule II drug, some
physicians may conclude that it is safer to use. It is not safer, particularly when
used with other depressant drugs.
The State of Oklahoma only recently designated Tramadol and cariosprodol
as controlled dangerous substances (CDS). Therefore many physicians may
Continued on page 2
continued from front page
assume they are relatively harmless. However, they are
• Make sure patients understand they must
addictive and also carry a significant risk of overdose.
never take two or more substances at the
Many overdose deaths are preventable. Here are a
same time—including alcohol—which depress
few recommendations that could save hundreds of lives:
the central nervous system.
• Check the OBN's Prescription Monitoring
• Do not prescribe opiates and benzodiazepines
Program's (PMP) history report on all
at the same time or decrease the dosage of
patients, particularly those taking controlled
each if they must be given together.
substances. Be sure patients are not receiving prescriptions from other providers.
*See "Upcoming CME Programs" on back page
• Determine if the patient has a history of
Extended-release / Long-acting Opioids REMS
While extended-release and long-acting (ER/LA)
ER/LA opioid analgesics with patients and/
opioid analgesics are approved for the management
or their caregivers every time you prescribe
of moderate to severe chronic pain in appropriately
these medicines. You may download the Patient
selected patients, these medications also are
Counseling Document on Extended-Release/
associated with serious risks and are the center of a
Long-Acting Opioid Analgesics (and also learn
major public health crisis due to increased misuse,
more about this REMS) at er-la-opioidrems.com.
abuse, addiction, overdose and death.
• Emphasize Patient and Caregiver Under-
Therefore, the United States Food and Drug
standing of the Medication Guide
Administration (FDA) has required a Risk Evaluation
to patients and caregivers the importance of
and Mitigation Strategy (REMS) for ER/LA opioid
reading the Medication Guide they will receive
analgesics. A REMS is a strategy to manage known, or
from their pharmacist every time an ER/LA
potential, serious risks associated with a drug product
opioid is dispensed to them.
and is required by the FDA to ensure that the benefits
• Consider Using Other Tools
- In addition
of a drug outweigh its risks. The drug products subject
to the Patient Counseling Document there
to this REMS include all extended-release oral-
are other publicly available tools to improve
dosage forms containing hydromorphone, morphine,
patient, household and community safety, as
oxycodone, oxymorphone, or tapentadol; fentanyl and
well as compliance with conditions of treatment,
buprenorphine-containing transdermal delivery systems;
including Patient-Prescriber Agreements and
and methadone tablets and solutions that are indicated
risk assessment instruments.
for use as analgesics.
To report all suspected adverse reactions
The FDA and manufacturers of ER/LA opioids are
associated with the use of ER/LA opioid analgesics
developing Continuing Medical Education programs for
contact the manufacturer of the specific product and/
or notify the FDA MedWatch program: 800-332-1088 or
Under the conditions of this REMS, prescribers of
ER/LA opioid analgesics are strongly encouraged to do
To learn more about the ER/LA Opioid REMS
all of the following:
program, call 800-503-0784 or er-la-opioidrems.com.
• Educate Yourself -
CME courses when they become available.
*See "Upcoming CME Programs" on back page
• Counsel Your Patients
- Discuss the safe
use, serious risks, storage and disposal of
Investigational Drug Compounding
Drugs listed as "investigational" or
study. Physicians who are not part of an investigational
"investigational new drug" (IND) by the United
study who are found on prescription audits to have
Stated Food and Drug Administration (FDA) must
prescribed investigational-only drugs will be referred to
be prescribed or ordered by a licensed prescriber
the Medical Board for appropriate action.
who has a FDA-sanctioned IND for a recipient/
A pharmacy and/or pharmacist found to be
patient who also is part of the IND study.
compounding and dispensing such prescriptions will
(This statement does not apply to a FDA-approved
be referred to the FDA enforcement office, in addition
drug which is used for an unapproved indication.)
to the Oklahoma Board of Pharmacy, for possible
The FDA defines the term IND as meaning an
unapproved drug or biological drug that may be used in
FDA policy requires that for a patient to gain
a clinical investigation study. The term may also include
access to an investigational drug outside a clinical trial,
a biological product that is used in vitro for diagnostic
the patient must have a serious or immediately life-
threatening disease or condition and no comparable
The Medical Board may not consider a prescription
or satisfactory therapeutic alternatives. Additionally,
for an "investigational only" drug ordered by a licensed
the drug manufacturer and the patient's physician
practitioner to be a valid prescription unless the
must make special arrangements to obtain the
physician is part of an investigational study for an
drug for the patient. These arrangements must
"investigational only" drug and the patient for whom
be authorized by the FDA.
These safeguards are in
the prescription is written is part of the investigational
place to avoid exposing patients to unnecessary risks.
Medical Board Pioneers Use of QR Codes
Oklahoma State Board of Medical Licensure and
address, telephone and office hours, hospital privileges,
Supervision (Medical Board) is the first in the nation to
insurance participation and board status. In the same
incorporate QR (quick response) codes on the medical
way that traditional UPC bar codes changed the way
licenses of physicians and other medical professionals.
we pay for groceries, the QR codes will allow for rapid
QR codes are two-dimensional bar codes first designed
check-in of medical professionals at training events,
for the automotive industry in Japan. They can contain
clinics, hospitals, etc.
more information than a regular bar code and may be
The QR code on medical licenses should provide
read by devices many people already own, such as
a real service during emergencies, according to Board
smart phones and tablets. The ubiquitous black and
Deputy Director Reji Varghese.
white square box will now appear in the lower right hand
"Law enforcement or emergency medical personnel
corner of all newly issued or renewed physician licenses
establishing an incident command system at the scene
of an accident or emergency will
Scanning the code will provide direct, instant access
be able to immediately identify and
to a physician's information page as it appears on the
confirm that the Good Samaritan
Board's website, www.okmedicalboard.org. Some of
offering assistance is indeed a
the data available includes the doctor's education,
licensed medical doctor," he said.
medical specialty and board certification, office
Treating Addicted Colleagues
I T 'S I LLEGAL AND UN E T HICAL TO ENAB LE
an addict. If symptoms and clinical judgment seem to
indicate addiction, that course of treatment must be
It is against the law for Oklahoma physicians to
pursued. Order a urinalysis and other appropriate drug
prescribe, sell, administer, distribute, order or give
screening tests. The treating physician should attempt
"any drug legally classified as a controlled substance
to learn if the colleague/patient is in a good recovery
or recognized as an addictive or dangerous drug for
mode, attends AA meetings, counseling sessions, etc.
other than medically accepted therapeutic purposes."
If possible, have a third party verify the recovery status.
(Oklahoma Medical Practice Act 435: 10-7-4 .) It
All this should be made a part of the colleague/patient's
is also illegal, "except as otherwise permitted by law,"
to prescribe, sell, administer, distribute, order or give
, if the treating physician is certain that
"to a habitué or addict or any person previously drug
the colleague/patient is doing well in documented,
dependent, any drug legally classified as a controlled
solid recovery and poses no "threat to the public"
substance or recognized as an addictive or dangerous
when practicing medicine, then the treating physician
drug." (Oklahoma Medical Practice Act 435: 10-7-4
DOES NOT have any obligation to report the colleague
). Inappropriately prescribing Controlled Dangerous
to the licensing board or any other entity. Doctor/
Substances (CDS) to patients known to be addicts is
patient confidentiality remains in effect. Appropriately
unprofessional conduct for which physicians, if found
document in the chart the reason for treating with CDS
guilty, may be disciplined, which can include the
and informed consent.
possibility of losing their medical licenses.
, if the treating physician knows the
colleague/patient is a substance abuser, a threat to the
".doctors face difficult, often uncomfortable,
public and not in a good recovery, the treating physician
ethical decisions when the addicted patient is
has two options.
another physician or health professional."
A. The treating physician can counsel the
In addition to the legal consequences, doctors face
colleague/patient and provide information on the
difficult, often uncomfortable, ethical decisions when
programs available in Oklahoma to assist and advocate
the addicted patient is another physician or health
for health professionals with substance abuse issues.
professional. When treating a member of the public
The treating physician can encourage the colleague/
who is an addict, physicians may simply dismiss that
patient to call the appropriate program and ask for an
patient from their practices if the patient refuses to
intervention and/or assessment to determine the current
follow medical advice. Treating the addicted colleague
status of substance use, abuse, or abstinence. ALL
presents both an ethical and legal dilemma. Physicians
THIS MAY BE DONE WITHOUT ANY NOTIFICATION
cannot skirt their ethical responsibility to the public
TO A LICENSING BOARD OR OTHER ENTITY,
and their profession by simply refusing to treat a non-
provided that the colleague/patient follows through
compliant addicted colleague.
with the process, agrees to and follows the program's
What is a physician to do when treating another
recommendations, including any required treatment
health professional who may be an addict?
and long-term recovery activities. All of the recovery
, when treating a colleague, DO NOT rule
programs will report to the appropriate licensing board
out the diagnosis of addiction because of misdirected
if the colleague/patient does not participate in the
professional respect or courtesy. It is human nature
assessment, treatment and recovery recommendations
for a treating physician to presume a colleague/patient
is being honest. That's not always the case under
Programs available to Oklahoma health
normal conditions and particularly when dealing with
Treating Addicted Colleagues
Oklahoma Health Professionals Program
(42) "Failure to inform the Board of a state of
Robert Westcott, MD, 405-601-2536
physical or mental health of the licensee or any other
(MD, DO, DDS,PA and DVM)
health professional which constitutes or which the licensee suspects constitutes a threat to the public."
Nursing Peer Assistance Program (NPAP)
Laura Clarkson, RN, 405-525-2277
(RN, NP, CNS, NMW, CRNA)
(43) "Failure to report to the Board unprofessional
conduct committed by another physician."
Allied Professional Peer Assistance
In Oklahoma, the authorities are:
Billy Stout, MD, 405-962-1450
Oklahoma Board of Medical Licensure and
(PT, RC, OT, AT, LD, RT, RE, AA, RA, PED,
405-962-1400, 1-800-381-4519, okmedicalboard.org
Oklahoma Pharmacists Helping Pharmacists
Oklahoma State Board of Osteopathic Examiners
Kevin Rich, 1-800-260-7574 Ext. 5773
Oklahoma State Board of Pharmacy
B. If the treating physician knows that the
colleague/patient is a substance abuser, a threat to
Oklahoma Board of Nursing
the public and not in a good recovery mode and the
colleague/patient REFUSES to contact the professional
Oklahoma Bureau of Narcotics and Dangerous Drugs
assistance program, then the treating physician has
a professional, legal and ethical obligation to the
profession and the public to report the colleague/
Oklahoma Offices U.S. Drug Enforcement Agency
patient to the proper authorities under the Oklahoma
Oklahoma City: 405-475-7500
Medical Practice Act, 435:10-7-4 (42,43), which states a
physician can be cited for unprofessional conduct for:
New Ban on Hydrocodone Refills Effective November 1st
Effective November 1, 2013, prescriptions for
at a time). Documentation for partial fil s would
any medication containing Hydrocodone may not
be required in accordance with OAC 475:30-1-12.
be refilled. This applies even if the prescription
Hydrocodone combination medications are stil
was written prior to November 1st. Transfers
classified as a CIII product and may be phoned
are considered to be a refil of a pre-existing
in. Mid-level practitioners (nurse practitioners,
prescription and are not al owed. Partial fil s
physician assistants, etc.) may continue to
would be permitted (i.e. a prescription is written
prescribe Hydrocodone combination medications
for 100 but the patient only wants to purchase 20
at this time.
Board CME Efforts Recognized
Upcoming CME Offerings
The Oklahoma Medical Board staff received Honorable
Mention Best of the Boards Award at the national meeting of
Safe Practical Pain Management for
Administrators in Medicine (AIM) for its ongoing public and
Primary Care Physicians & ER/LA
licensee educational outreach initiative, "It Takes a Village…to
Opioid REMS: Achieving Safe Use While
Put on a Great CME Program."
Improving Patient Care
September 20, 2013,
AIM Best of the Boards Awards recognize programs and
8 AM - 4:30 PM St. Luke's United Methodist Church,
initiatives that demonstrate outstanding "best practices" or
222 NW 15th St, OKC. Registration $75
innovations. The Award allows state boards to share the
benefit of their accomplishments with colleagues and receive
6.5 AMA PRA Category 1 Credits for entire conference.
recognition for their hard work.
A Day With The Judges
The Oklahoma Board was recognized for its efforts to
Pain Management, Telemedicine, EHR, Judicial
ease the delivery and increase the frequency of educational
System and Official Disability Guidelines
programs through the use of both new technology and
November 15, 2013, 8:30 AM – 4:15 PM
traditional face-to-face CME programs. The Board also was
Conference Center, INTEGRIS Baptist Medical Center,
commended for its commitment to collaboration through
3300 NW Expressway, OKC Registration $125.
strong partnerships with the Osteopathic Board, OU College of
ht p:/ sssanbar.wix.com/baptist
Medicine, Oklahoma State University College of Osteopathic
7 Hours CME
Medicine, Oklahoma State Medical Association, Oklahoma Osteopathic Association and professional liability carriers.
This publication, printed by Central Printing is issued by the Oklahoma State Board of Medical Licensure & Supervision as authorized by the Board. 11,800 copies
have been prepared and distributed at a cost of $6000.00. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.
Answers Vol 20 Issue 02 Summer 2013
Graefes Arch Clin Exp OphthalmolDOI 10.1007/s00417-012-2226-y Visual outcomes and complications following posterioriris-claw aphakic intraocular lens implantation combinedwith penetrating keratoplasty Johannes Gonnermann & Necip Torun &Matthias K. J. Klamann & Anna-Karina B. Maier &Christoph v. Sonnleithner & Antonia M. Joussen &Peter W. Rieck & Eckart Bertelmann Received: 21 August 2012 / Revised: 31 October 2012 / Accepted: 21 November 2012
Dietary Supplement Containing Biologically Active Substances For Improved Immune Function William J. Hennen, Ph.D. Dr. William J. Hennen holds a Ph.D in Bio-organic chemistry. An accomplished researcher, professor and author, Dr Hennen hold more than 10 patents and has published over 30 research