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Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine—as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse—are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes—tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Background: Provider–patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider–patient communication about prescription drug abuse from the perspective of prescribers. Methods:From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes.Results:Prescribers described 3 primary communication patterns with patients related to prescription drug abuse—informative, counteractive, and supportive. Prescribers also reported multiple factors—personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)—that affect provider–patient communication and, by association, delivery of patient care related to prescription drug abuse.Conclusions:The findings suggest that provider–patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

Background: There is a widespread and increasing use of psychoactive prescription drugs, such as opioid analgesics, anxiolytics, hypnotics and anti-epileptics, but their use is associated with a risk of drug use disorder, misuse and abuse. Today, these are globally recognized and emerging public health concerns. Aim: The aim of this thesis is to estimate the prevalence of psychoactive prescription drug (PPD) use disorders, misuse and abuse, and to investigate the association with some potential risk factors. Methods: A study using register data from forensic cause of death investigations investigated and described cases of fatal unintentional intoxication with tramadol (Study I). Based on register data on spontaneously reported adverse drug reactions (ADRs) reported cases of tramadol dependence were investigated and summarised (Study II). In a study in suspected drug-impaired drivers with a toxicology analysis confirming the intake of one out of five pre-specified PPDs, the prevalence of non-prescribed use was assessed and associated factors were investigated (Study III). From a cohort of patients initiating prescribed treatment with pregabalin, using data on prescription fills, a study investigated longitudinal utilisation patterns during five years with regards to use of the drug above the maximum approved daily dose (MAD), and factors associated with the utilisation patterns (Study IV). Results: In the first study, 17 cases of unintentional intoxications were identified, of which more concerned men, the median age was 44 years and the majority used multiple psychoactive substances (alcohol, illicit drugs and prescription drugs). The second study identified 104 spontaneously reported cases of tramadol dependence, in which more concerned women, the median age was 45 years, and a third reported a history of substance abuse and 40% of past psychoactive medication use. In the third study, more than half of the individuals suspected of drug-impaired driving used the drug without a recent prescription. Non prescribed use was most frequent in users of benzodiazepines and tramadol, and was more likely in younger individuals and in multiple-substance users. In the last paper five longitudinal utilisation patterns were found in pregabalin users, with two patterns associated with a particularly high risk of doses above the maximum approved dosing recommendation. This pattern of use was associated with male sex, younger age, non-urban residency and a recent prescribed treatment with an antiepileptic or opioid analgesic drug. Conclusions: This thesis shows that psychoactive prescription drug use disorders, misuse and abuse occur and may have serious and even fatal consequences. The prevalence varies between different drugs and populations. Abuse and misuse seem to be more common in young people. Fatal intoxications and misuse of prescribed drugs may be more common in men, while drug use disorders following prescribed treatment may be more common in women and non-prescribed use equally distributed between women and men. Individuals with a history of mental illness, substance use disorder or abuse, or of past use of psychoactive medications are likely important risk groups. In summary, the findings suggest a potential for improvements in the utilisation of psychoactive prescription drugs. The results may be useful in the planning of clinical and regulatory preventive interventions to promote the rational, individualised and safe use of such drugs.

Lifetime prevalence estimates of psychotropic medicine use as well as prevalence of DSM-IV prescription drug use disorders from the baseline investigation of the Early Developmental Stages of Psychopathology (EDSP) Study are presented. Use of prescription medication at some time in their life was reported by 27.4% of the respondents. Illicit use of prescription drugs, which means an intake without medical legitimation, was reported by 4.5% of the sample. The findings suggest that abuse of and dependence on prescription drugs, with most cases reporting polysubstance use, is quite rare in the 14- to 24-year-olds. DSM-IV abuse was more prevalent than dependence (0.5 vs. 0.3%). In general, women reported higher prevalence rates of prescription drug use, whereas men reported higher prevalence rates of prescription drug disorders. This result suggests that men have a higher risk to develop a substance-use-related disorder.

Syftet med detta projekt var att identifiera om en implementering av en standardisering för receptbelagda läkemedelsförpackningar, skulle kunna bidra till en minskad risk gällande feldosering eller felmedicinering av patient. Resultatet av studien konstaterar att en standardisering för ordinationer har större effekt. / The purpose of this project was to identify if an implementation of a standardization for prescription drugs packaging, could contribute to a reduced risk of error when medicating a patient with prescription drugs and dosage. The outcome of the study states that a standardization for prescriptions has a bigger impact.

Since its inception in 2003, Medicare Part D has become the largest addition to the Medicare benefit since it was signed into law in 1965. Despite this novel prescription drug coverage, the design and benefit structure of Medicare Part D has been challenging for beneficiaries and healthcare providers alike. Beneficiaries have been faced with a plethora of drug plan offerings. Additionally, the unique benefit structure and annual variation in plan offerings and plan parameters have left beneficiaries unaware of gaps in coverage and reluctant to re-evaluate plan offerings. Despite these issues, to date the total out-of-pocket costs for beneficiaries enrolled in Medicare Part D have not been examined. To mitigate this void, three studies were conducted to determine trends in the total out-of-pocket costs incurred by Medicare beneficiaries enrolled in Medicare Part D prescription drug plans. Pharmacy claims data of 50 randomly sampled patients from a database of Medicare-eligible individuals were used to generate medication profiles. To maintain a patient-perspective approach, these profiles were then entered into the Plan Finder Tool on the Medicare website in order to determine the estimated annual costs for each stand-alone prescription drug plan in each Medicare region. It was determined that Medicare Part D plan costs increased from 2007 to 2008 in most regions, however in 13 of 34 regions patients may not have paid more if they were enrolled in the lowest cost plan each year. Based on these findings, the opportunity cost of neglecting to re-evaluate prescription drug plan offerings for 2008 was examined. A significant increase ranging from $277 to $562 was observed nationally if patients did not switch to the lowest cost plan. Only 12% of the plans remained the lowest cost plan in 2008. Lastly, prescription drug plan cost trends in California were examined from 2007 to 2009 and confirmed that the estimated annual cost of a plan was the most consistent plan parameter. Collectively these studies indicate that Medicare Part D beneficiaries must annually re-evaluate all prescription drug plan offerings in order to minimize out-of-pocket drug costs.

Thesis (LLD )--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Acquisitive prescription (“prescription”), an original method of acquisition of ownership, is regulated by two prescription acts. Prescription is mostly regarded as an unproblematic area of South African property law, since its requirements are reasonably clear and legally certain. However, the unproblematic nature of this legal rule was recently brought into question by the English Pye case. This case concerned an owner in England who lost valuable land through adverse possession. After the domestic courts confirmed that the owner had lost ownership through adverse possession, the Fourth Chamber of the European Court of Human Rights in Strasbourg found that this legal institution constituted an uncompensated expropriation, which is in conflict with Article 1 of Protocol No 1 to the European Convention on Human Rights and Fundamental Freedoms 1950. This judgment may have repercussions for the constitutionality of prescription in South African law, despite the fact that the Grand Chamber – on appeal – found that adverse possession actually constitutes a mere (constitutional) deprivation of property. Therefore, it was necessary to investigate whether prescription is in line with section 25 of the Constitution. To answer this question, the dissertation investigates the historical roots of prescription in Roman and Roman-Dutch law, together with its modern requirements in South African law. The focus then shifts to how prescription operates in certain foreign systems, namely England, the Netherlands, France and Germany. This comparative perspective illustrates that the requirements for prescription are stricter in jurisdictions with a positive registration system. Furthermore, the civil law countries require possessors to possess property with the more strenuous animus domini, as opposed to English law that merely requires possession animo possidendi. The justifications for prescription are subsequently analysed in terms of the Lockean labour theory, Radin’s personality theory and law and economics theory. These theories indicate that sufficient moral and economic reasons exist for retaining prescription in countries with a negative registration system. These conclusions are finally used to determine whether prescription is in line with the property clause. The FNB methodology indicates that prescription constitutes a non-arbitrary deprivation of property. If one adheres to the FNB methodology it is equally unlikely that prescription could amount to an uncompensated expropriation or even to constructive expropriation. I conclude that prescription is in line with the South African property clause, which is analogous to the decision of the Grand Chamber in Pye. / AFRIKAANSE OPSOMMING: Verkrygende verjaring (“verjaring”), ‘n oorspronklike wyse van verkryging van eiendomsreg, word gereguleer deur twee verjaringswette. Verjaring word grotendeels beskou as ‘n onproblematiese aspek van die Suid-Afrikaanse sakereg, aangesien die vereistes daarvan taamlik duidelik en regseker is. Nietemin is die onproblematiese aard van hierdie regsinstelling onlangs deur die Engelse Pye-saak in twyfel getrek. Hierdie saak handel oor ‘n eienaar wat waardevolle grond in Engeland deur adverse possession verloor het. Nadat die plaaslike howe die verlies van eiendomsreg deur adverse possession bevestig het, het die Vierde Kamer van die Europese Hof van Menseregte in Straatsburg bevind dat hierdie regsreël neerkom op ‘n ongekompenseerde onteiening, wat inbreuk maak op Artikel 1 van die Eerste Protokol tot die Europese Verdrag van die Reg van die Mens 1950. Hierdie uitspraak kan implikasies inhou vir die grondwetlikheid van verjaring in die Suid-Afrikaanse reg, ten spyte van die Groot Kamer se bevinding – op appèl – dat adverse possession eintlik neerkom op ‘n grondwetlik geldige ontneming van eiendom. Derhalwe was dit nodig om te bepaal of verjaring bestaanbaar is met artikel 25 van die Suid-Afrikaanse Grondwet. Vir hierdie doel word die geskiedkundige wortels van verjaring in die Romeinse en Romeins- Hollandse reg, tesame met die moderne vereistes daarvan in die Suid-Afrikaanse reg, ondersoek. Daar word ook gekyk na hoe hierdie regsreël in buitelandse regstelsels, naamlik Engeland, Nederland, Frankryk en Duitsland, funksioneer. Hierdie regsvergelykende studie toon dat verjaring strenger vereistes het in regstelsels met ‘n positiewe registrasiestelsel. Verder vereis die sivielregtelike lande dat ‘n besitter die grond animo domini moet besit, wat strenger is as die Engelsregtelike animus possidendi-vereiste. Die regverdigingsgronde van verjaring word vervolgens geëvalueer ingevolge die Lockeaanse arbeidsteorie, Radin se persoonlikheidsteorie en law and economics-teorie. Hierdie teorieë illustreer dat daar genoegsame morele en ekonomiese regverdigings vir die bestaan van verjaring is in lande met ‘n negatiewe regstrasiestelsel. Hierdie bevindings word ten slotte gebruik om te bepaal of verjaring bestaanbaar is met die eiendomsklousule. Die FNB-metodologie toon dat verjaring neerkom op ‘n geldige, nie-arbitrêre ontneming volgens artikel 25(1). Indien ‘n mens die FNB-metodologie volg is dit eweneens onwaarskynlik dat verjaring op ‘n ongekompenseerde onteiening – of selfs op konstruktiewe onteiening – neerkom. Gevolglik strook verjaring wel met die Suid-Afrikaanse eiendomsklousule, welke uitkoms soortgelyk is aan dié van die Groot Kamer in die Pye-saak.

Bakgrunn: Misbruk av vanedannende legemidler er et viktig folkehelseproblem. Enkelte pasienter går fra lege til lege og driver såkalt legeshopping for å skaffe seg mest mulig av denne typen legemidler. Dette er et problem i forhold til å kunne begrense legemiddelmisbruket i befolkningen. Fastlegeordningen, som ble innført i Norge i 2001, er blant annet ment å skulle begrense mulighetene til legeshopping. Det er ikke tidligere gjort studier som kan kartlegge omfanget av legeshopping i en befolkning, verken i Norge eller andre land. FORMÅL: Kartlegge omfanget av legeshopping i befolkningen i Norge, og forsøke å klarlegge i hvilken grad bruk av flere leger kan skyldes shopping etter legemidler eller andre årsaker. MATERIALE OG METODE: Studere data fra det norske Reseptregisteret (NorPD) for kalenderåret 2004, som blant annet viser antallet leger benyttet, mengde utlevert av det aktuelle legemiddelet og samtidig mengde utlevert av benzodiazepiner og opioider for alle brukere av de vanedannende legemidlene diazepam, karisoprodol og kodein kombinasjoner sammenlignet med alle brukere av de ikke-vanedannende legemidlene esomeprazol, metformin og salbutamol. RESULTATER: De aller fleste pasienter bruker kun en eller to leger for å få utlevert samme legemiddel i løpet av ett kalenderår. Andelen som bruker tre eller flere leger er imidlertid mer enn dobbelt så høy for de vanedannende legemidlene som for de ikke-vanedannende, og for de som bruker fem eller flere leger, er andelen nesten ti ganger større. Med økende antall leger som er benyttet, er dessuten økningen i både utlevert mengde av legemidlet og samtidig mengde utlevert av benzodiazepiner og opioider langt mer uttalt for de vanedannende legemidlene enn for de ikke-vanedannende. KONKLUSJON: Det foregår etter innføringen av fastlegeordningen fortsatt en begrenset, men klar legeshopping blant pasienter som ønsker å få tak i mest mulig av vanedannende legemidler. Dette forhold må tas alvorlig av både de forskrivende legene og helsemyndighetene. / BACKGROUND: Abuse of prescription drugs is an important public health issue. Some patients go from one physician to another in so-called doctor-shopping (or physician-shopping) with the intention to have as much as possible of addictive drugs prescribed. This is a problem when trying to restrict prescription drug abuse in the population. The Regular General Practitioner (RGP) Scheme which was introduced in Norway in 2001 had among other things the intention to counteract doctor-shopping. So far there are no studies in Norway or other countries that have presented estimates of the proportions of patients that practice doctor-shopping. AIM: To explore the extent of doctor-shopping in the population in Norway and try to unveil if the use of several doctors is primarily a prescription drug shopping or if it has other reasons. MATERIAL AND METHODS: Data from The Norwegian Prescription Database (NorPD) for the year of 2004 was studied. The register includes information on the number of doctors used by individual patients and the amount of drug dispensed. There is also information about concomitant use of opioids and benzodiazepines. Users of the addictive drugs diazepam, carisoprodol and codeine combinations were compared to users of the non-addictive drugs esomeprazole, metformin and salbutamol. RESULTS: Most patients use only one or two doctors for prescription of the same drug over a period of one year. However the proportion of patients who uses three or more doctors for the addictive drugs is more than twice the comparable proportion of patients using the non-addictive drugs. For those who uses five or more doctors the proportion is nearly ten times larger. The amount of dispensed drug increases considerably more by increasing number of doctors used for users of the addictive drugs than for the users of the non-addictive drugs, as do the amount of concomitantly dispensed opioids and benzodiazepines. CONCLUSION: Also after the introduction of the Regular General Practitioner (RGP) Scheme in Norway doctor-shopping is still going on to a limited but significant extent by patients who appear to have the intention to get as much as possible of addictive drugs. This is a public health issue that has to be taken seriously by both prescribing doctors and health authorities. / <p>ISBN 978-91-85721-60-3</p>

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