Transcript Health Care and Pharmacy Education (Jim Middleton, Pharm.D.)

Paved with Good Intentions
Community Assessment Referral & Education
(CARE)
Chippewa Valley Coalition for Youth and Families
16 September 2010
Jim Middleton, Pharmacist and Educator
Calhoun/Kalamazoo Counties
Paved with Good Intentions
Back in the dark days of college.....
Paved with Good Intentions
Free Speech and Marketing
Paved with Good Intentions
Convenient life
Effortless life
--The unasked question – for whom?
--Stimulants for children? or teachers?
– Haldol for parents? or caregivers?
Growth Markets in Health
Mental Illness – DSM IV
Diabetes – a consequence of obesity
And, to make things interesting, many of the drugs
used to treat mental illness can result in a weight gain
leading to type 2 diabetes
Growth Markets in Health
Treating mental illness – take a pill
Treating hyperactivity – take a pill (what did we do
before 1955?)
Treating diabetes – take a pill, several pills
Treating obesity – take a pill
Growth Markets in Health
Attention Deficit Disorders – sponsorship of societies
and research
Prepping children into the drug culture
Paved with Good Intentions
The Duty to Warn
The Right to be Pain-Free
Medical Marijuana
Control of Pseudoephedrine (Sudafed)
A Marginalized Profession
A “challenged” system of health care
The Duty to Warn
Ancillary labels
HIPAA challenges
The Right to be Pain Free
A JCAHO mandate
A State of Michigan mandate
Question: What is the definition of pain?
Sources for pain management
Is a dental office an appropriate starting point?
Medical Marijuana
Who is in control here?
Is the program designed to fail?
“Faux marijuana” – K2 or “Spice”
Control of Pseudoephedrine
(Sudafed)
The first regulation: Public Acts 86 and 87 of 2005 in
Michigan – 18 year old limit and signature log
2006 – Federal level – quantity of 3.6 grams daily or 9
grams in 30 days – mail order of 7.5 grams in 30
days – signature log and a photo ID required
Note: 3.6 grams equates to 120 tablets of 30mg
pseudoephedrine
Control of Pseudoephedrine
(Sudafed)
The Problem:
– no requirement for general oversight
– county-by-county monitoring of logs and usage varies
wildly
– monitoring often gets cut with budget challenges
(Kalamazoo county)
– user can hop from one pharmacy to the next
A Marginalized Profession
Tied to a product, not a service
By one vote on the US Supreme court, pharmacists are
allowed to compound prescriptions
Evaporation of the independent “drug store”
A “challenged” system of
health care
“Health Systems” and not “Hospitals”
Management by UPS? Marketing over medicine?
Ancillary and unprofitable programs are cut – patient
education generally among the first to be eliminated,
and among those, diabetes patient education
Health care insurance driven – decisions at clinical
help desks by “Certified Pharmacy Technicians”
A “challenged” system of
health care
– Pharmacists are timed for every function in a chain
setting
– Pharmacists are rewarded – not for patient education
or clinical encounters, but for volume and
encouraging higher profit margin prescriptions
The Consequences
– Increase in prescription drug availability (however,
we have a drop in illegal drug use!)
– Increase in fraud/Gaming the system
– Increase in overdosing cases
– Competing with peer groups and the media for the
public's attention and education
– Less time for professionals to educate the public
Drugs We Watch
– Narcotics – Vicodin, Norco, Lortab, Lorcet (drugs
that contain hydrocodone), Stadol NS
– Strong Narcotics – Oxycontin (oxycodone based),
Percodan, Percocet, Morphine, Dilaudid
(hydromorphone), Methadone
– Sedatives – Xanax, Ativan, Valium, Librium
“benzodiazepines”
– Antipsychotics and Antidepressants – Seroquel,
Topamax
Drugs We Watch
– Stimulants – Adderall, Ritalin, Concerta
– Cough Syrups – Robitussin (guiafenesin) and
Robitussin DM (with dextromethorphan)
– OTCs – Sudafed, products with pseudoephedrine
(Zyrtec D, Claritin D)
How we know things are a
problem
– Talwin was very popular before Talwin NX
– Oxycontin before and after the “reformulation”
General side effects and
adverse effects
– Amplification of therapeutic activity
– CNS depressants – more sedation
– Stimulants – focus becomes agitation
– Antidepressants – weight loss and increased suicide
ideation
Think in Terms of Historic
Personalities
– Cocaine use – paranoia, risky behaviors, grandiose
ideation; weight loss
– Dexedrine use – paranoia, agitation, hypervigilence;
weight loss
– Narcotic use – hearing loss, constipation, respiratory
depression, sedation, need for external stimulation to
counter sedation
Consequences of overdoses
Death
Death always reported as a drug
reaction?
– not in Battle Creek
– homicides labeled “result of a gunshot wound”, not
“individual, while on meth, attempted to rob a crack
house and was shot in the process”
Drugs We Watch
– The opiate-heroin evolution – just what is a gateway
drug?
Once you get past the notion of a fire 2 inches from your
face, does it matter what's being burned?
Supply and demand, dropping costs, NAFTA among
smugglers?
– Meth, cocaine, and prescription stimulants
– Impairment from medicine – medical marijuana, but
also general prescription drugs (and not the usual
suspects, either)
What We Look For
1. Patients who know more about prescription drugs
than I do
2. Patients who know more about insurance coverage
than I do, or insist they have no prescription
coverage but like particular brands of drugs
3. Very thin, asymptomatic, agitated, toothless 20somethings wanting Sudafed 24-hour capsules
4. And sadly, incoming patients who are perhaps a bit
too friendly
What We Look For
6. Elaborate Excuses, generally involving trips to
Tennessee, an ex-spouse, neighbor's dog, a funeral, a
bathroom sink, a kitchen sink, a neighbor's spouse, a
neighbor's dog, a neighbor's ex-spouse from
Tennessee with a dog....
7. A phone call that starts with “OK, it's like this....”
What Parents and Educators
Should Look for
– Sedation or erratic behavior of sudden onset
– Constipation and stomach complaints
– Loss of weight, loss of teeth, bleeding or infected
gums
– Sudden interest in who in the family is ill, perhaps
with cancer
– A need to refill your prescription meds early,
especially if they have a sticker that reads “May
Cause Drowsiness or Sedation”
And
...we're just getting started...