Transcript which is a tamper resistant er/la opioid?

OPIOID MANAGEMENT and
REMS PRINCIPLES:
WHAT WOULD YOU DO?
• JAMES W. ATCHISON, DO (MODERATOR)
• MEDICAL DIRECTOR
• RIC CENTER FOR PAIN MANAGEMENT
DISTINGUISHED PANEL
• STEVEN STANOS, DO
• BRIAN BRUEHL, MD
• MICHAEL BRENNAN, MD
• R. NORMAN HARDEN, MD
DISCLOSURES
•
•
•
•
•
JAMES W. ATCHISON, DO
STEVEN STANOS, DO
BRIAN BRUEHL, MD
MICHAEL BRENNAN, MD
R. NORMAN HARDEN, MD
LEARNING OBJECTIVES
• Participants will be able to:
– Direct patient education according to reference
guidelines regarding safe prescribing, storage, and dose
adjustments of opioids.
– Utilize concepts of rational polyp pharmacy in chronic
pain management.
– Evaluate and recommend appropriate adjunct of
treatments beyond medications for chronic pain
management
REMS BLUEPRINT REVIEW
• MAJOR HEADINGS
– Why Prescriber Education is Important
– I. Assessing Patients for Treatment with
ER/LA Opioid Analgesic Therapy
– II. Initiating Therapy, Modifying Dosing,
and Discontinuing Use of ER/LA Opioid
Analgesics
– III. Managing Therapy with ER/LA Opioid
Analgesics
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REMS BLUEPRINT REVIEW
• MAJOR HEADINGS
– IV. Counseling Patients and Caregivers
about the Safe Use of ER/LA Opioid
Analgesics
– V. General Drug Information ER/LA Opioid
Analgesic Products
– VI. Specific Drug Information
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CASE PRESENTATION
• 48 y/o F presents for Tx w/ Hx of chronic Rt UL
pain. S/P Fx of Radius & Ulna 2 y/a after fall.
Pain level 5-8/10 ; referred due to completion of
all w/u & Tx from ortho. Increased pain w/ all
movements of arm and restricted use. Left knee
pain w/ walking and standing tolerance of 25
minutes. Works as Administrative Assistant.
Current Rx for Hydrocodone 5/325 to be used 12 q 4-6 hours as needed, and now taking 8 tabs
per day. All records available for review.
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WHAT WOULD YOU DO?
PROCESSES BEFORE RX
• Hx/visit includes Risk
Stratification
• Review possible risks &
side effects
• Review Patient
Counseling Document
• Review/sign Patient
Agreement
• Complete UDS
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INITIAL RX?
1. Hydrocodone 5/325 up to
4/day
2. Hydrocodone 10/325 up
to 4/day
3. Rotate to other Short
Acting opioid
4. Transition to Long Acting
opioid
5. No Rx on 1st visit
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RISK STRATIFICATION
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WHAT WOULD YOU DO?
COMMONLY USED TOOLS
WHICH IS BEST?
• ORT
• SOAPP-R
• PSYCOLOGY
INTERVIEW
• COMM
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REVIEW & SIGN PATIENT
AGREEMENT
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OPIOID ANALGESICS
• PATIENT AGREEMENTS
– OPIOID THERAPY UTILIZED ONLY AFTER ALL
OTHER REASONABLE ATTEMPTS HAVE
FAILED
– SINGLE PHYSICIAN PRESCRIBER &
PHARMACY
– PT MUST AGREE TO COGNITIVE-BEHAVIORAL
TX
– PRESCRIPTIONS MUST LAST UNTIL THE NEXT
VISIT
• BRING IN ALL UNUSED MEDICATIONS
OPIOID ANALGESICS
• PATIENT AGREEMENT
– PT MUST INFORM DOCTOR OF ALL OTHER
MEDICATIONS AND CHANGES
• NO BENZOS OR CARISOPRODOL
• ? PREGABLIN
– PT MUST AGREE TO RANDOM URINE
TESTING
– INFORM PATIENT OF ALL RISKS (LIST)
• INCLUDING TOLERANCE, DEPENDANCE,
ADDICTION
• SIDE EFFECTS
OPIOID ANALGESICS
• PATIENT AGREEMENT
– ANY EVIDENCE OF DRUG HOARDING, DRUG
DIVERSION, UNAGREED-UPON DOSE
CHANGES, LOSS OF RX, OR FAILURE TO
FOLLOW THE AGREEMENT WILL (MAY?)
RESULT IN TAPERING OF MEDICINE AND
DISCONTINUATION OF DOCTOR-PATIENT
RELATIONSHIP
• DESIGNED TO LIMIT DIVERSION
WHAT WOULD YOU DO?
DO YOU REGULARLY
USE THESE?
• YES
• NO
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REVIEW RISKS AND
SIDE EFFECTS OF OPIOIDS
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Clinical Effects of Opioids
Desirable effects
Analgesia
Relief of Anxiety
Undesirable effects
Nausea/vomiting
Urinary Retention
Mental Status Changes
Respiratory Depression
Tolerance / Dry Mouth / Drug Dependence
Circumstantial effects
Sedation
Cough Suppression
Euphoria
Decreased Bowel Motility
Mycek, et al., eds. Pharmacology, 2d ed. Philadelphia; Lippincott-Raven, 1997.
Opioid Adverse Effects
Usually dose related and some are drug specific
Common
Constipation
Dry mouth
Nausea/Vomiting
Sedation
Sweating
Less Common
Respiratory depression
Bad dreams/hallucinations
Dysphoria/delirium
Myoclonus/seizures
Arrhythmia
Pruritis/urticaria
Urinary retention
Amenorrhea/sexual dysfunction
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Anticipate/Manage Side
Effects
Respiratory Depression
- Sedation precedes respiratory depression
Role of sedation scales?
- Respiratory rate alone is not an indication of respiratory
function.
- Use Naloxone sparingly
Respiratory depression reverses before analgesia
Limit to doses of 100 micrograms at a time
One amp (0.4mg) in 4ml NS
Inject 1 ml at a time- can always give more.
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WHAT WOULD YOU DO?
UPDATED HISTORY
• Continues Hydrocodone
at 10/325 QID
• She experiences:
–
–
–
–
Constipation
Sleepiness in the afternoon
Occasional nausea
Occasional SOB
• She is not sleeping well
at night
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OPTIONS
• Add Colace, Sennakot,
Miralax, etc, daily
• Start Provigil in am & noon
• Use compazine PRN
• Use Albuteral inhaler PRN
• Start Clonazepam at HS?
• Repeat UDS
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REVIEW OF PATIENT
COUNSELING DOCUMENT
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Patient Counseling Document
(PCD)
• The DOs and DON’Ts of Extended-Release /
Long - Acting Opioid Analgesics
• DO:
–
–
–
Read the Medication Guide
Take your medicine exactly as prescribed
Store your medicine away from children and in a
safe place
–
Flush unused medicine down the toilet
–
Call your healthcare provider for medical advice
about side effects. You may report side effects to FDA
at 1-800-FDA-1088.
Patient Counseling Document
(PCD)
• DON’T:
Do not give your medicine to others
Do not take medicine unless it was prescribed for you
Do not stop taking your medicine without talking to your
healthcare provider
Do not break, chew, crush, dissolve, or inject your
medicine. If you cannot swallow your medicine whole,
talk to your healthcare provider.
Do not drink alcohol while taking this medicine
• For additional information go to: dailymed.nlm.nih.gov
Safe Storage of Opioids
Monitor
Patients should always be
in a position to know if any
pills are missing
• Take note of how many pills
are in each prescription
bottle or pill packet
• Keep track of your refills for
your own medication, as well
as for other members of the
household
• Make sure friends and
relatives— especially
grandparents—are aware of
the risks and regularly
monitor their own medicines
Secure
Secure prescriptions the same way
as other valuables in the home, like
jewelry or cash
• Take prescription medications out of
the medicine cabinet and hide them
in a place only you know about
• Encourage relatives and friends to
secure their medications
• If possible, keep all medicines in a
safe place
• An existing fire safe or gun safe
• Use a cut-proof bag designed for travel
safety
• Locking medicine box or cabinet
APF. PainSAFE™. Problems with Opioids Can Be Prevented. Available at:
http://www.painfoundation.org/painsafe/healthcareprofessionals/pharmacotherapy/opioids/preventing-problems.html. Accessed February 3, 2012.
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OPIOID SAFETY
• STORAGE OF MEDICATIONS
– LIMIT NUMBER OF PERSONS THAT ARE
AWARE YOU ARE USING PAIN MEDS
• BE AWARE OF OTHER PATIENTS OR PERSONS
AROUND PHYSICIAN’S OFFICE
• BE AWARE OF PERSONS WATCHING AT
PHARMACY
• LIMIT DISCUSSIONS WITH FAMILY AND FRIENDS
– KEEP MEDS AWAY FROM FAMILY MEMBERS
• DO NOT ASK THEM TO GET MEDICATIONS
FROM STORAGE
OPIOID SAFETY
• DATA FROM 2009-2010 National
Survey on Drug Use and Health
– 70% of the 2.4 million Americans who
abuse prescription drugs for the first time
each year get them from friends and family
• 1/3 are teenagers
OPIOID SAFETY
• DATA FROM 2009-2010 National
Survey on Drug Use and Health
– Casual Abusers of Rx Drugs(< 1x/wk)
• 55% got substances FREE from friends/family
• 11% PURCHASED substance from friends or
family
• 5% TOOK WITHOUT PERMISSION
substances from family/friends
OPIOID SAFETY
• DATA FROM 2009-2010 National
Survey on Drug Use and Health
– Chronic Users/Abusers of Rx Drugs(>
1x/wk for more than a year)
• 41% got substances WITH OR WITHOUT
PERMISSION from friends/family
• 25% PURCHASED substance from dealer or
the internet
• 25% OBTAINED THEM FROM A DOCTOR
WHAT WOULD YOU DO?
UPDATED HISTORY
• After 4 months, she calls
into clinic for early refill as
she is out of her pills and
is not sure why?
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OPTIONS
• Manage this over the
phone until next visit
• Review Patient
Agreement and DC from
the clinic
• Review pharmacy issues
• Review storage issues
• Repeat UDS?
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UDS MONITORING
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WHAT WOULD YOU DO?
UDS RESULTS
• No Substances present?
• Hydrocodone and
Hydromorphone present
–
–
–
–
–
–
w/ Oxymorphone
w/ benzodiazepine
w/ ETOH
w/ THC
w/ Cocaine
w/ Morphine, codeine, and
oxycodone
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OPTIONS
• Repeat the test w/ Inc
sensitivity – continue Tx
• Counsel pt and repeat at
next visit – continue Tx
• Counsel pt and DC from
clinic
– Give 1 month Rx?
• Counsel pt and Refer to
Addiction Medicine
– Give 1 month Rx?
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Choosing Opioid Therapy
• Chronic pain management should be
individualized
• Selection of a specific opioid based on criteria:
efficacy, tolerability, safety, and ease of use.
• Initiated at a low dose and gradually increasemonitor pain reduction and side effects.
• Patients must be fully informed about the nature
of their treatment, benefits and harmful effects
• Long acting versus breakthrough doses
WHAT WOULD YOU DO?
ADDITIONAL HISTORY
• Received Rx for
Hydrocodone 10/325 QID
for 6 months (compliant!).
• She previously split some
pills in ½, but is now
receiving less response
to whole pills. Pain 7-9/10
• Having a difficulty time
working.
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OPTIONS
1. Increase Hydrocodone to 68 tabs/day
2. Rotate to other SA Opioid
3. Initiate LA/ER Opioid
4. Test UDS & Continue
current Hydrocodone
5. Stop the medication
6. Refer to Addiction Medicine
7. Further Work-up?
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ROTATING SA THERAPY
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WHAT WOULD YOU DO?
SA OPTIONS
• Oxycodone
– w/ Aceteminophen?
•
•
•
•
Hydromorphone
Morphine Sulphate
Oxymorphone
Tapentadol
• How many MEQ?
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OPTIONS
• Taper the Hydrocodone,
then start new med
• Stop Hydrocodone; start
new med at lower MEQ
• Stop Hydrocodone; start
new med at same MEQ
• Stop Hydrocodone; start
new med at Inc MEQ
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DEPENDENCE
IS NOT ADDICTION
• Physical dependence:
– “Physical dependence is a state of
adaptation that is manifested by a
drug class specific withdrawal
syndrome that can be produced by
abrupt cessation, rapid dose
reduction, decreasing blood level of
the drug, and/or administration of an
antagonist.”
DEPENDENCE
IS NOT ADDICTION
• Addiction:
– “Addiction is a primary, chronic,
neurobiologic disease, with genetic,
psychosocial, and environmental factors
influencing its development and
manifestations.
– It is characterized by behaviors that include
one or more of the following: impaired
control over drug use, compulsive use,
continued use despite harm, and craving.”
OPIOID ANALGESICS
• TOLERANCE
– NEED FOR INCREASING AMOUNT OF
THE DRUG TO ACHIEVE THE SAME
EFFECT DUE TO THE PROGRESSIVE
LOSS OF EFFECTIVENESS OF THE
DRUG WITH ALL OTHER CONDITIONS
CONSTANT
INITIATING LA THERAPY
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WHAT WOULD YOU DO?
LA OPTIONS
• Oxycontin
• MSContin/Oramorph/
MSER/Avinza
• Duragesic, Fentanyl Patch
• Opana ER
• Exalgo
• Nucynta ER
• Dolphine, Methadone
• Butrans Patch
• Zohydro ER, Hysingla ER
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OPTIONS
• Taper the Hydrocodone,
then start new med
• Stop Hydrocodone; start
new med at lower MEQ
• Stop Hydrocodone; start
new med at same MEQ
• Stop Hydrocodone; start
new med at Inc MEQ
• Start new med and use
Hydrocodone for BTP
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WHAT WOULD YOU DO?
INFLUENCES
• Dosage Issues
• Insurance coverage
• Side Effects/History
• Current Medications
• Social History
• REMS rules
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START/DON’T START
• MS Contin
• Fentanyl
• Avinza
• Oxycontin
• Opana ER
• Nucynta ER
• Methadone
• Butrans
• Zohydro ER
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INITIATING THERAPY
OF ER/LA OPIOIDS
• According to Blueprint - may be used
for initial dosing in non-tolerant pts.
–
–
–
–
–
–
–
Avinza 30 mg daily
Butrans patch 5 mcg/hr every 7 days
Dolophine 2.5-10 mg every 8-12 hours
Embeda 20 mg/0.8 mg every 12-24 hours
Nucynta ER 50 mg every 12 hours
Opana ER 5 mg every 12 hours
Oxycontin 10 mg every 12 hours
INITIATING THERAPY
OF ER/LA OPIOIDS
• According to Blueprint - should not be
used for initial dosing in non-tolerant pt
–
–
–
–
Duragesic patch
Exalgo
Kadian
MS Contin (?)
• Require a calculation of dose from current use
– Based on conversion tables?
• There are increasing concerns with this!
INITIATING THERAPY
OF ER/LA OPIOIDS
• According to Blueprint - Initial
titration interval:
– (minimum number of days before it
can be changed again)
•
•
•
•
•
Oxycontin – 1-2 days
Kadian – 2 days
MS Contin – 2 days
Opana ER – 2 days
Avinza – 3 days
INITIATING THERAPY
OF ER/LA OPIOIDS
• According to Blueprint - Initial
titration interval:
– (minimum number of days before it
can be changed again)
•
•
•
•
•
•
Butrans – 3 days
Embeda – 3 days
Nucynta ER – 3 days
Duragesic – 72 hours
Exalgo – 3-4 days
Dolophine – Not reported – should be 7 days or
more
MODIFYING DOSING
OF ER/LA OPIOIDS
• Titrate increase in ER/LA opioid
medication on regular intervals
– 25-33% changes for 1-2 visits
– 10-20% for continuing visits
• Eventually titrate SA opioid to
return to only PRN use
MODIFYING DOSING
OF ER/LA OPIOIDS
• Stop further titration of ER/LA
opioid when:
– Adequate analgesic effects
– Unacceptable side effects
– No increase in analgesic response
for 1 – 2 changes
– Ceiling levels
• Avinza, Butrans, Nucynta, ?Dolphine
SIGNS/SYMPTOMS OF ONSET
RESPIRATORY DEPRESSION
• Any Trouble Breathing
– Hypopnea or apnea
• Cannot be easily aroused
– Intoxicated behavior – confusion,
slurred speech, stumbling
• Unusual snoring, gasping, or
snorting (especially with sleep)
• Fingertips/lips are blue/purple
SIGNS/SYMPTOMS OF ONSET
RESPIRATORY DEPRESSION
• Recent Review Article in NEJM
– Edward Boyer, MD, PhD
N Engl J Med 2012; 367; 146-155
• Internet Education/Assistance
– Opioids911.org
– Many Others
WHAT WOULD YOU DO?
WHAT ABOUT NALOXONE?
• I’ve thought about it!
• I regularly prescribe it!
• I don’t see the need for it!
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ROTATING LA TREATMENT
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WHAT WOULD YOU DO?
UPDATED HISTORY
• She returns a year later no • DC Opana ER; change to
better and wishes to
Duragesic Patch @ 100
change medications.
mcg/hr
• DC Opana ER; start
Oxycontin at 80 mg q12 h
• Currently on Opana ER 40
mg q8h/MSIR 15 mg qid
• Begin tapering Opana ER
by 10 mg per dose daily
until off and then start
MSER at 15 mg q 12 h
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II. Initiating Therapy, Modifying
Dosing, and Discontinuing Use of
ER/LA Opioid Analgesics
• e. (LO3) Prescribers should understand
the concept of incomplete crosstolerance when converting patients from
one opioid to another.
• f. (LO4) Prescribers should understand
the concepts and limitations of
equianalgesic dosing and follow patients
closely during all periods of dose
adjustments.
MODIFYING DOSING
OF ER/LA OPIOIDS
• Equianalgesic Dosing
– Based on Morphine Equivalents
– Some meds much less reliable
– Conversion Tables
• Lots of variability
• May be cause of some deaths/injuries?
OPIOID DOSING:
CONVERSION AND RISK
CONVERSION TO
MORPHINE MEQ
LOW
MODERATE
HIGH
VERY HIGH
MORPHINE
x1
0 - 30 mg
31 - 100 mg
101 - 200 mg
> 200 mg
HYDROCODONE
x1
0 - 30 mg
31 - 100 mg
101 - 200 mg
> 200 mg
OXYCODONE
x 1.5
0 - 20 mg
21 - 66 mg
67 - 133 mg
> 133 mg
HYDROMORPHONE
x4
0 - 7.5 mg
7.6 - 25 mg
26 - 50 mg
> 50 mg
OXYMORPHONE
x3
0 - 10 mg
11 - 33 mg
34 - 66 mg
> 66 mg
TAPENTADOL
x 0.33
0 - 75 mg
76 - 250 mg
251 - 500 mg
> 500 mg
METHADONE
x3
0 - 10 mg
11 - 30 mg
31 - 60 mg
> 60 mg
FENTANYL
PATCH x 5
NONE
12 mcg/hr
24 - 50 mcg/hr
> 50 mcg/hr
BUPRENORPHINE
PATCH ?
0 - 35 mcg
36 - 52.5 mcg
52.6 - 105 mcg
> 106 mcg
?
0 - 200 mg
201 - 400 mg
TRAMADOL
> 400 mg
Methadone Conversion
Relative potency based on Morphine Equivalent dose per day
- MEDD < 500mg, Conversion 5:1
- MEDD < 1000mg, Conversion 10:1
- MEDD > 1000mg Conversion 20:1
Ratios are starting points. Different variations in potency ratios
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INCOMPLETE
CROSS-TOLERANCE
• Current doses of ER/LA med not
providing adequate analgesia
– ?Tolerance vs Receptor responses
• A new/different ER/LA med may
not have similar potency
– Will act differently at the receptors
• Overdose is possible
MODIFYING DOSING
OF ER/LA OPIOIDS
• Best Option
– Taper current med to easier level
• Lower dose of current ER/LA med to make
easier conversion
• Start new ER/LA with low dose of current
med
• Complete transition without change in SA
opioid
• Begin to increase new ER/LA
• Still needs frequent FU due to inc pain
WHAT WOULD YOU DO?
WHICH IS A TAMPER
RESISTANT ER/LA OPIOID?
UPDATED HISTORY
• Some concerns about the
safety of storage and
• Fentanyl Patches
family members accessing • Avinza (morphine)
the medications.
• Opana ER (oxymorphone)
• Embeda (MS/Naltrexone)
• Oxymorphone ER
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•
•
•
•
•
CURRENTLY APPROVED
ABUSE DETERRENT LA/ER
OPIOIDS
Oxycontin (Oxycodone)
Opana ER (Oxymorphone)
Exalgo (Hydromorphone)
Embeda (Morphine/Naltrexone)
Hysingla ER (Hydrocodone)
• Suboxone (Buprenorphine/Naloxone)
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DISCONTINUE TREATMENT
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WHAT WOULD YOU DO?
UPDATED HISTORY
• She returns a year later no
better and wishes to stop
treatment.
INITIAL TREATMENT
• Refer to detox unit
• Stop the MSIR
• Lower LA Opana ER to
30 mg q8h, and reduce
• Currently on Opana ER 40
monthly
mg q8h/MSIR 15 mg qid
• Lower LA Opana ER to
30 mg q8h, and reduce
weekly
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WHAT IF THERE IS A PROBLEM
OR THEY ARE NOT WORKING?
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DEPENDENCE
IS NOT ADDICTION
• Physical dependence:
– “Physical dependence is a state of
adaptation that is manifested by a
drug class specific withdrawal
syndrome that can be produced by
abrupt cessation, rapid dose
reduction, decreasing blood level of
the drug, and/or administration of an
antagonist.”
DISCONTINUING USE
OF ER/LA OPIOIDS
• Dependance is not addiction
– Withdrawal symptoms include:
•
•
•
•
•
•
•
•
Severe dysphoria
Sweating
Nausea
Rhinorrea
Depression
Severe fatigue
Vomiting
Pain
AVOIDING WITHDRAWAL
DISCONTINUING USE
OF ER/LA OPIOIDS
• Tapering recommendations
– Variable rate and pattern
• 10% of dose per day to q weekly
– Have a detailed patient agreement
• May write out entire schedule?
• Removing from clinic/starting other Tx?
– Frequent FU visits
• Limit amount of Rx per visit
DISCONTINUING USE
OF ER/LA OPIOIDS
• Tapering recommendations
– Slow the taper after reaching 1/3 of
original dose
– Monitor for withdrawal, worsening
pain or mood and associated
function
• Objective measures
– Consider urine testing - compliance
WHY ARE YOU TAPERING:
COMPLIANCE vs INEFFECTIVENESS?
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DISCONTINUING USE
OF ER/LA OPIOIDS
• Use SA opioids to complete taper?
– The last step off the ER/LA meds
– Follow similar % reduction with the
SA meds
– Monitor for reduction in mood and
function
II. Initiating Therapy, Modifying
Dosing, and Discontinuing Use of
ER/LA Opioid Analgesics
• RECOMMENDATIONS
– STRUCTURE
– COMPLIANCE
– DOCUMENTATION
DISCONTINUING USE
OF ER/LA OPIOIDS
• DISPOSING OF MEDICATIONS
– FDA INSTRUCTIONS
• FLUSH MEDICATIONS
• DRUG TAKEBACK DAYS
• NEW PHARMACY REGULATIONS
– CONCERNS
• ENVIRONMENTAL
Counseling Patients and
Caregivers about the Safe Use of
ER/LA Opioid Analgesics
• HOW DO YOU WANT YOUR OFFICE TO
HANDLE ALL OF THIS?
– WRITTEN MATERIALS/HANDOUTS/DVD/WEB
•
•
•
•
•
PATIENT COUNSELING FORM
SPECIFIC MEDICATION INFORMATION
SIDE EFFECT AWARENESS
PATIENT AGREEMENT
OFFICE POLICIES
– DRIVING OR OPERATING MACHINERY
– SHOULD THEY SIGN ALL OF THESE?
• DOCUMENT THAT THEY RECEIVED THEM ALL?
Counseling Patients and
Caregivers about the Safe Use of
ER/LA Opioid Analgesics
• HOW DO YOU WANT YOUR OFFICE TO
HANDLE ALL OF THIS?
– TELEPHONE POLICIES/ISSUES
• SAME DAY APPOINTMENTS?
– MEDICATION NOT WORKING?
– SIDE EFFECTS?
– THEFT OR LOSS?
• DAYTIME vs NIGHTTIME NUMBERS?
• DOCUMANTATION OF PHONE CALLS?
– IS THIS REALLY A GOOD PT TO HAVE ON
OPIOIDS?
• HOW OFTEN ARE THEY CALLING?
Counseling Patients and
Caregivers about the Safe Use of
ER/LA Opioid Analgesics
• HOW DO YOU WANT YOUR OFFICE TO
HANDLE ALL OF THIS?
– FOLLOW-UP QUESTIONS
• DID YOU SHARE YOUR MEDS?
– ANY LOST OR STOLEN?
• DID YOU BREAK/CHEW/ALTER MEDS OR ADJUST THE
DOSE?
• DID YOU DRINK ALCOHOL?
• DID ANY OF YOUR OTHER MEDS CHANGE?
– DO WE NEED TO ASK THESE AT EVERY VISIT?
• CAN IT BE DONE ON A COMPUTER KIOSK?
WHAT WOULD YOU DO?
I FIND REMS PRINCIPLES:
• Helpful
• Not Helpful
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QUESTIONS