Transcript *This pain is killing me...* Medication Safety in Pain Management

‘This pain is killing me...’
Medication Safety in Pain
Management
Jayne Pawasauskas, PharmD, BCPS
Clinical Associate Professor
URI College of Pharmacy
Pharmacy Specialist – Pain Management
Kent Hospital
Learning Objectives
• Understand concepts of medication safety
pertaining to patients using opioids for
pain management
– Identify risks of opioid-related adverse events
& strategies to minimize these occurrences
– Recognize and prevent Rx drug abuse in
context of pain management
• Discuss safe use, storage, and disposal of
prescription drugs
• Discuss research findings on patients’
behaviors and perceptions of medication
safety
Disclosures
Current:
Speakers’ Bureau & Advisory Board:
Cadence Pharmaceuticals
Previous:
Speakers’ Bureau: Pricara
Consultant: Inflexxion, Painedu.org
Grant Funding: Purdue Pharma
•Focus on accidental opioid overdoses
•Database from 2004 – 2011 on opioid-related
ADEs
•47% wrong dose
•29% improper patient monitoring
•11% others (e.g.drug interactions, excessive
doses)
Risks for Respiratory Depression
• Longer length of time
• Sleep apnea
• Morbid obesity (BMI given anesthesia
>30) with high risk of during surgery
• Receiving other
sleep apnea
sedating drugs:
• No recent opioid use
benzo’s,
• Post-op; thoracic or
antihistamines,
upper abdominal
sedative, CNS
• Functional status
depressants
• Older age
• Pre-existing cardiac
• Smoker
or pulmonary dz;
major organ failure
Patient-Specific Risk Factors
• 48 y.o. ♂
• Problem list: diverticulitis with multiple
abdominal surgeries, recent colectomy
with complications; arthritis, anxiety, pain
• 4W
• BMI = 32.7
• + tobacco: 1 ppd (addressed in ID
consult)
• + EtOH, h/o pancreatitis
• No documented respiratory, cardiac, renal
or hepatic disease
• Combination of CNS depressant drugs
Pharmacokinetic Example
Narcan
Narcan Narcan
Pharmacokinetic Info
Oxycodone CR
Oxycodone IR
Lorazepam IV
Hydromorphone IV
Tmax
2.5hrs
1.5hrs
15-20 min
15 min
T 1/2
5-8hrs
4hrs
12-14hrs
2.3hrs
Multimodal Analgesic
Approach
Opioids
-2 agonists
NMDA antagonists
Acetaminophen
Opioids
-2 agonists
Local anesthetics
NSAIDs
COXIBs
Local Anesthetics
Recommendations
• Full body skin
assessment
– E.g. look for fentanyl
or buprenorphine
patch; incisions from
implanted pumps
• Assess respirations
– set frequency
• Consider when dose
changes or addition of
more opioids
• High-risk opioids
identified
– Methadone
– Fentanyl
– IV hydromorphone
• Use technology to
reduce system errors
– SmartPumps
– CPOE
– PCA to reduce risk
of oversedation
PCA PK
Sam et al. Journal of Clinical Anesthesia (2011) 23, 102–106
PCA PK
Peak M6G at ~25 hours
Sam et al. Journal of Clinical Anesthesia (2011) 23, 102–106
Considerations with PCA
• Weigh risks/benefit of continuous +
demand vs. demand only
– Start with demand only if pt opioid naïve
• Risk for respiratory depression can be
greatest on POD 1
– Depending on what else is on board
Predictors of Naloxone
Utilization
•
Patients who received naloxone at Kent
Hospital at any point between October 1st
2011 and September 30th 2012 were
included.
•
Exclusion criteria: no opioid use within the
24
hours
previous
to
naloxone
administration, naloxone used within 24
hours of being admitted, or if naloxone was
used in either the post anesthesia care unit
or operating room.
169 patients
received
naloxone from
inpatient Pyxis
records between
10/1/2011 and
9/30/2012
25 patients
received
naloxone
Within 24 hours
of being
admitted
65 patients are
eligible for the
experimental
group in this
study
13 patients did
not receive any
opioid
medications in
the 24 hours
prior to
naloxone
66 patients
received
naloxone while
in either the OR
or PACU
Methods
• Data collected by review of electronic
medical record (EMR): patient age,
BMI, smoking history, use of any
CNS-depressant medications, current
or past, renal disease, cardiac disease,
respiratory disease, or hepatic disease.
• Matched to patients who did not
require naloxone by daily MED
– Ave = 86 mg
Results…
Risk Factor Grouping Graph
30
Number of Patients
25
20
15
Control Group
Naloxone Group
10
5
0
0
1
2
3
4
5
6
7
Number of Risk Factors
8
9
PRESCRIPTION DRUG
ABUSE
US Office of National Drug Control Policy
2011 Prescription Drug Abuse
Prevention Plan
• Education. A crucial first step in tackling the
problem of prescription drug abuse is to educate
parents, youth, and patients about the dangers of
abusing prescription drugs, while requiring
prescribers to receive education on the appropriate
and safe use, and proper storage and disposal of
prescription drugs.
• Monitoring. Implement prescription drug
monitoring programs (PDMPs) in every state to
reduce “doctor shopping” and diversion, and enhance
PDMPs to make sure they can share data across states
and are used by healthcare providers.
US Office of National Drug Control Policy
• Proper Medication Disposal. Develop
convenient and environmentally responsible
prescription drug disposal programs to help decrease
the supply of unused prescription drugs in the home.
• Enforcement. Provide law enforcement with
the tools necessary to eliminate improper prescribing
practices and stop pill mills
What is Prescription Drug
Abuse?
Taking a medication that a doctor
prescribed for someone else
Taking more of a medication that a
doctor prescribed for you
Taking a medication that a doctor
prescribed for you differently than
how he/she intended
Heath Care Providers
Patient/Community
?
SAMHSA, 2011 National Survey on Drug Use and Health
Heath Care Providers
Patient/Community
Local Data
• Series of studies to assess patients’
behaviors & perceptions about various
aspects of medication safety
– Intent to capture data from a variety of
settings
• Adult out-patient family medicine practice
• Adult in-patient acute care hospital
• Parents of patients at a pediatric in-patient
acute care hospital
• College students at a public university
Adult Outpatients
Thundermist Health Center
Item (n=100)
Shared Your Medications
Response
10%
“Wanted to help,” “They ran out of theirs”,
“They couldn’t afford theirs”
Shared With You
29%
Locked
65% never
Patients with CS rx’s were more likely to report
someone sharing meds with them (p=0.004) and
saving unused meds for another time (p=0.05),
as opposed to disposing
Adult Outpatients, con’t
• 21% reported they would save unused
medications for a later time/need
– 56% would get rid of them by either
flushing or throwing in trash: flush (62%)
or throw in the trash (38%)
– 11.5% reported proper disposal
• Drug drop-off locations/DEA take-back, or
proper home disposal
Adult Parents of Pediatric Patients
UMass Memorial Children’s Hospital
Item (n=80)
Shared Your Medications
Response
21%
“They asked me,” “Wanted to help with their medical
problem,” “They didn’t have time to go to their doctor”
Shared With You
23%
Alleviation of symptoms, 1 ADR
Locked
54% never
Parents <25 y.o. were more likely to monitor storage of
Rx meds in the home (p=0.041), compared to older age
groups.
Adult Parents, con’t
• 18% reported they would save unused
medications for a later time/use
– 71% would flush or throw in trash
• 53% reported they had talked to their
kids about Rx drug abuse
– 6% no answer
– 41% did not talk to their kids
• ‘age too young’
• many had teen-aged children
• Parents > 35 y.o. were more likely to have had
discussions with their kids (p=0.003)
Education
• In the US, an average of 2,000 teenagers
EVERY DAY use prescription drugs without
a doctor's guidance for the first time
• Youth 12-17 years old, 2.8% reported pastmonth nonmedical use of prescription
medications
• Prescription and over-the-counter drugs are
among the most commonly abused drugs by
12th graders, after alcohol, marijuana,
synthetic marijuana and tobacco
http://teens.drugabuse.gov/drug-facts/prescription-drugs
College Students
URI Health Services
Item (n=333)
Response
Witnessed Sharing of Rx Meds
28%
Shared Your Medication
27%
“To help them with their medical condition,”
“didn’t see a reason not to”
Shared With You
41%
Alleviation of symptoms
Locked
77% never
Disposal
52.6% save; of those who would
dispose, 81% throw in trash
Passik et al. Oncology 1998;12(4):517-521.
Aberrant Drug Behaviors
More Predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing
another patient’s drugs
• Obtaining prescription drugs
from non-medical sources
• Concurrent abuse of illicit
drugs
• Multiple unsanctioned dose
escalations
• Recurrent prescription losses
•
•
•
•
•
•
•
Less Predictive
Aggressive complaining about
need for higher doses
Drug hoarding during periods of
reduced symptoms
Requesting specific drugs
Acquisition of similar drugs
from other medical sources
Unsanctioned dose escalations
1-2 times
Unapproved use of the drug to
treat another symptom
Reporting psychic effects not
intended by the clinician
“What Can I Do?”
• Prescription Drug
Monitoring
Program
• Inventory/Crime
Prevention
• Education
– Counseling
– Drug Storage
– Drug Disposal
• Communication
– Prescribers
– Parents/Adolescents
• Therapy assessment
and monitoring
– Interaction
– Alternative
treatments
– Recognition
Opioids: Symptoms to Watch For…
Overdose
•
•
•
•
↓ level of consciousness
Pinpoint pupils
↓ Heart rate
↓ Respiratory rate
– Patient may appear
cyanotic (blue lips & nails)
• Seizures
• Muscle spasms
• Unarousable
Withdrawal
Early: agitation, anxiety,
muscle aches,
lacrimation, rhinorrhea,
diaphoresis, yawning,
chills, drug cravings
Late: abdominal cramping,
diarrhea, dilated pupils,
N/V, piloerection,
dysphoria, akathesia,
insomnia, tachycardia or
hypertension
Opioids/Narcotics
Drug Names
Oxycodone (OxyContin, Percocet,
Percodan)
Street Names
Hillbilly heroin, OC, oxy, percs,
cotton, kicker
Morphine (Avinza, Kadian, MSContin, Dreamer, hows, Miss Emma,
Roxinol)
Mister Blue, Unkie
Hydrocodone (Vicodin, Lortab,
Vikes, Hydros, Watson 387
Lorcet)
Codeine
Fentanyl (Duragesic, Actiq, Lazanda,
Onsolis, Abstral, Fentora)
Empirin
Dance fever, goodfellas,
jackpot, incredible hulk, murder
8
Hydromorphone (Dilaudid, Exalgo)
Methadone (Dolophine, Methadose)
Fizzies, amidone
Benzodiazepines
Overdose
•
•
•
•
CNS Depression
Ataxia
Slurred speech
Respiratory
depression
• Coma
Withdrawal
•
•
•
•
•
•
•
•
•
•
Severe sleep disturbance
Irritability
Tension/anxiety/panic
Tremor, Diaphoresis
Difficulty concentrating/
cognition
Dry retching/nausea/abd pain
Weight loss
Palpitations, Headache
Muscle pain/stiffness
Hallucinations, seizures,
psychosis
Sedatives & Depressants
Benzodiazepines
Diazepam (Valium), Triazolam (Halcion)
Alprazolam (Xanax), Clonazepam (Klonopin)
Street Names
Candy, downers,
sleeping pills, tranks
Lorazepam (Ativan), Temazepam (Restoril)
Barbiturates
Phenobarbital & Primadone
Secobarbital
Pentobarbital
Barbs, reds, red birds,
phennies, tooies,
yellows, yellow jackets
Mephobarbital
Butalbital (Fioricet, Fiorninal)
Sleep Aids
Zolpidem (Ambien), Zaleplon (Sonata)
Eszopiclone (Lunesta)
A-minus, zombie pills
Non-controlled Rx drugs
Not all drugs that are abused are
controlled substances
Gabapentin (Neurontin)
• Alcohol/cocaine abusers
• Doses ranged up to 7200 mg/day
• Creates relaxation, ‘laid back’ feeling,
euphoria, giggling, similarity to
marijuana-like effects, addicts report
suppression of cravings; some report
negative effects (‘zombie-like’
feeling)
Gabapentin (Neurontin)
• Cocaine users were more likely to
snort powder from the capsules
• Withdrawal symptoms reported to
include disorientation, confusion,
tachycardia, diaphoresis,
tremulousness, and agitation
Quetiapine (Seroquel)
• Often prescribed to treat anxiety,
especially in substance abuse
populations
• Many request and abuse it for sleep
potential
– ‘come down’ from a ‘high’
– Mix with other drugs of abuse to achieve
a more calm ‘high’
SSRIs: Examples of Fluoxetine Abuse
• Reports of taking 80-140 mg of
fluoxetine
• Sometimes in combination with alcohol
– Caused increased energy, talkativeness,
mood elevation and slight “jitters”
– One reported it was unlike “speed” because
she also felt numb and calm
– One experienced an amphetamine-like effect
requiring trazodone and diazepam to sedate
him at night
• Withdrawal symptoms not noted 
fluoxetine has long t½
Serotonin Syndrome
NEJM 2005;352:1112-20.
Over-the Counter Medications
• Dextromethorphan (Robitussin)
– Serotonin syndrome
– Change in mental status, autonomic
hyperactivity, neuromuscular abnormalities
• Pseudoephedrine (Sudafed)
– Diaphoresis, mydriasis , ↑ heart rate,
hyperthermia
• Diphenhydramine (Benadryl)
– Delirium, hallucinations, urinary retention,
mydriasis, ↑ heart rate, hyperthermia
Kent Hospital ED
• For chronic and chronic-intermittent
pain
• ‘Prescriptions for opioid pain medicine
given on discharge from the ED will be
for no more than a 3-day supply with no
refills.”
– Adapted from the American Academy of
Emergency Medicine Guidelines, 2013
Take Home Naloxone
• Naloxone and Overdose Prevention
Education Program of Rhode Island
www.noperi.org
Accessed from www.noperi.org
Education
• Drug is intended for patient only
– Do NOT share medication with others
• The Controlled Substances Act of Title
21 FDA US Code 13
– "knowingly or intentionally to possess a
controlled substance" not lawfully obtained
from a doctor could lead to a year in prison
or a $5,000 fine, or both on a first conviction
– Penalty for a second offense doubles the
penalties
Education
• Increase in malicious administration of
pharmaceuticals to children
– Mean number of 160 cases per year
– In 51% of cases, at least 1 sedating agent
• Analgesics
• Stimulants/street drugs
• Sedatives/hyponotics/antipsychotics
• Cough and cold preparations
• Ethanol
Yin S. The Journal of Pediatrics 2010
Proper Drug Storage
• Massachusetts Law
– Pharmacy dispensing schedule II, III,
IV or V prescription drugs shall make
available prescription lock boxes for
sale at each store location.
• Within 50 feet of pharmacy
counter and readily viewable by
public upon picking up
prescription
• Maintain a stock of lockboxes
• Encourage consumers buying
over-the-counter or prescription
medications to purchase one
Drug Disposal
• TakeAway Environmental Return
System ™
– Envelope with instructions on what
can/cannot be mailed
– For purchase at local pharmacies
• DEA take-back days
– http://www.deadiversion.usdoj.gov/dru
g_disposal/takeback/
Drug Disposal
• Rhode Island drop-off locations for
unwanted non-controlled prescription
and over-the-counter drugs
–
–
–
–
–
–
Ocean Healthmart Pharmacy
Baker’s Pharmacy of Jamestown
Newport Prescription Center
Simpson’s Pharmacy
East Side Prescription Center
Oxnard Pharmacy
Drug Disposal
• Medication drop boxes located in
over 20 police department buildings
for controlled substances
Drug Disposal
• If none available
– Take pills out of container & mix with
coffee grounds/kitty litter
• Throw out in sealable bag such as Ziploc bag
• Make unappealing to both children and pets
• Flushing is NOT an option
– Water contamination
Summary
• Appropriate prescribing and dispensing of
(pain) medications is not enough
• We should take every opportunity to
provide patient education
• Even brief encounters can make a
difference
– “It’s not safe to share medications. A drug may work
just fine for you, but could be deadly to someone
else.”
– “Don’t keep unused medications in your home.
There are many convenient places you can go to drop
off unwanted/unused medications.”