Download - kroll - ishp.wildapricot.org
4/6/2015
1
Kati Kroll, PharmD
PGY1 Pharmacy Resident
Saint Alphonsus Regional Medical Center
• The presenter has no vested interest nor anything to disclose
4/6/2015
2
1. Briefly summarize the societal and medical concerns surround prescription drug abuse, misuse and diversion.
2. List basic strategies to identify and prevent prescription drug abuse, misuse and diversion.
3. Recognize warning signs that indicate a patient should be triaged to the emergency room instead of calling poison control upon ingestion or exposure to medications or other substances.
4. Recite and/or be able to locate the phone number for poison control.
Is prescription abuse and misuse a problem?
What problems are associated with prescription drug abuse?
Is it our problem? (Pharmacies)
4/6/2015
3
Intentional
Medication Abuse/Intentional
overdose
“pharming”Generation Rx
Unintentional/Accidental
Misunderstandings/ Errors
Poisoning
4/6/2015
4
• Directed or intentional effort to obtain and utilize pharmacologic agents to induce or produce a psychological or physiological effect
• Terminology: • Non-medical use • “pharming”• Generation Rx
• Incidence growing in recent decades:• Abuse of pharmaceuticals has now surpassed rates of abuse of all illicit drugs in the US except marijuana1
• 2010: an estimated 2.4 million Americans used prescription medications non-medically for the first time within the past year2
• Averages to over 6,000 initiations per DAY
• Who:• Majority: adolescents (18-25 years old)
• Males vs Females: similar rates
• Concomitant depression
• 2x rate of non-medical and illicit drug use
• Small metropolitan and rural America
• Why:• Perception that abusing prescription medications is “safer” than illicit drugs
• Lesser legal repercussions than illicit drugs
• Ease of access- majority of adolescents describe as “fairly or very easy” to obtain
• Stimulation of dopamine reward pathway in the brain
• Coping mechanism
4/6/2015
5
Choose a health condition associated with pain… can you find the signs and
symptoms online?
Example: neuropathy
Could you tell a doctor what the
symptoms are, even though you may not
have it?
• More common amongst middle-aged women
• Multiple prescriptions from multiple prescribers
Doctor Shopping
• Employees and/or public
• In 3 year period: 28 million dosage units of controlled substances stolen
Theft (homes or pharmacies)
• Two-thirds of teens reported this mode of obtaining meds (stolen or given)
• “Pharming” parties
Friends or Relatives
• Buying from patients• Internet prescriptions without medical visits
Internet/Drug dealers/patients
• Self-diagnosis • Drug seeking • Internet searches provide the “right words to say” in appointments
Feigning Illness
• Stolen prescription pads
• Altered quantities• Non-local prescribers
Forged or Alerted Prescriptions
4/6/2015
6
Methods of Abuse
• Medications used without an indication
• Higher doses or frequencies
• Alternative routes of administration
• Crushing
• Snorting
• Injecting
• Combination with other medications or drugs
Opioids
OpioidsEffects: pain relief, euphoria, drowsiness, sedation, weakness, impaired coordination,
confusion, constipation, itching, dry mouth, dizziness, nausea and vomiting
Dangers: slowed or arrested breathing, anoxic brain damage,
unconsciousness/coma, and death
Codeine Robitussin A-C, Tylenol
#3
CII, CIII and
CV
Injected
Swallowed
Morphine Roxanol, duramorph, MS
contin
CII, CIII Injected
Swallowed
Smoked
Methadone Methadose CII Swallowed
Injected
Fentanyl &
analogs
Actiq, duragesic,
sublimaze
CII Injected
Smoked
Snorted
Oxycodone Oxycontin, Percocet CII and CIII Chewed/Swallowed
Snorted
Injected
Suppositories
Hydrocodone Vicodin, norco, dilaudid CII and CIII
Meperidine or
Ketamine
Demerol, Darvocet CII, CIII and
CIV
4/6/2015
7
Stimulants
Stimulants
Effects: exhilarated feelings, increased energy, mental alertness,
"buzzed", insomnia and decreased appetite
Dangers: increased heart rate, tremor, weight loss, nervousness/anxiety,
seizures, heart attacks and strokes
Amphetamines Adderall and
Dexedrine
CII Injected
Swallowed
Smoked/snorted
Methylphenida
tes
Concerta, Ritalin CII Injected
Swallowed
Snorted
Sedatives/Depressants
Depressants
Effects: sedation/drowsiness, decreased anxiety, feelings of well-being, lowered
inhibitions, slurred speech, poor concentrations, confusion, dizziness, impaired
coordination and memory
Dangers: hypotension, slowed breathing, tolerance, withdrawal, addiction,
increased risk of respiratory distress and death when combined with alcohol
Barbiturates Phenobarbital,
Nembutal, seconal,
amytal
CII, CIII
and CV
Injected
Swallowed
Benzodiazepines Ativan, halcion, Librium,
valium, xanax
CIV Swallowed
Sleep
Medications
Ambien (zolpidem),
sonata (zaleplon),
lunesta (eszopiclone)
CIV Swallowed
Snorted
4/6/2015
8
Inconveniences
• Nausea/Vomiting • Constipation • Cardiovascular dysfunction• Drowsiness/ Sedation • Incoordination/ Numbness
Serious Events
• Physical dependence/ Addiction • Seizures • Neurological damage (hypoxia)• Suppressed or cessation of
breathing • Coma and Death
• Controlled substance scheduling:
• Actual or potential risk for abuse
• Current patterns of abuse
• Dependence liability
• Known or possible risks to public health
• Scope, duration and significance of the drug’s abuse
• Precursor of another controlled substance
4/6/2015
9
Reasons for abuse/misuse:• Ease of access
• Available at many retail stores (not just pharmacies)
• Perception that they are safe/harmless
• Relatively low cost
• Substitute for a prescription medication
• Intensify or lessen effects of other drugs
Top 10 OTC Products of Abuse6
• Dextromethorphan• Pain medications• Caffeine and energy drinks• Diet Pills• Laxatives and herbal diuretics • Motion sickness medications• Sexual performance enhancers• Pseudoephedrine• Herbal ecstasy• Herbal hallucinogens/stimulants
Over-the-Counter (OTC) medications are most commonly abused by adolescents aged
13-16 years old6
4/6/2015
10
Pseudoephedrine
• Used to produce methamphetamine
• Combating Methamphetamine Epidemic Act (CMEA) 2006
• Restricted access & sales limits
• Locked or behind the counter
• Daily: 3.6 grams
• Monthly: 9 grams
• Identification and log book
Role of Pharmacy Technicians:
1. Comply with policy on sale and record keeping
2. Explain to patients the purpose of limits 3. Know what to do when abuse is suspected
(reporting)4. Recognize other supplies to make Meth:
• Iodine, anhydrous ammonia, propane, rubbing alcohol, Epsom salts, lithium, etc
5. Recognize physical signs of Meth abuse:• Formication (crawling skin), punding
(non-goal-directed repetitive activity), dyskinesia, poor teeth (meth mouth), depression, anxiety or psychosis
Schedule 5 Medications
• Small amounts of prescription medications that are CVs can be sold OTC
• Limits on quantities sold within 48 hours
• Special record-keeping and restrictions
Role of Pharmacy Technicians:
1. ONLY a pharmacist can complete the sale
2. Customer must have valid ID or be personally known to the pharmacist and be >18 years old
3. Know your pharmacy’s policy on these medications
Medications:
Guaifenesin plus codeine (Cheratussin AC)
4/6/2015
11
??Behind The Counter
??
Prescription
Non-Prescription
(OTC)
Behind-the-Counter (BTC)
• Has been proposed and considered by the Food and Drug Administration (FDA)• Four times in past few decades
• Proposed:• Only available in healthcare settings
• Require an intervention by a pharmacist
• No prescription required
• Keep an eye on this issue in the future
What characteristics or behaviors would make you suspicious that someone is abusing medications?
4/6/2015
12
Drug Abuse
?
Depression/Low Self Esteem
Attempted Early Refills
Declining hygiene/ Lack of Interest
Aggression/ Rebellion/ Defensive
Inattention/ Social
Withdrawal
Family history
Sluggish/ Flat Affect
Sleep disturbances
Frequent borrowing of
money/ unexpected
cash
4/6/2015
13
• Unintentional or accidental use of medications which results in overdose, adverse effects, inadequate therapy or poisoning
• Use of medications is increasing in the United States
• More complicated indications
• Confusing for patients (especially elderly)
• Multiple changes to therapy
• Medication misuse contributes to ~50% of emergency room visits (2011)1
• Second leading cause of accidental death in the US (second to car accidents)
• Elderly especially at risk• Higher or lower doses, wrong route, etc
Misunderstanding Instructions
• Medications without indications• Antibiotics or antipsychotics
Inappropriate Prescribing
• Dispensing errors: wrong medication, wrong patient or incorrect instructions
Medication Errors
• Toxicities• Failure to adjust doses (renal function) and/or appropriate monitoring
Adverse Drug Events
• Medications that look like candy
Poisoning
4/6/2015
14
Elderly
• Account for over 1/3 of all prescriptions dispensed3
• Cognitive decline
• Dementia
• Poor hearing and vision
• Changes in metabolism= greater risk for toxicity
• Retention of discontinued medications
Children
• Unfamiliar dosing by healthcare workers
• Off-label indications
• Dependence on caretakers
• Difficult/unclear diagnosis
• Inadequate therapy
• Visits to physicians, urgent care or emergency department
• Poisioning/Death
• “Opioid analgesic poisoning” listed on death certificates increased 91% from 1999 to 2002
4/6/2015
15
• Often medications can look like candy to a child • Colorful
• Similar shapes
• Gummy/Chewy Texture
• Flavored Medications
• Medications should never be referred to as “candy”
4/6/2015
16
Clues of Possible Poisoning
• Breath that smells like chemicals
• Stains or odors on person
• Clothing or surroundings
• Burns
• Empty containers
Signs and Symptoms
1. Burning/Redness of skin or lips
2. Nausea or vomiting3. Difficulty breathing 4. Sleepiness/
Incoordination5. Confusion6. Seizures
• Who to call for help:• Poison control: 800-222-1222
• Appears stable
• Collect:
• Symptoms
• Age and weight
• Any information on poison
• Timeline of exposure
• 911/Emergency services
• Unconsciousness/unresponsive
• Difficulty or lack of breathing
• Uncontrollable restlessness
• Having seizures
4/6/2015
17
1. Store medications where kids cannot reach them
2. Put medications away after each use
• Don’t store in bathrooms or public areas
3. Utilize safety caps on bottles
4. Double-check medication instructions
5. Educate guests and children
6. Emergency preparedness
• Program poison control number into cell phones
4/6/2015
18
• Available or under construction in 48 states
• Facilitate investigation of controlled substance refill history
• Data collected:• Patient data: Name, DOB and address
• Prescription: medication, quantity, date filled and date written
• Prescriber
• Pharmacy-specific policies differ concerning pharmacist’s responsibilities: • Report to prescriber
• Refusal to fill
• Confidential information: HIPPA
• Screen for drug abuse
• Only 40% of physicians report receiving training to identify prescription drug abuse or addiction1
• Investigate patient requests for early refills
• Be mindful and aware of “doctor shopping”
• Limit punishment of those legitimately in pain
• Must be seen right away• Unable to provide medical details• Unsure of names of previous
prescribers• Use of specific medication
names/doses
• Claimed allergies to non-opioids• Unusual knowledge of controlled
substances • Use of surrogate (child, elderly) • Pressure prescriber: guilt/threats• Scripted symptoms (internet diagnosis)
Deceptive Patient Practices:
4/6/2015
19
• Follow prescription instructions
• Ask for instruction or clarification if needed
• Be aware of drug interactions
• Consult with prescriber/pharmacist before changing or starting therapy
• Tell each prescriber all current medications (medication list)
• Discard un-used/expired prescriptions
• Practice safe storage of medications- educate children
• Recognize signs of toxicity, number for poison control and when to call 911 vs poison control
Potential for drug abuse or addiction
• ≥2= Probable Addiction
Screening/Self-Assessment Questionnaire: CAGE
CUT
Have you ever felt the need to CUT down on your use of prescription drugs?
ANNOYED
Have you ever felt ANNOYED by remarks your friends or loved ones made about your use of prescription drugs?
GUILTY
Have you ever felt GUILTY or remorseful about your use of prescription drugs?
EVER
Have you EVER used prescription drugs as a way to “get going” or to “calm down”?
4/6/2015
20
• Screen for medication over or under use
• Attempt to verify “legitimate medical purpose”
• Be skeptical of out of town prescribers
• Communicate with prescribers
• Screen for prescription alteration
• Changed quantities or evidence of photocopies
• Unusual legibility, lack of abbreviations, etc
• Be suspicious of unusual prescribing patterns
• Prescribing numerous similar medications
• Prescribing of antagonist medications (stimulants+sedatives)
• Utilize prescription monitoring databases for controlled substances
• Learn or create policies for information obtained
Education
• Medication use
• Removing old patches before applying new ones
• Scheduling of twice daily (12 hours), three times daily (8 hours) and prn medications
• Signs of toxicity
• Proper/safe storage
• Disposal of expired/un-used medications
Patients Characteristics:
1. Patient’s lack of familiarity with prescriber
2. Prescription irregularities/ abnormalities• Call alternate number for prescriber (Google it)
3. Specific requests concerning brand or dosage forms
4. Out of town- patient or prescriber 5. Overly friendly, nervous, paranoid,
aggressive, etc6. Paying cash 7. Pharmacists gut instinct
4/6/2015
21
• We are directly related in the dispensing of medications • Last stop in the chain of healthcare providers
• Screen for abuse
• Educate to prevent misuse
• Taxes are higher because of abuse and misuse • Non-medical use of controlled substances is estimated to cost the healthcare system $72 billion annually5
• Lives are being lost unnecessarily • Medication misuse: Second leading cause of accidental death in the US
• Deaths from overdose: 15,000 people2
Once an opioid medication pain medication is prescribed and dispensed, it is estimated that 75% of these drugs are used without a prescription by someone else1
Group effort:
• Education (schools, public service announcements, parents, etc)
• Prescriptions and OTCs can be dangerous if used inappropriately
•Cooperation of medical professions
• Sharing of information/concerns
•Discourage internet medical advice/questionnaires
• Referrals to counseling/abuse therapy
• Involvement of friends and loved ones (HIPPA)
4/6/2015
22
1. Gianutsos G PhD. Prescription Drug Abuse: Strategies to Reduce Diversion. US Pharmacist. December 2009. Accessed Janurary 28, 2015. Available at: http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/106448/
2. Dart RC, Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, Green JL. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015 Jan 15;372(3):241-8. doi: 10.1056/NEJMsa1406143. PubMed PMID:25587948
3. Nau D.P., Kirking D.M. Nau, David P., and Duane M. Kirking.(2010). Chapter 2. Understanding Problems in the Use of Medications. In Warholak TL, Nau DP. Warholak T.L., Nau D.P. Eds. Terri L. Warholak, and David P. Nau. (Eds), Quality and Safety in Pharmacy Practice. Retrieved January 23, 2015 from http://0-accesspharmacy.mhmedical.com.libcat.ferris.edu/content.aspx?bookid=452&Sectionid=40698438.
4. Buxton I.O. Buxton, Iain L. O.(2011). Appendix I. Principles of Prescription Order Writing and Patient Compliance. In Brunton LL, Chabner BA, Knollmann BC. Brunton L.L., Chabner B.A., KnollmannB.C. Eds. Laurence L. Brunton, et al. (Eds), Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e. Retrieved January 23, 2015 from http://0-accesspharmacy.mhmedical.com.libcat.ferris.edu/content.aspx?bookid=374&Sectionid=41266282.
5. United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 2003 National Survey on Drug Use and Health. http://oas.samhsa.gov/nhsda.htm. Accessed August 17, 2009.
6. Understanding Sales Restrictions for Non-Prescription Drug Products. PowerPAK Continuing Education for Pharmacists and Pharmacy Technicians. http://www.powerpak.com/course/content/110880