ten tips prescribing controlled substances
TRANSCRIPT
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Ten Tips for Prescribing Controlled Substances
Charlie Reznikoff MD [email protected]
Hennepin County Medical Center
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Tip #1: Avoid prescribing highly reinforcing
(addictive) drugs
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Tip #1: Avoid prescribing highly reinforcing
(addictive) drugs… when other options are available
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Highly reinforcing medications
• Alprazolam (xanax)
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Highly reinforcing medications
• Alprazolam (xanax) – Preferred: lorazepam (ativan)
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol)
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol)
– Preferred: morphine
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall)
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall)
– Preferred: long acting methylphenidate (concerta)
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro)
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro)
– Preferred: long acting oxycodone (oxycontin 2.0)
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone
– Long acting tamper proof oxycodone
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone • Gel based fentanyl patch
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone • Gel based fentanyl patch
– Embedded mesh formulation
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Highly reinforcing medications
• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone • Gel based fentanyl patch
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What makes a drug reinforcing?
• Crushable (snortable, injectable) • Large dosage (gel based fentanyl patch) • Rapid cns onset (lipophilicity, absorption) • Unique receptor action (serotonin?) • Individual patient differences • Cultural preference
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Conceptualize and communicate about addictive behavior as an
adverse event inherent to certain medications
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Streetrx.com
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Tip #2: Know which problematic controlled
substances are commonly overlooked
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Drugs falsely believed to be safe(r)
• Carisoprodol (soma) – Barbiturate (eqinil) pro-drug – NOW schedule IV
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Drugs falsely believed to be safe(r)
• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet)
– short-acting barbiturate – Schedule III
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Drugs falsely believed to be safe(r)
• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.)
– low-potency benzodiazepine – Schedule IV – FDA lowered its dosing recommendation
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Drugs falsely believed to be safe(r)
• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.) • Tramadol (ultram)
– Low potency opioid with norepi blockade – Causes seizures before respiratory depression – NOW schedule IV
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Tramadol now sch. 4
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Drugs falsely believed to be safe(r)
• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.) • Tramadol (ultram) • Promethazine with codeine (phenergan syrup)
– “Purple drank” – Cultural preference within southern African Americans – Schedule V
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Drugs falsely believed to be safe(r)
• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.) • Tramadol (ultram) • Promethazone with codeine (cough syrup) • Hydrocodone containing products (Vicodin,
lortab) – FULL AGONIST OPIOID – NOW schedule II
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Hydrocodone sch. 2
starting October 6,
2014
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These drugs all have their uses… but they are not addiction-proof!
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Tip #3: Avoid prescribing meds (or for
conditions) outside your training
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05/01/2014 08/01/2015
May 29
Medical Cannabis Bill
signed into law
Director of Office of Medical Cannabis
starts
Aug 13
Manufacturer application published
Manufacturer application due
Sept 5 Oct 3
Two Manufacturers
registered
Dec 1
Dosage recommendations Patient
registration
Medical Cannabis available to patients
Spring 2015 July1
Deadline to publish notice of proposed
rules
Aug 8
Manufacturer Interested Parties
Meeting
Jan 1
Medical Cannabis Timeline
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Doctors providing marijuana recommendations are expected to follow the patient as the treating doctor of the qualifying condition
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Indications
• Dying of cancer with pain or nausea • Dying of HIV/AIDS with pain or nausea • MS, ALS • Glaucoma • Seizure • Tourette’s syndrome
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Minnesota Medical cannabis
• Limited forms • Smoking prohibited • Controlled production • Patient and doctor registry
• NOT: approval of casual marijuana use over a
wide swath of Minnesotans
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Tip #4: Limit total daily doses of opioids
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Tip #4: Limit total daily doses of opioids,
and dangerous mixes of drugs
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120 mg morphine
equiv. per day
limit
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Other risks of opioid overdose death
• Concomitant alcohol • Concomitant benzodiazepine • Comorbid medical conditions
–renal, psyche, pulmonary, addiction
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Tip #5: Dispose and store of meds safely
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Pill disposal
• Schedule 2– flush, pill take back site • Schedule 3-5– mix with unpalatable
substances and throw away • Fentanyl patches need special care
• www.fda.gov/Drugs/ResourcesForYou/Consu
mers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm
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Safe disposal of fentanyl patches
• Folded upon themselves and flushed
• Every year toddlers and pets die from exposure to fentanyl patches
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Store controlled substances:
private safe
ideally locked out of the reach of children hidden from house guests
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Tip #6 Pill misuse equally affects (young Caucasian) women
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Tip #7: Do not negotiate with intoxicated or
withdrawing patients
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Heavy eyelids “Nodding off”
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When you determine someone to be intoxicated you have only one job…?
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…Make sure they are getting home safely
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Tip #8: Check the prescription monitoring
program
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The next regulation: mandatory PMP searches for all scripts?
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Tip #9: Do not prescribe under duress
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Pressure from many angles
• Productivity, time • Patient satisfaction scores • Emotional pressure: manipulation, flirting,
bullying • Your internal drive to please patients • Your internal drive to fix problems
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Ways to deal with pressure
• Self Awareness • Exit the room • Discuss, debrief with a colleague • Addiction and pain are chronic diseases that
cannot be fixed in one visit
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Treat the patient as you’d want a loved one treated
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Tip #10: Ignore pain scores and pain talk.
Assess function
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What objective measures can we use titrating pain medications?
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What objective measures can we use titrating pain medications?
Function (enough) Opioid toxicity (too much)
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Acute pain research shows pain scores lowered by 30% in patients
given opioids
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Tip #11: Above all retain your relationship
with your patient
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Healing is about relationships
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Thank you! Questions?
References following this slide