Presentation is loading. Please wait.

Presentation is loading. Please wait.

Controlled Substance Prescribing in the Geriatric Population

Similar presentations


Presentation on theme: "Controlled Substance Prescribing in the Geriatric Population"— Presentation transcript:

1 Controlled Substance Prescribing in the Geriatric Population
Lisa Byrd PhD, FNP-BC, GNP-BC Gerontologist

2 Outline Review classes of controlled substances
Guidelines for Prescribing Discuss onset of action of short-acting, long- acting, & rapid onset opioids Identify enduring & emerging opioid therapies Describe elements of an overall treatment program that includes opioids Outline the advantages and disadvantages of risk management tools & techniques to identify aberrant behavior, abuse, & addiction

3 DISCLOSURE Medications to manage pain & other symptoms will be discussed Controlled Substances will be discussed Off-label use may be mentioned but this will be discussed Generic & Trade names will be used Material has been researched & presented by author of this presentation Presenter is on Speaker’s Bureau for: Novartis Pharmaceuticals Avanir Pharmaceuticals

4 USE OF CONTROLLED SUBSTANCES
are essential to the treatment of a myriad of disorders and represent a wide spectrum of pharmaceutical agents prescribing these substances involves considering a number of important medical, social, and cultural variables along with adherence to applicable federal and state regulations prescribers often stand at the crossroads of these issues and serve as the ultimate gatekeepers of safe and effective treatment

5 PRESCRIBERS… Must be well-versed in the legal requirements including knowledge of both federal & state law Controlled Substances Act (CSA) is the federal law that regulates such substances The Drug Enforcement Administration (DEA) publishes a guide for prescribers entitled: "Practitioner's Manual, an Informational Outline of the Controlled Substances Act" must be well-versed in the legal requirements including knowledge of both federal & state law Controlled Substances Act (CSA) is the federal law that regulates such substances it is a rather complete and functional law and provides an operational framework the prescriber should understand The Drug Enforcement Administration (DEA) publishes a guide for prescribers entitled: "Practitioner's Manual, an Informational Outline of the Controlled Substances Act" a resource which provides a comprehensive overview of the Controlled Substances Act and the federal requirements for prescribing controlled substances

6 TYPES OF PRESCRIBERS Physicians, Doctor of osteopath, Dentists, Podiatrists, & Veterinarians to prescribe controlled substances Other licensed healthcare professionals: Nurse Practitioners Physician Assistants Naturopathic Physicians Optometrists Medscape's US Nurse Practitioner Prescribing Law: A State-by-State Summary DEA's Midlevel Practitioners Authorized by State Website Physicians, doctor of osteopath, dentists, podiatrists, & veterinarians to prescribe controlled substances Some states can authorize other licensed healthcare professionals to prescribe controlled substances, including clinicians such as nurse practitioners & physician assistants with proper DEA registration. In rare cases, naturopathic physicians and optometrists can prescribe controlled substances in certain states with important limitations Medscape's US Nurse Practitioner Prescribing Law: A State-by-State Summary DEA's Midlevel Practitioners Authorized by State Website

7 Evaluation of a Patient
Medical history & physical examination FOR PAIN MANAGEMENT: the medical record should document: the nature & intensity of the pain current & past treatments for pain underlying or coexisting diseases or conditions the effect of the pain on physical & psychological function history of substance abuse Medical indications for the use of a controlled substance A medical history and physical examination must be obtained, evaluated, and documented in the medical record FOR PAIN MANAGEMENT: The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance

8 TREATMENT PLAN: PAIN MANAGEMENT
State objectives that will be used to determine treatment success should indicate if any further diagnostic evaluations or other treatments are planned Adjust drug therapy to the individual medical needs of each patient Other treatment modalities or a rehabilitation program may be necessary The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned After treatment begins, the prescriber should adjust drug therapy to the individual medical needs of each patient Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment

9 INFORMED CONSENT & AGREEMENT FOR TREATMENT
Discuss the risks & benefits of the use of controlled substances One prescriber & One pharmacy If at high risk for medication abuse or has a history of substance abuse consider the use of a written agreement The prescriber should discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient or with the patient's surrogate or guardian if the patient is without medical decision-making capacity The patient should receive prescriptions from one prescriber and one pharmacy whenever possible If the patient is at high risk for medication abuse or has a history of substance abuse, the prescriber should consider the use of a written agreement between prescriber and patient outlining patient responsibilities, including urine/serum medication levels screening when requested; number and frequency of all prescription refills; and reasons for which drug therapy may be discontinued (e.g., violation of agreement).

10 Pain Management Contract
between prescriber and patient outlining patient responsibilities: urine/serum medication levels screening when requested number and frequency of all prescription refills reasons for which drug therapy may be discontinued e.g., violation of agreement

11 STATE PRESCRIPTION DRUG MONITORING PROGRAMS
support access to legitimate medical use of controlled substances drug abuse & diversion intervention with & treatment of persons addicted to prescription drugs inform public health initiatives educate individuals about PDMPs The Alliance of States with Prescription Monitoring Programs support access to legitimate medical use of controlled substances identify and deter or prevent drug abuse and diversion facilitate and encourage the identification, intervention with and treatment of persons addicted to prescription drugs inform public health initiatives through outlining of use and abuse trends educate individuals about PDMPs and the use, abuse and diversion of and addiction to prescription drugs

12 PERIDODIC REVIEW The course of pain treatment & any new information about the etiology of the pain Evaluate progress toward treatment objectives Satisfactory response to treatment Objective evidence of improved or diminished function If the patient's progress is unsatisfactory, the prescriber should assess the appropriateness of continued use The prescriber should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health Continuation or modification of controlled substances for pain management therapy depends on the prescriber's evaluation of progress toward treatment objectives Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, or improved quality of life Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient's response to treatment. If the patient's progress is unsatisfactory, the prescriber should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities

13 CONSULTATION Refer the patient as necessary
Special attention if potential misuse, abuse or diversion History of substance abuse or with a co-morbid psychiatric disorder The prescriber should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives Special attention should be given to those patients with pain who are at risk for medication misuse, abuse or diversion The management of pain in patients with a history of substance abuse or with a co-morbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients

14 MEDICAL RECORDS The prescriber should keep accurate and complete records to include: 1. medical history & physical examination 2.diagnostic, therapeutic and laboratory results 3. evaluations & consultations 4. treatment objectives 5. discussion of risks & benefits 6. informed consent 7. treatments 8. medications including date, type, dosage & quantity prescribed 9. instructions and agreements 10. periodic reviews Records should remain current and be maintained in an accessible manner and readily available for review Records of patients should be thorough and includes all of the following items listed It is not acceptable to prescribe based on ‘I usually get this med and get this many pills every month’ The reason must be justified by the History & Physical, all pertinent test results etc Periodic review is also necessary

15 Compliance With Controlled Substances Laws and Regulations
Prescriber must be licensed in the state & comply with applicable federal and state regulations Manual of the U.S. Drug Enforcement Administration and (any relevant documents issued by the state medical board) for specific rules governing controlled substances as well as applicable state regulations To prescribe, dispense or administer controlled substances, the prescriber must be licensed in the state and comply with applicable federal and state regulations Prescribers are referred to the Manual of the U.S. Drug Enforcement Administration and (any relevant documents issued by the state medical board) for specific rules governing controlled substances as well as applicable state regulations

16 COMMON TERMS IN USE OF CONTROLLED SUBSTANCES
DEFINITIONS COMMON TERMS IN USE OF CONTROLLED SUBSTANCES We need to review some common terms relevant to use of controlled substances. Although many controlled substances are used for pain management, controlled substances are also used to manage anxiety, hyperactivity, insomnia, and a variety of other conditions

17 PAIN an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

18 ACUTE PAIN is the normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus & typically is associated with invasive procedures, trauma and disease generally time-limited is the normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus & typically is associated with invasive procedures, trauma and disease And it is generally time-limited

19 CHRONIC PAIN persists beyond the usual course of an acute disease
or persists after healing of an injury or may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years

20 CHRONIC PAIN SYNDROME (CPS)
presents a major challenge to healthcare providers because of its complexity ongoing pain lasting longer than 6 months as diagnostic, minimum of 3 months as the minimum criterion constellation of syndromes that usually do not respond to the medical model of care Chronic pain syndrome (CPS) is a common problem that presents a major challenge to healthcare providers because of its complex natural history, unclear etiology, and poor response to therapy. CPS is a poorly defined condition. Most authors consider ongoing pain lasting longer than 6 months as diagnostic, and others have used 3 months as the minimum criterion. In chronic pain, the duration parameter is used arbitrarily. Some authors suggest that any pain that persists longer than the reasonable expected healing time for the involved tissues should be considered chronic pain. CPS is a constellation of syndromes that usually do not respond to the medical model of care. This condition is managed best with a multidisciplinary approach, requiring good integration and knowledge of multiple organ systems. (The images below demonstrate conditions associated with CPS.)

21 CPS-Pathophysiology Multifactorial & Complex
Some suggest-learned behavioral syndrome External re-inforcers Individuals prone: major depression, somatization disorder, hypochondriasis, & conversion disorder The pathophysiology of chronic pain syndrome (CPS) is multifactorial and complex and still is poorly understood. Some authors have suggested that CPS might be a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior then is rewarded externally or internally. Thus, this pain behavior is reinforced, and then it occurs without any noxious stimulus. Internal reinforcers are relief from personal factors associated with many emotions (eg, guilt, fear of work, sex, responsibilities). External reinforcers include such factors as attention from family members and friends, socialization with the physician, medications, compensation, and time off from work. Patients with several psychological syndromes (eg, major depression, somatization disorder, hypochondriasis, conversion disorder) are prone to developing CPS.

22 TOLERANCE is a physiologic state resulting from regular use of a drug in which an increased dosage is needed may or may not be evident during treatment does not equate with addiction is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time tolerance may or may not be evident during treatment and does not equate with addiction

23 SUBSTANCE ABUSE is the use of any substance(s) for non- therapeutic purposes or use of medication for purposes other than those for which it is prescribed

24 PHYSICAL DEPENDENCE is a state of adaptation that is manifested by drug class-specific signs & symptoms that can be produced by: abrupt cessation rapid dose reduction decreasing blood level of the drug, and/or administration of an antagonist it is, by itself, does not equate with addiction is a state of adaptation that is manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist it is, by itself, does not equate with addiction

25 PSUEDOADDICTION the iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction resolve upon institution of effective analgesic therapy the iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction the relief seeking behaviors resolve upon institution of effective analgesic therapy

26 ADDICTION is a primary, chronic, neurobiologic disease, with genetic, psychosocial, & environmental factors influencing its development and manifestations it is characterized by behaviors: impaired control over drug use, craving, compulsive use, & continued use despite harm physical dependence & tolerance are normal physiological consequences of extended therapy and are not the same as 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 the following: impaired control over drug use, craving, compulsive use, and continued use despite harm physical dependence and tolerance are normal physiological consequences of extended therapy and are not the same as addiction

27 A Treatment Improvement Protocol Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

28 is every patient’s right
Pain Control… is every patient’s right

29 BASIC PRINCIPLES Pain diagnosis based on inferred pathophysiology
identification of contributing factors identification of barriers Pain diagnosis is based on ‘What is the cause of the pain’ What are the contributing factors and what are the barriers to pain releif

30 Principles of Pain Management
Anticipate, prevent, and treat pain Anticipate, prevent, and treat adverse effects of pain management The principles of pain management include anticipating the onset of pain, preventing factors which cause or worsen pain and treat pain appropriately (Next bullet) as well as monitoring for as well as decreasing adverse effects of medications used to manage pain

31 Pain Assessment Pain history Location Intensity Quality Pattern
Aggravating or alleviating factors Medication history Determine the type of pain you are wishing to manage-the onset of the pain, where it is, the intensity and if it is constant or if it comes and goes-what is the pattern of the pain as well as what worsens the pain or lessens it, also identify past medication-both prescription and over-the-counter medications

32 Physical Examination Observe for non-verbal cues Examine sites of pain
withdrawal, fatigue, grimaces, irritability Examine sites of pain skin breakdown, changes in bony structure Palpate areas of tenderness Assess the patient Auscultate lungs, abdomen Percuss for fluid accumulation or gas Conduct neurological exam Look at both the complaints the person is verbalizing but also look at non-verbal clues such as withdrawal or guarding, grimacing or groaning, fatigue or irritability Examine the site of pain-look for skin integrity, if skin blanches, changes in boney structure or if a mass is present Palpate the site as well as examine the whole patient

33 These are some special tests to help identify the true cause of the pain or at least help narrow down the possible causes for example a positive homans sign in the calf may indicate a deep vein thrombosis of the leg

34 4 types of pain Nociceptive Neuropathic Muscular Psychogenic
Mechanical Inflammatory Tissue destructive Neuropathic Muscular Psychogenic Different pains have differing causes and are managed differently

35 NOCICEPTIVE PAIN Nociception implies active mechanical, thermal or chemical process Nociception implies active mechanical, thermal or chemical process which stimulates the primary sensory nerves for pain

36 Neuropathic pain Aberrant signaling in the pain transmission or pain modulation pathways Diabetic patient with neuropathy can experience pain due to spontaneous firing of damaged nerves Quality is typically burning & often there is a paroxysmal quality such as shooting, jabbing or shock-like pain comes from aberrant signaling in the pain transmission or pain modulation pathways the diabetic with neuropathy can experience pain due to spontaneous firing of damaged nerves the location is usually in a peripheral nerve distribution or a stocking/glove distribution or it may follow a dermatome or spinal level The quality is typically burning and often there is a paroxysmal quality such as shooting, jabbing or shock-like pain

37 MUSCULAR PAIN is pulling, tight or aching
certain movements or positions may accelerate or trigger muscular pain the location or pattern coincides with the affected muscles is pulling, tight or aching certain movements or positions may accelerate or trigger muscular pain the location is frequently drawn by the patient on a pain diagram in a pattern that coincides very closely with the affected muscles

38 Psychogenic pain is pain that originates through cognitive & emotional processing examples are conversion disorder, factitious disorder, & somatization disorder is pain that originates through cognitive and emotional processing examples are conversion disorder, factitious disorder, & somatization disorder

39 PAIN SCALES In acute pain: assessment of pain intensity using formal rating scales 0 – 10 visual analog scale where intensity is marked on a 10 cm line from NO PAIN to WORST POSSIBLE PAIN In chronic pain management, intensity is evaluated based on assessing impairment, function, impact of pain & relative improvement in pain In acute pain a strong emphasis is placed on continual assessment of pain intensity using formal rating scales like , or a visual analog scale where intensity is marked on a 10 cm line from NO PAIN to WORST POSSIBLE PAIN. Such scales and formalized intensity ratings are important in a hospital setting where care is delivered by many, and where doses and drugs are continually changing In chronic pain management, intensity scores play a lesser role to the role of assessing impairment, function, impact of pain and relative improvement in pain

40 Pain management must include cognitive as well as behavioral therpay, spiritual therapy, and consider complimentary medicine in combination with medications

41 Types of pain management agents
Analgesic agents Nonsteroidal anti- inflammatory agents Non-opioids Opioids Antidepressants Anticonvulsants Anxiolytic agents There are a variety of medications used to manage pain

42 Routes of Administration
Oral-offers pain relief equivalent to other routes but due to first pass metabolism-dosing must be increased when compared to IM, IV, or SQ routes i.e.10 morphine IV, IM, or SQ is equivalent to 30 mg orally Immediate release-MS IR Liquid Long acting (sustained release)-MS Contin, Oxycontin, Oramorph, Kadian sprinkles Longer acting allows dosing of 8, 12, 24 hour intervals There are several route for medication administration-consider the first pass metabolism of a medication-the intestinal and hepatic degradation or alteration of a drug or substance taken by mouth, after absorption, removing some of the active substance from the blood before it enters the general circulation.

43 Routes of Administration
Rectal (also stomal/vaginal) Thrombocytopenia or painful lesions preclude this routes Long acting opioid tablets can be placed rectally when patients are no longer able to swallow Pharmacokinetic studies demonstrate approximately 90% of concentrations in plasma levels achieved when compared to oral delivery Transdermal Only formulary is fentanyl-patch applied every 72 hours (25, 50, 100 mcg/hr) Delayed peak of onset of 17 hours after applying 1st patch Effects of cachexia and fever are believed to accelerate drug distribution

44 TRICYCLIC ANTIDEPRESSANTS
are effective adjuvant analgesics in a wide range of painful conditions unless contraindicated, consider in most chronic pain patients, especially in cases of neuropathic pain with continuous dysesthesias side effects of these drugs help us choose them for individual patients based on which side effects are minimized or advantageous are effective adjuvant analgesics in a wide range of painful conditions their analgesic effect is distinct from their effect on mood. unless contraindicated, they should be considered in most chronic pain patients, especially in cases of neuropathic pain with continuous dysesthesias side effects of these drugs help us choose them for individual patients based on which side effects are minimized or advantageous Trazodone may have adjuvant analgesic properties though there is less data supporting this It has the advantage of fewer side effects and a better safety profile. Fluoxetine and the other selective serotonin reuptake inhibitors have not been shown to possess analgesic effects independent of their effect on depression.

45 ANTICONVULSANTS used in the management of
Neuropathic pain Trigeminal neuralgia Carbamazepine is usually the first choice anti- convulsant for pain Phenytoin, clonazepam and valproic acid are also used in the same settings Newer anti-convulsant gabapentin (NeurontinB) for managing neuropathic pain are also widely used in the management of neuropathic pain Tend to be used when pain is characterized as lancinating or paroxysmal Compared with tricyclic antidepressants, there is much less data supporting the effectiveness of anti-convulsants as analgesics Trigeminal neuralgia is the exception, where these drugs are well established choices Anti-convulsants are administered for pain in the same manner as for seizures: beginning with low doses and titrating up as tolerated toward a therapeutic effort or blood level Carbamazepine is usually the first choice anti-convulsant for pain Phenytoin, clonazepam and valproic acid are also used in the same settings Many pain specialists and neurologists now favor the newer anti-convulsant gabapentin (NeurontinB) for managing neuropathic pain. Its use in pain is based on anecdotal reports and experience rather than on clinical trials. Gabapentin generally has less toxicity and fewer drug interactions than other anti-convulsants Typical doses range from 300 mg per day to 2700 mg per day in three divided doses

46 PAIN MEDICATIONS NON-OPIOIDS WEAK OPlOlDS OPIOID AGONIST/ANTAGONISTS
Non-steroidal anti-inflammatory drugs Acetaminophen WEAK OPlOlDS Codeine, Propoxyphene, Hydrocodone, Tramadol OPIOID AGONIST/ANTAGONISTS Butorphanol, Nalbuphine, Pentazocine STRONG OPlOlDS Morphine, Hydromorphone, Oxycodone, Levorphanol, Methadone, Meperidine, Fentanyl NON-OPIOIDS Non-steroidal anti-inflammatory drugs Acetaminophen WEAK OPlOlDS Codeine, Propoxyphene, Hydrocodone, Tramadol OPIOID AGONIST/ANTAGONISTS Butorphanol, Nalbuphine, Pentazocine STRONG OPlOlDS Morphine, Hydromorphone, Oxycodone, Levorphanol, Methadone, Meperidine, Fentanyl

47 Pharmacological Therapies for Pain Management
Nonopioids Acetaminophen (Tylenol) Action-analgesia, antipyretic DOSAGE: Acetaminophen (Tylenol) 325–500mg every 4 h or 500–1,000mg Maximum dose usually 4 g daily Reduce maximum dose 50% to 75% in patients with hepatic insufficiency or history of alcohol abuse Nonopioids Acetaminophen (Tylenol) Action-analgesia, antipyretic Adverse effects-can cause liver dysfunction in routine doses higher than 4000 mg/day in patients with normal liver functioning DOSAGE: Acetaminophen (Tylenol) 325–500mg every 4 h or 500–1,000mg Maximum dose usually 4 g daily Reduce maximum dose 50% to 75% in patients with hepatic insufficiency or history of alcohol abuse

48 Pharmacological Therapies for Pain Management
Nonsteroidal anti-inflammatory drugs (NSAIDS) Aspirin, Ibuprofen (Motrin), Naproxen (Naprosyn) Action-Analgesia, antiinflammatory, antipyretic, and inhibits prostoglandins by blocking cyclooxygebase. Prostoglandins are rich in the periosteum of bones and in the uterus-thus NSAIDS are very useful in relieving bone pain and dysmenorrhea Do have a ceiling effect-increasing doses above a certain point will not increase analgesia Nonsteroidal anti-inflammatory drugs (NSAIDS) Aspirin, Ibuprofen (Motrin), Naproxen (Naprosyn) Action-Analgesia, antiinflammatory, antipyretic, and inhibits prostoglandins by blocking cyclooxygebase. Prostoglandins are rich in the periosteum of bones and in the uterus-thus NSAIDS are very useful in relieving bone pain and dysmenorrhea Do have a ceiling effect-increasing doses above a certain point will not increase analgesia Adverse effects-can produce gastric toxicity and gastrointestinal bleeding especially in the elderly population, persons at risk for ulcers, and in combination with other drugs (such as corticosteroids); increases risk of bleeding due to platelet aggregation; can cause renal dysfunction especially if a person is dehydrated

49 Tramadol (UltramB) is an analgesic drug that works through two different mechanisms: a weak mu opioid receptor agonist has properties of serotonin and norepinephrine reuptake inhibition Requires a DEA number for prescriptions Analgesic potency is similar to that of other weak opioids. Doses are mg every 4-6 hours up to 400 mg per day. most common side effects are gastrointestinal symptoms, dizziness, dry mouth, drowsiness, constipation, & seizures is an analgesic drug that works through two different mechanisms: It is a weak mu opioid receptor agonist with about one tenth the affinity of codeine for the mu receptor It also has properties of serotonin and norepinephrine reuptake inhibition like amitriptyline. It remains an unscheduled drug even though there are limited reports of abuse Requires a DEA number for prescriptions Analgesic potency is similar to that of other weak opioids. Doses are mg every 4-6 hours up to 400 mg per day. The most common side effects are gastrointestinal symptoms, dizziness, dry mouth, drowsiness and constipation Seizures have been reported, so Ultrama is generally avoided when other factors are present that lower seizure threshold

50 Pharmacological Therapies for Pain Management
Opiods-Agonists Codiene Morphine (MS Contin, Oramorph, Kadian, Roxanol) Hydrocodone (Vicodin, Lortab) Methadone (Dolophine) Oxycodone (OxyContin, Roxicodone, Roxifast) Large class of opioid agents

51 CODIENE CIII Used to relieve mild to moderate pain
ADULT DOSE:15 mg orally every 6 hours as necessary. May titrate up to 20 mg every 4 hours. Maximum 120 mg/day. GERIATRIC DOSE: 10 mg orally every 6 hours as necessary. Lower doses necessary if renal impairment of liver impairment Acetaminophen with codiene Tylenol #3 (30/300) Tylenol #4 (60/300) Codeine is a schedule 3 medications Used to relieve mild to moderate pain-it works by changing the way the body senses pain. Can be used in combination with other medications, to reduce coughing (antitussives)- it works by decreasing the activity in the part of the brain that causes coughing Combination products that contain codeine and promethazine should not be used in children younger than 16 years of age. ADULT DOSE:15 mg orally every 6 hours as necessary. May titrate up to 20 mg every 4 hours. Maximum 120 mg/day. GERIATRIC DOSE: 10 mg orally every 6 hours as necessary. PEDIATRIC DOSE: 2-6 years: 2.5 to 5 mg orally every 4 to 6 hours. Maximum 30 mg/day. 6-12 years: 5 to 10 mg orally every 4 to 6 hours. Maximum 60 mg/day. Lower doses necessary if renal impairment of liver impairment Acetaminophen with codiene Tylenol #3 (30/300) Tylenol #4 (60/300)

52 MORPHINE CII Used to treat moderate to severe pain
Short-acting formulations are taken as needed for acute pain Extended-release formulations are used when chronic pain relief is needed Used to treat moderate to severe pain-works by dulling the pain perception center in the brain. Short-acting formulations are taken as needed for pain. Extended-release formulations are used when around-the-clock pain relief is needed.

53 MORPHINE CII Immediate release 2.5–10mg every 4 h
Available in tablet form & concentrated oral solution (MSIR, Roxanol) most commonly used for episodic or breakthrough pain and for patients unable to swallow tablets. Sustained release mg every 8–24 h (Avinza, Kadian, MSContin, Oramorph SR) see dosing guidelines in the package insert for each specific formulation Immediate release 2.5–10mg every 4 h Available in tablet form and as concentrated oral solution, which is (MSIR, Roxanol) most commonly used for episodic or breakthrough pain and for patients unable to swallow tablets. Sustained release mg every 8–24 h (Avinza, Kadian, MSContin, Oramorph SR) see dosing guidelines in the package insert for each specific formulation Usually started after initial dose determined by effects of immediate-release opioid or as an alternative to a different long-acting opioid due to indications for opioid rotation. Toxic metabolites of morphine may limit usefulness in patients with renal insufficiency or when high-dose therapy is required. Continuous-release formulations may require more-frequent dosing if end-of-dose failure occurs regularly. Significant interactions with food and alcohol toxicity.

54 MORPHINE DOSING: ADULT
Oral, Sublingual, or Buccal: 5 to 30 mg every 3 to 4 hours PRN Extended release: range from 10 mg to 600 mg daily, given in equally divided doses every 8 to 12 hours or given as one dose every 24 hours IM or subcutaneous: 2.5 to 20 mg every 3 to 4 hours PRN IV: 4 to 15 mg every 3 to 4 hours PRN. Give very slowly over 4 to 5 minutes. Starting doses up to 15 mg every 4 hours have been used. Chest pain: 2 to 4 mg repeat PRN Continuous IV: 0.8 to 10 mg/hour. Maintenance dose: 0.8 to 80 mg/hour. Rates up to 440 mg/hour have been used. IV patient controlled analgesia or subcutaneous patient controlled analgesia: 1 to 2 mg injected 30 minutes after a standard IV dose of 5 to 20 mg. The lockout period is 6 to 15 minutes. The 4 hour limit is 30 mg. Continuous subcutaneous: 1 mg/hour after a standard dose of 5 to 20 mg Epidural: 5 mg one time. May give 1 to 2 mg more after one hour to a maximum of 10 mg. Intrathecal: 0.2 to 1 mg one time Intrathecal Continuous: 0.2 mg/24 hours. May be increased up to 20 mg/24 hours. Intracerebroventricular: 0.25 mg via an Ommaya reservoir. Rectal: 10 to 30 mg every 4 hours as needed. Oral, Sublingual, or Buccal: 5 to 30 mg every 3 to 4 hours as needed Extended release: range from 10 mg to 600 mg daily, given in equally divided doses every 8 to 12 hours or given as one dose every 24 hours IM or subcutaneous: 2.5 to 20 mg every 3 to 4 hours as needed IV: 4 to 15 mg every 3 to 4 hours as needed. Give very slowly over 4 to 5 minutes. Starting doses up to 15 mg every 4 hours have been used. Chest pain: 2 to 4 mg repeat as necessary Continuous IV: 0.8 to 10 mg/hour. Maintenance dose: 0.8 to 80 mg/hour. Rates up to 440 mg/hour have been used. IV patient controlled analgesia or subcutaneous patient controlled analgesia: 1 to 2 mg injected 30 minutes after a standard IV dose of 5 to 20 mg. The lockout period is 6 to 15 minutes. The 4 hour limit is 30 mg. Continuous subcutaneous: 1 mg/hour after a standard dose of 5 to 20 mg Epidural: 5 mg one time. May give 1 to 2 mg more after one hour to a maximum of 10 mg. Intrathecal: 0.2 to 1 mg one time Intrathecal Continuous: 0.2 mg/24 hours. May be increased up to 20 mg/24 hours. Intracerebroventricular: 0.25 mg via an Ommaya reservoir. Rectal: 10 to 30 mg every 4 hours as needed.

55 MORPHINE DOSING: Premedication for anesthesia IV: 3 to 4 mg once, may repeat in 5 minutes if necessary. Oral: 0.2 to 0.5 mg/kg/dose every 4 to 6 hours (tablets/solution) or 0.3 to 0.6 mg/kg/dose every 12 hours (extended release) IM,subcutaneous, IV: 0.05 to 0.2 mg/kg/dose (up to 15 mg) every 4 hours as needed IV/subcutaneous Continuous: to mg/kg/hour (sickle cell or cancer pain) or 0.01 to 0.04 mg/kg/hour (postop pain) Epidural (use preservative-free formulation): mg/kg/dose every 6 to 8 hours (postop pain). Maximum per 24 hours: 5 mg. IV patient controlled analgesia: mg/kg/dose (postop pain); lockout period of 10 minutes; 4 hour limit of 0.25 mg/kg. In infants-use preservative free morphine. The dosages for All children will be based in body weight and route necessary dependent on the cause of the pain

56 HYDROMORPHINE CII an opioid (narcotic) analgesic-works by binding to certain receptors in the brain and nervous system to reduce pain DOSAGE: 2 mg to 4 mg, orally, every 4 to 6 hours an opioid (narcotic) analgesic-works by binding to certain receptors in the brain and nervous system to reduce pain DOSAGE: 2 mg to 4 mg, orally, every 4 to 6 hours. Appropriate use of Hydromorphone Hydrochloride Tablets must be decided by careful evaluation of each clinical situation. A gradual increase in dose may be required if analgesia is inadequate, as tolerance develops, or if pain severity increases. The first sign of tolerance is usually a reduced duration of effect.

57 FENTANYL CII A potent synthetic narcotic analgesic with a rapid onset & short duration of action It has been used to treat breakthrough pain 100 times more potent than morphine, with 100 micrograms of fentanyl approximately equivalent to 10 mg of morphine and 75 mg of pethidine (meperidine) in analgesic activity Available 12.5; 25; 50; 100 mcg/hr patches applied every 72 hours A potent synthetic narcotic analgesic with a rapid onset and short duration of action It is a strong agonist at the μ-opioid receptors It has been used to treat breakthrough pain Is commonly used in pre-procedures as a pain reliever as well as an anesthetic in combination with a benzodiazepine Is approximately 100 times more potent than morphine, with 100 micrograms of fentanyl approximately equivalent to 10 mg of morphine and 75 mg of pethidine (meperidine) in analgesic activity Available 12.5; 25; 50; 100 mcg/hr patches applied every 72 hours

58 FENTANYL PAIN PATCH CONVERSION
This is a dose conversion chart to assist in transitioning to another agent of necessary

59 HYDROCODONE CIII opiate (narcotic) analgesics - changes the way the brain and nervous system respond to pain Hydrocodone must be used with caution in children. Extended-release products containing hydrocodone should not be given to children younger than 6 years of age and should be used with caution in children 6-12 years of age. Hydrocodone is available only in combination with other ingredients, and different combination products are prescribed for different uses. Hydrocodone is in a class of medications called opiate (narcotic) analgesics by changing the way the brain and nervous system respond to pain. Antitussive properties by relieving the cough by decreasing activity in the part of the brain that causes coughing. Hydrocodone must be used with caution in children. Extended-release products containing hydrocodone should not be given to children younger than 6 years of age and should be used with caution in children 6-12 years of age.

60 HYDROCODONE DOSE Schedule II — Includes pure hydrocodone & formulations containing more than 15 mg hydrocodone per dosage unit. Written prescription required for refills. Schedule III — Includes hydrocodone products containing less than 15 mg per dosage unit. May be refilled using phoned prescription. Formulations: (Lortab 2.5/500; 5/500, 7.5/500, 10/500; elixer) (Norco 5/325; 7.5/325; 10/325) (Vicodin regular strength; ES; HP) (Xocol 5/300; 7.5/300; 10/300) (Zydone 5/400; 7.5/400; 10/400) Schedule II — Includes pure hydrocodone & formulations containing more than 15 mg hydrocodone per dosage unit. Written prescription required for refills. Schedule III — Includes hydrocodone products containing less than 15 mg per dosage unit. May be refilled using phoned prescription. Formulations: Lortab 2.5/500; 5/500, 7.5/500, 10/500; elixer Norco 5/325; 7.5/325; 10/325 Vicodin regular strength; ES; HP Xocol 5/300; 7.5/300; 10/300 Zydone 5/400; 7.5/400; 10/400 For short-term (generally less than 10 days) management of acute pain: 1 tablet every 4 to 6 hours as needed Maximum dosage: 5 tablets in 24 hours Renal Dose Adjustments Treatment with hydrocodone-ibuprofen is not recommended in patients with advanced renal disease. If hydrocodone-ibuprofen therapy must be initiated, close monitoring of the patient's renal function is advisable. Liver Dose Adjustments Any patient with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver test has occurred, should be evaluated for evidence of the development of more severe hepatic reactions while on hydrocodone-ibuprofen therapy.

61 OXYCODONE CII Oxycodone is used to relieve moderate to severe pain-works by changing the way the brain and nervous system respond to pain. Oxycodone is also available: in combination with acetaminophen (Endocet 10/325) (Percocet 2.5/325; 5/325; 7.5/325; 7.5/500; 10/325; 10/500) (Roxicet 5/325) (Tylox 5/500) in combination with aspirin (Endodan, Percodan, Roxiprin, others) in combination with ibuprofen (Combunox) Oxycodone is used to relieve moderate to severe pain-works by changing the way the brain and nervous system respond to pain. Oxycodone is also available: in combination with acetaminophen Endocet 10/325 Percocet 2.5/325; 5/325; 7.5/325; 7.5/500; 10/325; 10/500 Roxicet 5/325 Tylox 5/500 in combination with aspirin (Endodan, Percodan, Roxiprin, others) in combination with ibuprofen (Combunox)

62 OPIOID ANALGESIC EQUIVALENTS WITH APPROXIMATELY EQUIANALGESIC POTENCY
* OPIOID ANALGESIC EQUIVALENTS WITH APPROXIMATELY EQUIANALGESIC POTENCY Nonproprietary (Trade) Name IM or SC Dose ORAL Dose *   Dosages, and ranges of dosages represented, are a compilation of estimated equipotent dosages from published references comparing opioid analgesics in cancer and severe pain. Morphine sulfate 10 mg 40-60 mg Hydromorphone HCl (DILAUDID) 1.3-2 mg mg Oxymorphone HCl (Numorphan) 1-1.1 mg 6.6 mg Levorphanol tartrate (Levo-Dromoran) 2-2.3 mg 4 mg Meperidine, pethidine HCl (Demerol) mg mg Methadone HCl (Dolophine) 10-20 mg This charts shows opioid equivalaents

63 Opioids-Agonists Actions-block the release of neurotransmitters that are involved in the processing of pain Adverse effects- allergic reactions are rare-only absolute contraindication Respiratory depression may occur It is reversible with Narcan Constipation Sedation Urinary retention- Nausea and Vomiting-treat with antiemetics or changing to a different opioid Pruritis-antihistamines can be helpful Actions-block the release of neurotransmitters that are involved in the processing of pain Adverse effects- allergic reactions are rare-only absolute contraindication is a history of hypersensitivity (wheezing, edema)-Nausea is not a symptom of allergic reaction. Test with short acting synthetic opiod (intravenous fentanyl or intradermal injection) Respiratory depression, rare but usually preceded by sedation. Respirations of 6 to 8/minute are considered normal if oxygenation appears normal. May be reversed with Narcan. Constipation Sedation Urinary retention- Nausea and Vomiting-treat with antiemetics or changing to a different opioid Pruritis-antihistamines can be helpful

64 Pharmacological Therapies for Pain Management: MEPERIDINE CII
Meperidine-used to relieve moderate to severe pain changes the way the body senses pain. Oral bioavailability is poor-50mg orally is equivalent to 650mg aspirin. Injectable Meperidine is painful Meperidine (Demerol)-used to relieve moderate to severe pain. It works by changing the way the body senses pain. not indicated for chronic pain management or at the end of life since it is metabolized into normeperidine in the liver and excreted by the kidneys. In patients with renal dysfunction-meperidine is not excreted and builds up in the blood stream, can be toxic, and can lead to seizures. Oral bioavailability is poor-50mg orally is equivalent to 650mg aspirin. Injectable Meperidine is painful

65 Opioid Agonist Treatment
refers to the treatment of a narcotics addiction in humans via the administration of similar opioid drugs, agonists, and the resultant cross tolerance and physical dependence. Methadone (CII) is a full opioid agonist Buprenorphine (CIII) is a partial opioid agonist and has substantially less severe withdrawal effects versus methadone refers to the treatment of a narcotics addiction in humans via the administration of similar opioid drugs, agonists, and the resultant cross tolerance and physical dependence. Methadone (CII) is a full opioid agonist and so is the preferred treatment in heroin addiction as it creates a feeling of euphoria, though not as strong as from taking heroin; however, after repeated doses, tolerance develops to the euphoric effects of methadone and eventually becomes minimal or nonexistent. Buprenorphine (CIII) is a partial opioid agonist and has substantially less severe withdrawal effects versus methadone and other strong opioids making it very desirable as a treatment. However, the high from Buprenorphine is also reduced leading to addicted individuals preferring methadone treatment.

66 Pharmacological Therapies for Pain Management
Mixed agonist-antagonist Butorphanol (Stadol) CII Nalbuphine (Nubain) Rx Pentazocine (Talwin) CIV synthetically derived opioid agonist-antagonist analgesic of the phenanthrene series Mixed agonist-antagonist Butorphanol (Stadol) CII Nalbuphine (Nubain) Rx Pentazocine (Talwin) CIV synthetically derived opioid agonist-antagonist analgesic of the phenanthrene series INDICATIONS: Moderate to severe pain. Also provides: Analgesia during labor, Sedation before surgery, Supplement to balanced anesthesia. Not recommended for treatment of chronic pain Ceiling effect-increasing dose will not increase pain relief High rate of psychotomimetic effects (hallucination & disorientation) Withdrawal-agitation, abdominal cramping, diarrhea, runny nose, tearing, yawning, ‘goose bumps’, and can lead to seizures

67 Pharmacological Therapies for Pain Management Adjuvant Analgesics
Tricyclic antidepressants Amitriptyline (Elavil) Nortriptyline (Pamelor) Desiprmine (Norpramin, Pertofrane) Action-Inhibition of norepinephrine and serotonin. Amitriptyline (Elavil) Nortriptyline (Pamelor) Desiprmine (Norpramin, Pertofrane) Action-Inhibition of norepinephrine and serotonin. Adverse effects-anticholinergic effects such as dry mouth and constipation. Cardiac arrythmias, conduction abnormalities, narrow-angle glaucoma, and prostatic hyperplasia are contraindications for use. Discouraged for use with elderly patients due to the cardiac adverse effects

68 Pharmacological Therapies for Pain Management Adjuvant Analgesics
Anticonvulsants Carbamazepine (Tegretol) Action-blocks pain through sensory neurons. Works well with ‘shooting’ pains. Adverse effects-liver dysfunction and aplastic anemia Gabapentin (Neurontin) Action-unclear but believed to act on the gamma amino butyric acid system. Non-end of life pain conditions report using mg/day in divided doses Anecdotal reports suggest that pain may be relieved at lower doses

69 Pharmacological Therapies for Pain Management Adjuvant Analgesics
Local Anesthetics Lidocaine- stabilizes the neuronal membrane by inhibiting the ionic fluxes used intravenously, spinally, or topically Bupivacaine (Marcaine) EMLA cream or Lidoderm Local Anesthetics Lidocaine- stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. used intravenously, spinally, or topically Bupivacaine (Marcaine) EMLA cream or Lidoderm Action-inhibits the movement of sodium ions across the membrane of the sensory nerve and prevents transmission of pain along the neuron

70 Pharmacological Therapies for Pain Management Adjuvant Analgesics
Corticosteroids Dexamethasone (Decadron) Prednisolone (Prednisone) Action-inhibits prostaglandin synthesis and reduces edema surrounding tissues. Useful in treating neuropathic pain, bone pain, and visceral pain Standard doses vary-16-24mg/day or higher Corticosteroids Dexamethasone (Decadron) Action-inhibits prostaglandin synthesis and reduces edema surrounding tissues. Useful in treating neuropathic pain, bone pain, and visceral pain Standard doses vary-16-24mg/day or higher

71 ANXIOLYTICS used for the treatment of anxiety, & its related psychological and physical symptoms minor tranquilizers Indicated for management of Anxiety and are also referred to as mild tranquilizers

72 Anxiolytics/Benzodiazepines Rx:CIII *Generally used on as needed basis*
Alprazolam (Xanax) mg every 6 to hours Clonazepam (Klonipin) mg every hours **Long half-life** Clorazepapte (Tranxene) mg every hours Lorazepam (Ativan) mg every 6 to hours **SE of class: ataxia, memory impairment, hypotension, falls, tremors, hallucinations Non narcotic alternative: Buspirone (Buspar) 5-15 mg tid

73

74 hyperactivity Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder generally characterized by the following symptoms: Inattention Distractibility Impulsivity Hyperactivity Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder generally characterized by the following symptoms: Inattention Distractibility Impulsivity Hyperactivity

75 HYPERSOMNIA excessive daytime sleepiness or prolonged night- time sleep recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep different from feeling tired due to lack of or interrupted sleep at night, persons with hypersomnia are compelled to nap repeatedly during the day, often at inappropriate times such as at work, during a meal, or in conversation

76 STIMULANTS Psychoactive drugs which induce temporary improvements in either mental or physical function or both Also known as Stimulants Psychoactive drugs which induce temporary improvements in either mental or physical function or both Examples of these kinds of effects may include enhanced alertness, wakefulness, and locomotion, among others Due to their effects typically having an "up" quality to them, stimulants are also occasionally referred to as "uppers"

77 Methylphenidate CII central nervous system stimulant
used to treat attention deficit disorder (ADD) & attention deficit hyperactivity disorder (ADHD) also used in the treatment of a sleep disorder called narcolepsy an uncontrollable desire to sleep Brand Names: Concerta, Metadate, Methylin, Ritalin a central nervous system stimulant it affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control used to treat attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) should be an integral part of a total treatment program that may include counseling or other therapies also used in the treatment of a sleep disorder called narcolepsy (an uncontrollable desire to sleep) Brand Names: Concerta, Metadate, Methylin, Ritalin

78 Methylphenidate Dosage
For children > 6 y/o: Methylphenidate should be started at 5 mg twice daily (before breakfast and lunch) For adults with narcolepsy, the total dosage of Methylphenidate per day is usually 20 mg to 30 mg (divided into two or three doses) For children age six and over, Ritalin should be started at 5 mg twice daily (before breakfast and lunch) If necessary, may slowly increase the dosage up to Ritalin 60 mg per day For adults with narcolepsy, the total dosage of Ritalin per day is usually 20 mg to 30 mg (divided into two or three doses) Some people may need less Ritalin, while others may need as much as 60 mg per day

79 INSOMNIA trouble falling asleep or staying asleep through the night
episodes may come and go (episodic), last up to 3 weeks (short-term), or be long-lasting (chronic) Defined as sleeping less than 5 hours a night -trouble falling asleep or staying asleep through the night episodes may come and go (episodic), last up to 3 weeks (short-term), or be long-lasting (chronic)

80 Insomnia Management Sleep Hygiene Melatonin 0.3mg daily
Melatonin Receptor Agonists (Non- Scheduled) ramelteon 8 mg hs Nonpharmacological management is the first step Sleep Hygiene involves-going to bed when sleepy, if unable to sleep-get out of bed; do not eat a large meal before bedtime, No eating in bed, reading in bed, watching television in bed-the body gets confused what the bed is used for Decrease or eliminate caffiene, empty bladder prior to going to bed BUT when this fails, some individuals may need a medication

81 Non Benzodiazepines cyclopyrrolones eszopiclone 1, 2, 3 mg tablets
2-3 mg hs 1 mg hs in elderly or debilitated; max 2 mg 1 mg hs in severe hepatic impairment; max 2 mg imidazopyridines zolpidem zolpidem (controlled release) 5, 10 mg tablets 6.25, 12.5 mg tablets 10 mg hs; max 10 mg 5 mg hs in elderly, debilitated, or hepatic impairment 12.5 mg hs 6.25 mg hs in elderly, debilitated, or hepatic impairment pyrazolopyrimidines zaleplon 5, 10 mg capsules 10 mg hs; max 20 mg 5 mg hs in elderly, debilitated, mild to moderate hepatic impairment, or concomitant cimetidine

82 Benzodiazepines estazolam 1, 2 mg tablets 1-2 mg hs
0.5 mg hs in elderly or debilitated temazepam 7.5, 15, 30 mg capsules 15-30 mg hs 7.5 mg hs in elderly or debilitated triazolam 0.125, 0.25 mg tablets 0.25 mg hs; max 0.5 mg 0.125 mg hs in elderly or debilitated; max 0.25 mg flurazepam 15, 30 mg capsules 15 mg hs in elderly or debilitated

83 WEIGHT MANAGEMENT

84 WEIGHT LOSS All serious diet or weight loss pills
When using diet pills, make them part of comprehensive weight-loss program that includes regular exercise and a healthy low-calorie diet. All serious diet or weight loss pills are designed for overweight people suffering from obesity. They are anti-obesity drugs - not pills for fast or easy weight loss. Diet pills, supplements, drugs and other weight loss medications are not going to melt away the fat and solve a person’s weight problem by themselves. Most weight loss trials show that diet pills offer (at best) short term support. When using diet pills, make them part of comprehensive weight-loss program that includes regular exercise and a healthy low-calorie diet.

85 BODY MASS INDEX (BMI), kg/m2
Height (feet, inches) Weight (pounds) 5′0″ 5′3″ 5′6″ 5′9″ 6′0″ 6′3″ 140 27 25 23 21 19 18 150 29 24 22 20 160 31 28 26 170 33 30 180 35 32 190 37 34 200 39 36 210 41 220 43 230 45 240 47 250 49 44 40

86 Diet suppressants may be indicated…
For obese individuals who have attempted to lose weight through diet and exercise BMI of 30 and above with no obesity-related conditions BMI of 27 and above with obesity-related conditions, such as diabetes or high blood pressure. For obese individuals who have attempted to lose weight through diet and exercise People with a body mass index(BMI) of 30 and above with no obesity-related conditions. A person with a BMI of 27 and above with obesity-related conditions, such as diabetes or high blood pressure.

87 BENEFITS OF DIET PILLS Over the short term, weight loss in obese individuals Some diet pills lower blood pressure, blood cholesterol, triglycerides (fats) and decrease insulin resistance (the body's inability to use blood sugar) over the short term Long-term studies are needed to determine if diet and weight loss pills can improve health Over the short term, weight loss in obese individuals may reduce a number of health risks. Studies looking at the effects of weight-loss medication treatment on obesity-related health risks have found that some diet pills lower blood pressure, blood cholesterol, triglycerides (fats) and decrease insulin resistance (the body's inability to use blood sugar) over the short term. However, long-term studies are needed to determine if diet and weight loss pills can improve health.

88 RISKS OF DIET PILLS Abuse of, or dependence on diet pills -
Development of tolerance to diet pills Abuse of, or dependence on diet pills - Currently, all prescription drugs to treat obesity are controlled substances, meaning prescirbers need to follow certain restrictions when prescribing weight-loss medications. Although abuse and dependence are not common with non-amphetamine appetite suppressant medications, prescribers should be cautious when they prescribe these medications for patients with a history of alcohol or other drug abuse. Development of tolerance to diet pills - Most studies of weight-loss drugs show that a patient's weight tends to level off after four to six months while still on medication. While some patients and prescribers may be concerned that this shows tolerance to the diet pills, the leveling off may mean that the medication has reached its limit of effectiveness. Based on the currently available studies, it is not clear if weight gain with continuing treatment is due to drug tolerance.

89 Health risks of diet agents
Potential Complications: Hypertension Primary Pulmonary Hypertension (PPH) – a rare, frequently fatal disease of the lungs Valvular Heart Disease Addiction Contraindications: Advanced arteriosclerosis, cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to the sympathomimetic amines, glaucoma. Agitated states. Patients with a history of drug abuse. During or within 14 days following the administration of monoamine oxidase inhibitors (hypertensive crises may result). Potential Complications: Hypertension Primary Pulmonary Hypertension (PPH) – a rare, frequently fatal disease of the lungs Valvular Heart Disease Addiction Contraindications: Advanced arteriosclerosis, cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to the sympathomimetic amines, glaucoma. Agitated states. Patients with a history of drug abuse. During or within 14 days following the administration of monoamine oxidase inhibitors (hypertensive crises may result).

90 WEIGHT MANAGEMENT AGENTS
Two approved appetite suppressant diet pills that affect serotonin release and reuptake have been withdrawn from the market (fenfluramine, dexfenfluramine). Medications that affect catecholamine levels (such as phentermine, diethylpropion, and mazindol) may cause symptoms of sleeplessness, nervousness, and euphoria (feeling of well-being) BRAND NAMES (CIV) Adipex-P, Obenix, Oby-Trim

91 CONTRACTS Informs on rules of obtaining controlled substance prescriptions Prevent misunderstandings Prevent misunderstandings Must disclose all medications received from any healthcare provider Agrees to drug testing If patient breached contract-the prescriber may discontinue prescribing medication

92 Pain contracts protect the prescriber-legally as well as make clear the rules of pain management

93 Controlled Substance Contracts KEY ELEMENTS
Patient name, Date Patient discloses all medications and past use of controlled substances Patient agrees to take medications as prescribed Patient agrees to drug testing Patient has been truthful in symptoms, past history, & current use of medications Patient signs Prescriber signs

94 Opiate Contract Pain Management Agreement
The purpose of this agreement is to prevent misunderstandings about certain medications you will be taking for pain management. This is to help you and your doctor to comply with the law regarding controlled pharmaceuticals. _____ I understand that this Agreement is essential to the trust and confidence necessary in a prescriber/patient relationship and that my doctor undertakes to treat me based on this Agreement. _____ I understand that if I break this Agreement, my prescriber will stop prescribing these pain control medicines. _____ In this case, my prescriber will taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended. ______ I would also be amenable to seek psychiatric treatment, psychotherapy, and/or psychological treatment if my prescriber deems necessary. ______ I will communicate fully with my prescriber about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. Pain contracts protect the prescriber-legally as well as make clear the rules of pain management Prevent Misunderstandings Prescriber retains the right to STOP PRESCRIBING if the patient violates the contract rules

95 cocaine, etc., nor will I misuse or self-prescribe/medicate with legal
______ I will not use any illegal controlled substances, including marijuana, cocaine, etc., nor will I misuse or self-prescribe/medicate with legal controlled substances. Use of alcohol will be limited to time when I am not driving, operating machinery and will be infrequent. ______ I will not share my medication with anyone. ______ I will not attempt to obtain any controlled medications, including opiod pain medications, controlled stimulants, or anti-anxiety medications from any other prescriber. ______ I will safeguard my pain medication from loss or theft. Lost or stolen medications will not be replaced. ______ I agree that refills of my prescriptions for pain medications will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. I agree to use: ________________________________________________ Name of Pharmacy: _______________________Located:_____________ Telephone number: _____________ for filling my prescriptions for all of my pain medicine. A contract also makes clear what not to do-take other medications, use alcohol concurrently, or use street drugs Do not share medications, Medications will not be replaced when the patient says the med was lost or stolen Refills (if given) will only be provided at office visits-not as a call in especially after office hours

96 Board of Pharmacy, in the investigation of any possible misuse, sale,
______ I authorize the prescriber and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication. I authorize my prescriber to provide a copy of this Agreement to my pharmacy, primary care practitioner and local emergency room. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. ______ I agree that I will submit to a blood or urine test if requested by my prescriber to determine my compliance with my program of pain control medications. ______ I agree that I will use my medicine at a rate no greater that the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. ______ I will bring unused pain medicine to every office visit. ______ I agree to follow these guidelines that have been fully explained to me. Blood and urine tests may be requested to verify the patient is taking the medication as prescribed

97 A copy of this document has been given to me.
All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me. This Agreement is entered into on this _____ day of ___________, 20__. Patient signature: __________________________________________________ Prescriber signature: Witnessed by: The patient must sign the contract & be provided a copy of the contract

98 Substance Abuse: Medications
Misuse or inappropriate use of prescription or over-the-counter medications Sedatives Hypnotics Narcotics Non-narcotic analgesics Diet aides Decongestants Medical marijuana Misuse or inappropriate use of prescription or over-the-counter medications

99 Substance Abuse: Street Drugs
Younger addicts who have grown old Expanded drug experimentation from the 1960s Marijuana Opiates Cocaine Crack Heroin Other

100 Substance Abuse-Medications
Signs Cognitive changes Falls Kidney or liver disease Increased morbidity and mortality Proactive Approach to Monitoring Evaluate prescription drug use every 1 to 3 months (minimum every 6 months)

101 Weaning from medications
Start with usual dose & wean by 10% of dosing in 24 hour period every three half-lives of the medication Provide support & counseling 12-step program

102 References Pubmed (2012) Retrieved December 11, 2011 @ www.nlm.nih.gov
ADHA (2012). The Basics. Retrieved January 30, 145.html?ic=506048 Choy (2007). Managing Side Effects of Anxiolytics. Primary Psychiatry. 14(7) Geriatric Nursing Review Syllabus (2007). Chapter 4 Legal & Ethical Issues. Hariharan,J., Lamb,L., & Neuner, J. (2007). Long-Term Opioid Contract Use for Chronic Pain Management in Primary Care Practice. A Five Year Experience. J Gen Intern Med April; 22(4): 485–490; Published online 2007 January 5. doi:  /s MPR (2011). Haymarket Media Publications: New York. NINDS (2011). Hypersomnia. Retrieved December 5, Pubmed (2012) Retrieved December 11, St. Marie, B. (2nd Ed.).(2010). Core curriculum for pain management nursing. American Society for Pain Management Nursing: Kendall Hunt Professional


Download ppt "Controlled Substance Prescribing in the Geriatric Population"

Similar presentations


Ads by Google