‘This pain is killing me...’ Medication Safety in Pain Management

1. ‘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

2. 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

3. Disclosures Current: Speakers’ Bureau & Advisory Board: Cadence Pharmaceuticals Previous: Speakers’ Bureau: Pricara Consultant: Inflexxion, Painedu.org Grant Funding: Purdue Pharma

5. 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)

6. Risks for Respiratory Depression • Sleep apnea • Morbid obesity (BMI >30) with high risk of sleep apnea • No recent opioid use • Post-op; thoracic or upper abdominal • Functional status • Older age • Smoker • Longer length of time given anesthesia during surgery • Receiving other sedating drugs: benzo’s, antihistamines, sedative, CNS depressants • Pre-existing cardiac or pulmonary dz; major organ failure

7. 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

8. Pharmacokinetic Example Narcan Narcan Narcan

9. Multimodal Analgesic Approach Opioids -2 agonists NMDA antagonists Acetaminophen Opioids -2 agonists Local anesthetics NSAIDs COXIBs Local Anesthetics

10. 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

11. PCA PK Sam et al. Journal of Clinical Anesthesia (2011) 23, 102–106

12. PCA PK Peak M6G at ~25 hours Sam et al. Journal of Clinical Anesthesia (2011) 23, 102–106

13. 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

14. 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.

16. 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

17. Results…

18. Risk Factor Grouping Graph

19. Prescription drug abuse

20. 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.

21. 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

22. 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

23. Heath Care Providers Patient/Community ?

24. SAMHSA, 2011 National Survey on Drug Use and Health

25. REMS PMPs CME/CE Programs Camps such as Y2Y International Regulations/protocols Community-based drug disposal Consensus statements Public Service Announcements Individual educational activity Patient Contracts Heath Care Providers Patient/Community

26. 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

27. Adult OutpatientsThundermist Health Center

28. 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

29. Adult Parents of Pediatric PatientsUMass Memorial Children’s Hospital

30. 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)

31. 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 past-month 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

32. College StudentsURI Health Services

33. 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

34. “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

35. Opioids: Symptoms to Watch For… Overdose 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 • ↓ level of consciousness • Pinpoint pupils • ↓ Heart rate • ↓ Respiratory rate • Patient may appear cyanotic (blue lips & nails) • Seizures • Muscle spasms • Unarousable

36. Opioids/Narcotics

37. Benzodiazepines Overdose 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 • CNS Depression • Ataxia • Slurred speech • Respiratory depression • Coma

38. Sedatives & Depressants

39. Non-controlled Rx drugs Not all drugs that are abused are controlled substances

40. 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)

41. 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

42. 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’

43. 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

44. Serotonin Syndrome NEJM 2005;352:1112-20.

45. 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

47. 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

48. Take Home Naloxone • Naloxone and Overdose Prevention Education Program of Rhode Island www.noperi.org

49. Accessed from www.noperi.org