2017 Pharmacy Educations3.proce.com/res/pdf/CHS2017Sep20Handout.pdf · • account for ~50% of...
Transcript of 2017 Pharmacy Educations3.proce.com/res/pdf/CHS2017Sep20Handout.pdf · • account for ~50% of...
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 1
2017 Pharmacy Education Series
September 20, 2017The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare Practitioners
Featured Speakers:
Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D Tracie Chambers, RPhClinical Associate Professor Regional Director of PharmacyUniversity of Georgia College of Pharmacy CHSPSC, LLCAthens, Georgia Franklin, Tennessee
2
Submission of an online post‐test and evaluation is the only way to obtain CE credit for this webinar
Go to www.ProCE.com/CHSRx
Webinar attendees will also receive an email with a direct link to the web page
Print your CE statement of completion online
– Credit for live or enduring (not both)
Deadline: October 20, 2017
CPE Monitor (applicable to pharmacists and pharmacy technicians)
– CE credit automatically uploaded to NABP/CPE Monitor upon completion of post‐test and evaluation (user must complete the “claim credit” step)
Online Evaluation, Self-Assessmentand CE Credit
Attendance Code
Code will be provided at the end of today’s activity
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 2
How to Ask a Question
Locate menu bar on your computer desktop
Click orange arrow button to open menu box
Type question into question box
Click Send
Do not close menu box
– This will disconnect you
from the Webcast
Please submit questions throughout
presentation
Click No!
Click
Enter question
3
Accessing PDF Handout Click the hyperlink that is
located directly above the question box
Do not close menu box
– This will disconnect you
from the Webcast
No!
Clickhyperlink
4
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 3
2016 Pharmacy Education Series
5
It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Dr. Norton does not have any relevant commercial and/or financial relationships to disclose. Ms. Chambers does not have any relevant commercial and/or financial relationships to disclose.
Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.
September 20, 2017The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare Practitioners
Featured Speakers:
Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D Tracie Chambers, RPhClinical Associate Professor Regional Director of PharmacyUniversity of Georgia College of Pharmacy CHSPSC, LLCAthens, Georgia Franklin, Tennessee
CE Activity Information & Accreditation
ProCE, Inc. (Pharmacist and Pharmacy Technician CE)
– 2.0 contact hours
6
Funding:This activity is self‐funded through CHSPSC.
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 4
The Pain of Pleasure: Heroin and Other Opioids-The Implications for Healthcare Practitioners
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-DClinical Associate Professor
University of GeorgiaCollege of Pharmacy
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D7
Disclosures
Merrill Norton, PharmD, DPh, ICCDP-D, declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D8
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 5
Objectives
Pharmacists:
At the conclusion of this presentation, participants will be able to:
1. List the risk factors contributing to substance use disorders.
2. Describe effective prevention strategies for prevention of opioid use and overdose.
3. Discuss current treatment strategies for opioid use disorders.
4. Explain the current neurobiology of substance use disorders.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D9
ObjectivesPharmacy Technicians :
At the conclusion of this presentation, participants will be able to:
1. List the risk factors contributing to substance use disorders.
2. Describe effective prevention strategies for prevention of opioid use and overdose for patient care.
3. Discuss current treatment strategies for opioid use disorders for patient care.
4. Discuss the current neurobiology of substance use disorders.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D10
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 6
Case Study- Why I Am Here
LD is a 26 year-old, Caucasian female who is a third year pharmacy student. She has been married to her husband for 4 years and has 1 child
LD came to our treatment center for an opiate addiction. LD stated “I've hit my bottom; I don't want to live this way anymore.” She reports consuming 100 mg of oxycodone per day by taking four Percocet 5 mg tablets 5 times a day. She would also take Lortab and Tramadol to supplement her Percocet abuse. When she drank she would drink about 10 drinks per day on the weekends. LD denies any other prescription drug abuse or illicit drug use
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D11
Case Study The first time LD used Lortab was in 2006 when she broke up with her boyfriend
at the time; she knew her mother had Lortab in the cabinet and took them to escape the emotional pain. LD’s oxycodone use began in 2010 after the birth of her first child. She reports that she began drinking alcohol at age 17 and had developed a regular pattern of weekend drinking by 19
LD had jaw surgery in early 2012 and was prescribed Percocet and Lortab; this marked the beginning of her abuse of opiates. During this time she was prescribed opiates chronically; switching between Lortab and Percocet prescriptions. She reports only using the prescribed dose for the first 4 to 5 months until she built up a tolerance. At that point LD began to increase her use of Percocet beyond the prescribed doses. She stated, “I just liked the feeling of not feeling”. She also described herself as “numb, I could handle stress and anxiety a lot easier. I didn’t know how to manage my emotions when I wasn’t on something.” She tried discontinuing her narcotic use in early 2013, but ultimately returned to the drug when her husband had to go out of town for a business trip. This period of sobriety lasted about 1 month. LD eventually realized that she would be unable to stop on her own and sought treatment
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D12
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 7
Case Study This is LD’s first admission for a substance use disorder. She will need
both medical and psychological therapy to reach and continue sobriety. LD has shown good motivation while in treatment. She strives to learn about this disease, is a willing participant in therapy sessions, and has the support of her family. She knows that recovery will be challenging, and has already faced one challenge in the form of marital distress.
After completing treatment and starting aftercare- LD was found by her husband- dead from drug overdose- she was 27 years old. She was only six months away from graduating with her Pharm.D.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D13
The Epidemic
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D14
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 8
Global Market Study on Opioids
By product, the global opioid market is segmented into morphine, codeine, fentanyl, meperidine and methadone.
The morphine and codeine segments collectively accounted for around 62% of the overall market in 2014.
By application, the global opioids market is segmented into analgesia, cough suppression and diarrhea suppression.
The analgesia segment was valued at US $22,776.3 million
in 2014 and is anticipated to reach US $28,436.8 million by
2021. US has 65% of the global opioid market.
Global Market Study on Opioids: Widespread Usage in Treatment of Cancer to Drive the Growth of Opioids Market During the Forecast Period PR Newswire
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D15
Chronic Pain and Prescription Opioids
11% of Americans experience daily (chronic) pain
Opioids frequently prescribed for chronic pain
Primary care providers commonly treat chronic, non‐cancer pain
• account for ~50% of opioid pain medications dispensed
• report concern about opioids and insufficient training
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.
16
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 9
17
SHARP INCREASE IN OPIOID PRESCRIPTIONS INCREASE IN DEATHS
18
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 10
Role of Prescribing Opioids and Overdose Deaths
*Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System
19
20
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 11
Challenges
While there were 16,235 deaths involving prescription opioids in 2013, an increase of 1% from 2012, the number of deaths involving heroin increased dramatically. There were 8,257 heroin-related deaths in 2013, up 39% from 2012. Total drug overdose deaths in 2013 hit 43,982, up 6% from 2012.
In 2016, over 59,000 overdose deaths were reported- more deaths than occurred during the Vietnam War.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D21
Opioids: Double-edged Sword
Cornerstone of pain
management Mood altering properties
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D22
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 12
Opiates (Natural Alkaloids)
Semi-syntheticsNatural
alkaloids
morphine heroin
codeineoxycodone
hydrocodone
thebaine buprenorphine
naloxone
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D 23
Morphine, Heroin or Codeine:
It does not make any difference
Morphine can arise in the blood and urine through the administration of morphine itself or through the
metabolism of heroin or codeine
Morphine
Morphine CodeineHeroin
6-MAM
Brennan,MJ, Heit,HAChronic Pain: Overcoming Treatment Barriers for Effective Outcomes, Medscape Pharmacists CE, 12/8/2004
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D24
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 13
Opiates/Opioids Pure
agonists
FULL
• Morphine• Heroin• oxycodone• Fentanyl
PARTIAL
butorphanol
pentazocine
AntagonistsPURE
naloxone
naltrexone
Mixed agonists/
antagonists
buprenorphine
nalbuphine
others
tramadol
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D25
Opioid Use ( Addiction) Changes the
following:
Opioid Receptors (mu, kappa, delta)-euphoria
The Endogenous Opioid Peptide System (Endorphins /Dynorphins)
Cellular Membrane Action- down regulation of GTP to GDP (conversion of release of arrestin)
Dopamine Pathways- decreased production, storage, and transport
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D26
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 14
Opioid Receptors (Euphoria Receptors)
μ (mu): Activated by morphine: Analgesia
Primary action site of all opioids
Distribution: primarily in CNS and also GI
Linked to substance use disorders
δ (delta): for endogenous peptides (endorphins)- Nerve Conduction-slows pain signal between the peripheral nervous system and the central nervous system(brain, hypothalamus, spinal cord)
κ (kappa): analgesia, endocrine changes and dysphoria (brain-amygdala, spinal cord) [dynorphins] Stress Reduction, relationships**
��
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D27
Opioid Receptors
Five classes of opioid receptoro Mu(), Delta(), Kappa() Nociceptin Subtypes (, receptors
Subtype of , , receptor
Structural characteristics** ( The more characteristics, the higher addiction liability)
o Typical G-protein-coupled receptor Seven hydrophobic region Three intracellular loops Three extracellular loops Intracellular carboxy-terminal tail Extracellular amino-terminal tail
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D28
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 15
Opioid Receptors ( II )
29
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 29
The “Dynamite” of Opioids
Aspirin
(1 stick)
Codeine
(1 stick)
Hydrocodone
(3 sticks)
Morphine
(4 sticks)
Fentanyl
(21 sticks)
30
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 30
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 16
Who is At Risk for Developing An Addiction? Young developing brains- 12-26years
Aging declining brains 50+ years
Pain brains-acute or chronic
Trauma brains-physical or emotional
Stress brains- competition, grades, relationships, $$
Genetic brains- family history of addiction, mental illness, trauma, suicide
High use brains- low dose long time or high dose short time
Mentally disordered brains-ADHD, MDD, GAD, BP I or II, psychosis
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D31
Dynorphin, Dysphoria, and Dependence: the
Stress of Addiction
The hypothesis that the dynorphin-kappa opioid receptor system may be a key component of the neuroplasticity associated with stress-
induced mood disorders and the ‘dark side’ of addiction (withdrawal-negative affect stage) continues to gain preclinical and clinical
experimental support. The endogenous kappa opioid peptides derived from prodynorphin encode the dysphoric, anxiogenic, and cognitive
disrupting responses to behavioral stress exposure (Bruchas et al, 2010; Carroll and Carlezon, 2013)
Neuropsychopharmacology 41, 373-374 (January 2016) | doi:10.1038/npp.2015.258.
Charles Chavkin and George F Koob
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D32
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 17
Diacetlymorphine
In 1874, English chemist C.R. Wright ventured out into making a non-addictive form of codeine and morphine. In doing so he combined anhydrous morphine alkoid and acetic andhydride (Hodgson). This produced what is known as diacetylmorhpine (Hodgson). In short diacetylmorphine is an acetylated version of morphine.
AcetylationMorphine
Diacetlymorphine
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D33
The reason for the that addicts can not stop using is once the dopaminergic system is deactivated (depleted) due to multiple neurobiological reasons- the reinforcing effects of the drug becomes more powerful than a mother’s love for her children. In 2016, the potencies of most street drugs (marijuana/heroin) have increased. This increased potency creates the increased reinforcing effects of dopamine thus increasing the addiction liability of the drug on the brain.
Opioid Addiction is Greater Than a Mother’s Love (Dynorphin)
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D34
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 18
The “Why” Heroin is So Deadly Heroin and its metabolite 6-monoacetylmorphine [6-MAM] crosses
the blood-brain barrier one-hundred times faster than morphine. This rapid diffusion is due to heroin being highly soluble in lipids.
Heroin’s short-term effects will last over a period of three to six hours.
Pinpoint pupils. Nausea and vomiting. Constipation or explosive diarrhea. Urinary retention due to activity on GIT sphincter muscle systems (plus anticholinergic activity-dry mouth, blurred vision)
Depression of medulla oblongata creates bradycardia( heart rate below 60 BPM ) and abnormal low respirations( less than 8 per minute)
35
Then Add A Little Fentanyl
The death rate from accidental drug overdose has risen 19% for 2016 with as estimated 59,000 overdose deaths being reported;
STAT, a national healthcare publication, states that if strong preventive measures are not put into place, the death toll could reach 650,000 in the next decade;
Fentanyl is a synthetic opioid, 50-100 times more potent than morphine, depending on which fentanyl analog;
Added to low potency heroin to increase the “Kick” of the heroin; A new street drug, Gray Death, a mix of several synthetic fentanyl
derivatives can and does cause an “instant overdose”….and death
36
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 19
Dopamine
Primary chemical in the brain responsible for activating the reward pathway
During the preoccupation phase of addiction, dopamine is being released stimulating desire for a drug
During the intoxication phase, all the dopamine in the brain is released giving the user a euphoric feeling
During the withdrawal phase, the brain has run out of dopamine and can not function properly until more is made
37
38
Fig.8
1.)Behaviors-Pleasure2.)Euphoria-Addiction3.)Movement-Parkinson’s Disease-EPS
4.)Perception-Psychosis
Dopamine Neural Pathways
1
2
3
4
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D38
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 20
MESOLIMBIC DOPAMINE SYSTEM
Circuit #1 Mu Use- DopamineRelief/Like/Pleasure
Pleasure/Pain circuitMeso-accumbens
Circuit #2 Delta Abuse-Endorphins
Repeat/Want/ReinforcementDesire and urge circuitBasolateral n. of amygdala
Circuit #3 Kappa Addiction-Dynorphin A/B
Need/Craving/AddictionPathologic desire & demand circuitPeriaqueducal gray of brain stemStimulation of the periaqueductal gray
matter of the midbrain activates enkephalin-releasing neurons that project to the raphe nuclei in the brainstem.
Enkephalin (endogenous opioid neurotransmitter), binds to mu opioid receptors.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D39
The Changing of the Brain’s Communication Highway
1.) Alcohol, Marijuana, Rx medications alter the receptors and neurotransmitters with any use; it happens like this:
2.) The person experiences euphoria from the release of dopamine (excessive amounts) when they drink or use a drug;
3.) The brain records this pleasurable experience in short term memory-”this was a good time”;
4.) If the person begins to repeat the pleasurable experience, the dopamine becomes depleted, the brain attempts to stabilize the chemistry by using another set of chemicals, the endorphins, to reset the brain back to normal; but this attempt just creates a need for more of the drug-tolerance and withdrawal;
5.) If the persons continues to use (thinking that they can get back to normal), the brain activates a third set of chemicals, the dynorphins, to keep the brain’s communication highway open.
40
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 21
The Changing of the Brain’s Communication Highway
6.) The dynorphins are responsible for many things in the brain, one of the most important is stress reduction created by intimate relationships (family, friends, church,etc.) A long term memory system is activated.
7. As the person continues to use the drug, the dynorphins are depleted over time, making normal relationships less important.
8. As the depletion of the dynorphins continues, the brain will begin to substitute the drug of abuse for the brain’s natural dynorphin.
9.) The brain becomes “hijacked” using the drug of abuse as the primary relationship of importance, instead of the normal relationships in the person’s life. This is addiction.
10.) Once the hijacking occurs-it is irreversible-addiction is a chronic disease process.
41
Overdosing- #1 Issue
Drug overdose is now one of the top causes of death in US claiming over 59,000 deaths in 2016.
The CDC reports that for every overdose death in the U.S., a person taking opioids on average will overdose nine times. While overdose deaths can occur anytime, the most high-risk individuals are those using escalating doses of drugs and those using a combination of drugs such as opioids and benzodiazepines.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D42
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 22
Naloxone
Antidote; Opioid Antagonist
Significant adverse reactions:
Related to reversing dependency and precipitating withdrawal
Withdrawal symptoms are the result of sympathetic excess
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D43
How does naloxone work?
Naloxone has a strongeraffinity to the opioidreceptors than the opioid, soit knocks the heroin off thereceptors for a short timeand lets the person breatheagain.
Opioid receptor
Naloxone
Opioid
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D44
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 23
Naloxone Safety
Naloxone requires a prescription
Opioid antagonist - no potential for abuse
Little to no effect on person unless they are experiencing an opioid overdose
Accidental administration poses no threat or danger
Including to children or pregnant women
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D45
Naloxone Safety WHO’s List of Essential Medicines
>50,000 people in US trained to administer naloxone
>10,000 opioid overdoses have been reversed with naloxone from 1996 to 2010
Studies suggest laypersons trained in administration can do so as effectively as EMS personnel
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D46
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 24
Recognizing an Overdose
Unresponsiveness to yelling or stimulation, like rubbing your knuckles on breast bone
Effectively draws the line between overdosing and being really high but not overdosing
Slow, shallow, or no breathing
Turning pale, blue or gray (especially lips and fingernails)
Choking sounds
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D47
Risk Factors
Overdose is most common when:
History of prior overdose
Tolerance is down due to not using – like after being in jail, detox or drug-free treatment
Drugs are mixed, especially with alcohol or benzodiazepines
Person uses alone
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D48
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 25
What NOT to do During an Overdose
DO NOT put the individual in a bath They could drown.
DO NOT induce vomiting or give the individual something to eat or drink They could choke.
DO NOT give over-the-counter drugs or vitamins
(eg, No-Doz or niacin) They don’t help and the patient could choke.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D49
Responding to a Suspected Opioid
Overdose
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D50
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 26
Step 1 - Rub to wake
Rub your knuckles on the bony part of the chest (sternum) to try to get them to wake up and breathe.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D51
Step 2 - Call 911
Tell them
The address and where to find the person
A person is not breathing
When medics come tell them what drugs the person took if you know
Tell them if you gave Naloxone
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D52
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 27
Step 3 - If the person stops breathing, give breaths
mouth to mouth or use a disposable breathing mask
Put them on their back
Pull the chin forward to keep the airway open put one hand on the chin, tilt the head back, and pinch the nose closed
Make a seal over their mouth with yours and breathe in two breaths. The Chest, not the stomach, should rise
Give one breath every 5 seconds
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D53
Step 4 - Give naloxone
Injectable:
Give naloxone (discard any opened naloxone within 6 hours of using) Injectable naloxone: inject into the arm or upper outer top of thigh muscle 1cc at a time always start from a new vial
Intranasal:
Squirt half the vial into each nostril, pushing the applicator fast to make a fine mist.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D54
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 28
Injectable Naloxone
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D55
Intranasal Naloxone
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D56
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 29
Step 5 - Stay with the person and keep them breathing
Continue giving mouth to mouth breathing if the person is not breathing on their own after that administration of naloxone
Give second dose of naloxone after 2-5 minutes if they do not wake up and breath more than 10-12 breaths a minute
Naloxone can spoil their high and they may want to use again, make sure they are aware that overdosing is still possible when naloxone wears off
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D57
Step 6 - Place the person on their side
People can breathe in their own vomit and die.
If a person is breathing put them on their side to prevent this.
Naloxone can induce vomiting, this position will help protect them from inhaling that vomit.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D58
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 30
Step 7 - Convince the person to
follow the paramedics advice
If paramedics advise to proceed to an emergency room then health care staff can
Relieve symptoms of withdrawal
Prevent a second overdose
Observe and administer naloxone as needed
Assess risk of the person for other overdoses brought on by drugs other than opioids
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D59
Contents Of Narcotic Overdose Kit
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D60
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 31
Withdrawal # 2 Issue
The onset of withdrawal symptoms vary among users. Typically those who use heroin once a day experience peak withdrawal effects within 36-48 hours of there last administered dose. Symptoms such as pain, restlessness and vomiting go away within in 7-10 days.
Medication assisted treatments (MAT) is recommended by SAMHSA for withdrawal.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D61
Why is it needed?
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D62
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 32
Clinical Opiate Withdrawal Scale
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D63
Source: NSW Department of Health (2007) NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D64
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 33
Heroin Withdrawal
0 1 2 3 4 5 6 7 8 9 10
Day
Withdra
wal
sev
erity
Unmedicated
Lofexidine / clonidine
Methadone (7 day)
Buprenorphine (7 day)
Rapid detox' (naltrexone)
Lintzeris, N (2008) unpublished data. Reprinted with permission.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D65
Think About This- Opioids Act
As Hormones
Fibromyalgia, Autism, and Opioid Addiction as Natural and Induced Disorders of the Endogenous Opioid Hormonal System
Autism is a hyperopioidergic response and opioid maintained individuals relate autistically
Post Withdrawal of Opioid Addiction is fibromyalia
Hypothesis 1 — The Endogenous Opioid System is a Hormonal System that Regulates Both Pain and Relatedness
Hypothesis 2 — Neuropsychoanalytic Therapy Including LDN Enhances Outcomes of Opioid Addiction Treatment by Addressing Key Aspects of the Disease Including Persistent Low Opioid Tone
http://www.discoverymedicine.com/Brian-Johnson-2/files/2014
/10/discovery_medicine_no_99_brian_johnson_figure_1.jpg
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D66
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 34
Think About This- Opioids
Act As Hormones
Hypothesis 3 — Fibromyalgia Is an Autoimmune Disease of the Endogenous Opioid System
Hypothesis 4 — Autism May Be Treatable with High Dose Naltrexone
Hypothesis 5 — The Increasing Prevalence of Autism Is Caused by the Increasing Administration of Opioids During Childbirth
http://www.discoverymedicine.com/Brian-Johnson-2/files/2014/10/discovery_medicine_no_99_brian_johnson_figure_1.jpg
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D67
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D68
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 35
Figure 1. The hypothesized ʹinverse Uʹ relationship of pleasure and opioid tone in central nervous system subcortical pathways. The left side of the x-axis corresponds with low opioid tone, associated with post acute withdrawal syndrome and opioid induced hyperalgesia (OIH) after opioid withdrawal and with fibromyalgia. The right side of the x-axis corresponds with high opioid tone, associated with patients maintained on opioid drugs and with autism. Pleasure is at its peak when regulated by human interactions in the band labeled ʹhealthy functioning.ʹ
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D69
What Is MAT?
MAT is any treatment for opioid addiction that includes a medication (e.g., methadone, buprenorphine, naltrexone, naloxone) approved by the U.S. Food and Drug Administration (FDA) for opioid addiction detoxification or maintenance treatment. MAT may be provided in an OTP or an OTP medication unit (e.g., pharmacy, physician’s office) or, for buprenorphine, a physician’s office or other health care setting. Comprehensive maintenance, medical maintenance, interim maintenance, detoxification, and medically supervised withdrawal are types of MAT.
TIP 43 U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. HHS PublicationSMA12-4214. First Print 2005, Reprinted 2006, 2010, 2011,2012, 2014.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D70
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 36
Outcome Challenge: The Treatment
Gap: DATA 2000 Waiver
Waiver Authority for Physicians Who Dispense or Prescribe Certain Narcotic Drugs for maintenance or detoxification treatments:o # of Physicians in the U.S. = 916,264o # of DATA Certified Physicians = 33,806
This comes out to only 3.7% of physicians being DATA Certified, left to treat 1.9 million opioid addicted patients in the US.
One physician for 55,800 opioid addicted patientsUnderstanding the Epidemic. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/drugoverdose/epidemic/index.htmlPhysician and Program Data. Substance Abuse and Mental Health Services Administration Web site. http://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/physician-program-data
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D71
Cravings # 3 Issue
Craving: memory of rewarding aspects of drug use superimposed on a negative emotional state
o Compels drug-seeking in dependent individuals
3 Types of Cravingso Withdrawal inducedo Cue-inducedo Drug-induced
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D72
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 37
Methadone Stabilization
Reprinted from The Lancet. Haber, PS et al (2009) “Management of injecting drug users admitted to hospital” Lancet, 374(9697):1284-93. © 2009 with permission from Elsevier.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D73
Options of Pharmacological Treatment
1. Methadone • Full μ agonists
• Once/day dosed
• 40-60 mg/d: sufficient to block withdrawal sx.
2. Buprenorphine and Buprenorphine/Naloxone• μ Receptor partial agonist
• Kappa receptor partial antagonist
• 12-16 mg/d
• Combination ↓ risk of diversion
3. Naltrexone • Opioid antagonist
• Oral or injectable
• This extended-release injectable medication is the most recent drug, approved in October of 2010, for the treatment of opioid addiction.
4. Naloxone- Overdose Prevention
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D74
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 38
Components of Comprehensive Drug Addiction Treatment
www.drugabuse.gov75
BuprenorphineDetoxification
Buprenorphine and Medically Supervised Withdrawal
BUP can be used to cease opiate use or to transition out of agonist (methadone) treatment. Cease opiate use
Withdrawal symptoms present
1-2 initial doses on first day
Build up dose over next couple days
Make sure consumer is compliant and stable
Reduction of dose over next few days
Some consumers may need to take longer in reduction phase or enter maintenance treatment
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D76
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 39
Other MedicationsMedication
Managing Symptoms
Clonidine, nausea & diarrhea meds, hypertension meds, etc.
Full Agonist
Methadone
Partial Agonist
Buprenorphine
Partial Agonist w/ Antagonist
Buprenorphine-Naloxone
Full Antagonist
Naltrexone (Revia, Depade, Vivitrol)
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D77
CDC Guidelines for Prescribing Opioids
for Chronic Pain
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D78
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 40
Purpose, Use, and Primary Audience
Primary Care Providers• Family medicine, Internal medicine• Physicians, nurse practitioners, physician assistants
Treating patients >18 years with chronic pain• Pain longer than 3 months or past time of normal tissue healing
Outpatient settings
Does not include active cancer treatment, palliative care, and end‐of‐life care
79
Determine when to initiate or continue opioids for chronic painRecommendations 1-2
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D80
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 41
Opioid selection, dosage, duration, follow-up, and discontinuationRecommendations 3-6
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D81
Assessing Risk and Addressing Harms of
Opioid Use Recommendations
6-12
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D82
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 42
• FDA REMS for opioid medications.• Good medical practice requires Screening & monitoring all patients for signs of abuse and addiction;
Use opioid agreement;
Keep detailed prescribing records;
Educate patients/caregivers:
Take medication only as prescribed,
Protect against accidental use, theft, and misuse
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D
Principles of BalanceOpioid Therapy
83
Elements to Assure Safe Use (ETASU)
May require any of the following:
Training or certification of prescribers
Training or certification of pharmacists and pharmacies
Restriction on where drug is dispensed (e.g., infusion settings, hospital)
Evidence of patient safe use conditions such as lab results
Patient monitoring
Enrollment of patients in a registry
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D84
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 43
Screening Instruments
Overview
Looking for HIDDEN substance abuse
Subjective (self-report) vs. objective
Active vs. latent
Testing vs. application
Access resources in clinical practice
PainEDU.org
www.appalachianaware.org
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D85
Screening Instruments
CURRENT Substance Abuse
Subjective
Interview history
CAGE and Trauma Test
Drug Abuse Screening Test (DAST)
Reassessment: Current Opioid Misuse Measure (COMM)
Objective
Addiction Behaviors Checklist
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D86
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 44
Screening Instruments
LATENT Substance Abuse
Screener and Opioid Assessment for Patients in Pain (SOAPP®)
Long (24 questions) and short (5) versions
Opioid Risk Tool (ORT®)
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D87
Pain Management of the Cancer Patient
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D88
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 45
The Statistics
• In 2016, an estimated 1,685,210 new cases of cancer will be diagnosed in the United States and 595,690 people will die from the disease.
• The number of people living beyond a cancer diagnosis reached nearly 14.5 million in 2014 and is expected to rise to almost 19 million by 2024.
• Approximately 39.6% of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2010-2012 data).
• In 2014, an estimated 15,780 children and adolescents ages 0 to 19 were diagnosed with cancer and 1,960 died of the disease.
• As the overall cancer death rate has declined, the number of cancer survivors has increased.
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D89
AmericanSocietyofClinicalOncology(ASCO)
Statementonthe OpioidEpidemic
Regulations designed to curb opioid abuse and addiction should "largely exempt cancer patients," according to a policy statement from the American Society of Clinical Oncology (ASCO)
Characterizing cancer patients as a "special population,”ASCO said a broad exemption from regulations that limit access to or doses of prescription opioids is justified because of the "unique nature of their disease, its treatment, and potentially life-long adverse health effects from having had cancer.”
ASCO Policy Statement on Opioid Therapy: Protecting Access to Treatment for Cancer-Related Pain 2016
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D90
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 46
ASCO Recommendations for Cancer Patients
Healthcare provider access to a choice of materials on prescribing education that is "evidence based and tailored by specialty”; No prescription limits that would "artificially impede access to medically necessary treatment for patients with cancer";
Patient education emphasizing safe use, storage, and disposal of prescription pain medication;
Allowances in prescription drug monitoring programs for providers who treat cancer related pain and "may prescribe relatively large numbers of opioids or provide multiple controlled drugs at relatively high doses";
Appropriate patient screening and assessment before and during opioid treatment, although use of compliance tools should not be mandated for all patients who receive opioids;
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D91
ASCO Recommendations for Cancer Patients
Use of abuse-deterrent -- or non-abuse deterrent -- formulations of prescription pain medication, as determined by clinical and patient-specific circumstances;
Rapid patient access to assessment, diagnosis, and treatment for opioid misuse, abuse, or addiction;
Increased access to naloxone, "a life-saving medication in cases of opioid overdose"; and
Prescription "take-back" programs to decrease availability of unused or unwanted opioids, including readily available authorized collection sites for patients.
ASCO Policy Statement on Opioid Therapy: Protecting Access to Treatment for Cancer-Related Pain 2016
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP‐D92
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 47
Tools and Materials
Provider and patient materials
• Checklist for prescribing opioids for chronic pain
• Fact sheets
• Posters
• Web banners and badges
• Social media web buttons and infographics
CDC Opioid Overdose Websitewww.cdc.gov/drugoverdose/index.html
93
References
CDC. Wide‐ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.
Centers for Disease Control and Prevention. CDC Health Advisory: Increases in Fentanyl Drug Confiscations and Fentanyl‐related Overdose Fatalities. HAN Health Advisory. October 26, 2015. http://emergency.cdc.gov/han/han00384.asp
Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid‐Involved Overdose Deaths —United States, 2010–2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6550e1
National Institute on Drug Abuse. (2015). Drugs of Abuse: Opioids. Bethesda, MD: National Institute on Drug Abuse. Available at http://www.drugabuse.gov/drugs‐abuse/opioids.
The United Nations Office on Drug and Crime(UNDOC) “2015 World Drug Report”www.undoc.org/wrd2015
94
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 48
For more information on CDC Guideline on Prescribing Opioids for Chronic Pain please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1‐800‐CDC‐INFO (232‐4636)/TTY: 1‐888‐232‐6348
Visit: www.cdc.gov | Contact CDC at: 1‐800‐CDC‐INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control 95
Narcotic Diversion MonitoringThriving in Tough Terrain
Presented by:
Tracie Chambers, RDOP
96
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 49
Narcotic Diversion Monitoring
A necessary evil…
97
Narcotic Diversion Monitoring
• CHS CS policies provide a strong foundation for the necessary monitoring .
– Located on the CHS intranet under my policies
– CS policies begin with RX15‐01‐RX15‐23
• Build upon these policies to provide a solid program that assures safe and appropriate CS usage in your facility.
98
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 50
Narcotic Diversion Monitoring
Establish a written controlled substance plan– Evaluate CS use in all areas of the hospital
– Include all staff
– Include all CS medications
– System to look at non‐profile machines
– Limit access for staff
– Process to remove employees from ADM that have separated from the system (run report of users that have not accessed the ADM system within last 90 days)
99
Narcotic Diversion MonitoringPotential Red Flags
• The same individual’s name on monthly Proactive Diversion Report
• Discrepancies created by the same person repeatedly
• Provider utilizing more medications per case than peers
• Incorrect counts on Tylenol/ASA/Benadryl injection
The basics working for your success• Entering data from daily
reconciliations into a spreadsheet for tracking and trending
• CII safe Compare report/Send to non‐ADM report
• Discrepancy reports
• Last access >90 days
• Proactive Diversion Report
– Nursing
– Anesthesia providers 100
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 51
Narcotic Diversion Monitoring
Discrepancy reports– Potential issue with pharmacies/technicians throwing away sleeves of drugs in “empty boxes”
• Implement process that all CS must be removed from packaging before delivery and all packaging must be saved and checked by another person before discarding
– Miscount is chosen for resolution 99.9% of the time
• Verify and validate
101
Narcotic Diversion Monitoring
• Compare reports verify all CS removed from the Narcotic vault are delivered to the appropriate Med station‐ this should be run daily prior to the technician leaving.
• How do you verify if medications removed from the Narcotic vault/pharmacy are not delivered to a Med station?
102
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 52
Review Narcotic vault daily event report?Scanning bar codes on delivery records?
Easiest solution:Reports, review reports, send reports, check date, click Not into ADM
103
Narcotic Diversion Monitoring
ED reconciliations and OR reconciliation
– Completed daily
– Make the work useful
– Input data into a spreadsheet
– Look for trends among drugs and users including nurses, prescribers and other staff.
104
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 53
Narcotic Diversion Monitoring
ED spreadsheet example
Date#
Reviewed Type of errorPatient ID
# Floor Other FindingsNurse
Involved Dr.
Anesthesia spreadsheet example
RPh/Tech Date
# Reviewed Provider
Patient ID #
Waste Verified? Other Findings Action
# of narcotics removed / # of
cases
Average # of
narcs/case
105
Narcotic Diversion MonitoringProactive Diversion Search
Step 1 Step 2
106
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 54
Proactive Diversion Search
Step 3
• Holds data forever
• Never deletes a user
• Can set specific parameters
Note: Similar information can also be obtained from CareFusion Analytics
107
Narcotic Diversion Monitoring
Additional tips learned from previous diversions:
– When counting expired control meds, seal the bags and sign across the seal
– Implement process for accountability of prescription blanks that are stored on the floors
– Reconcile all overrides daily and log into spreadsheet for tracking and trending
108
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 55
Success
• Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.– Andrew Carnegie
109
110
The Pain of Pleasure: Heroin and Other Opioids‐The Implications for Healthcare PractitionersCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 56
112
Jerry H. Reed, MS, RPh, FASCP, FASHP
Senior Director, Pharmacy Services
Community Health Systems
Update on Current Pharmacy Initiatives and Strategies
113