Controlled Substance Prescribing in the Geriatric PopulationLisa Byrd PhD, FNP-BC, GNP-BCGerontologist

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

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

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

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"

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

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

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

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

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

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 www.pmpalliance.org

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

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

MEDICAL RECORDS• The prescriber should keep accurate and complete

records to include:1. medical history & physical examination2.diagnostic, therapeutic and laboratory results3. evaluations & consultations4. treatment objectives5. discussion of risks & benefits6. informed consent7. treatments8. medications

including date, type, dosage & quantity prescribed9. instructions and agreements10. periodic reviews

• Records should remain current and be maintained in an accessible manner and readily available for review

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

DEFINITIONSCOMMON TERMS IN USE OF CONTROLLED SUBSTANCES

PAIN

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

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

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

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

CPS-Pathophysiology• Multifactorial & Complex• Some suggest-learned behavioral syndrome • External re-inforcers• Individuals prone:

▫major depression, somatization disorder, hypochondriasis, & conversion disorder

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

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

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

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

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

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

http://store.samhsa.gov/shin/content//SMA12-4671/SMA12-4671.pdf

Pain Control…

is every patient’s right

BASIC PRINCIPLES

•Pain diagnosis based on ▫inferred pathophysiology▫identification of contributing factors▫identification of barriers

Principles of Pain Management

•Anticipate, prevent, and treat pain•Anticipate, prevent, and treat adverse

effects of pain management

Pain Assessment

•Pain history•Location•Intensity•Quality•Pattern•Aggravating or

alleviating factors•Medication history

Physical Examination•Observe for non-verbal cues

▫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

4 types of pain

•Nociceptive ▫Mechanical▫Inflammatory▫Tissue destructive

•Neuropathic•Muscular•Psychogenic

NOCICEPTIVE PAIN

•Nociception implies active mechanical, thermal or chemical process

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

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

PSYCHOGENIC PAIN

•is pain that originates through cognitive & emotional processing▫examples are conversion disorder,

factitious disorder, & somatization disorder

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

Types of pain management agents•Analgesic agents•Nonsteroidal anti-

inflammatory agents•Non-opioids•Opioids •Antidepressants•Anticonvulsants•Anxiolytic agents

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

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

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

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

PAIN MEDICATIONS•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

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

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

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 50 - 100 mg every 4-6 hours up to 400

mg per day. • most common side effects are gastrointestinal

symptoms, dizziness, dry mouth, drowsiness, constipation, & seizures

Pharmacological Therapies for Pain Management•Opiods-Agonists

▫Codiene▫Morphine (MS Contin,

Oramorph, Kadian, Roxanol)▫Hydrocodone (Vicodin, Lortab)▫Methadone (Dolophine)▫Oxycodone (OxyContin,

Roxicodone, Roxifast)

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)

MORPHINECII

• 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

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 15mg every 8–24 h ▫(Avinza, Kadian, MSContin, Oramorph SR)

see dosing guidelines in the package insert for each specific formulation

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.

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 neededIV/subcutaneous Continuous: 0.025 to 0.206 mg/kg/hour (sickle cell or cancer pain) or 0.01 to 0.04 mg/kg/hour (postop pain)Epidural (use preservative-free formulation): 0.025 mg/kg/dose every 6 to 8 hours (postop pain). Maximum per 24 hours: 5 mg.IV patient controlled analgesia: 0.015 mg/kg/dose (postop pain); lockout period of 10 minutes; 4 hour limit of 0.25 mg/kg.

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

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

FENTANYL PAIN PATCH CONVERSION

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 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)

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)

OPIOID ANALGESIC EQUIVALENTS WITH APPROXIMATELY EQUIANALGESIC POTENCY

Nonproprietary(Trade) Name

IM or SCDose

ORALDose

*   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 6.5-7.5 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) 75-100 mg 300-400 mg

Methadone HCl(Dolophine) 10 mg 10-20 mg

*

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

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

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

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

Pharmacological Therapies for Pain ManagementAdjuvant Analgesics

•Tricyclic antidepressants▫Amitriptyline (Elavil)▫Nortriptyline (Pamelor)▫Desiprmine (Norpramin, Pertofrane)

Action-Inhibition of norepinephrine and serotonin.

Pharmacological Therapies for Pain ManagementAdjuvant 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 900-

3600mg/day in divided doses Anecdotal reports suggest that pain may be relieved at

lower doses

Pharmacological Therapies for Pain ManagementAdjuvant Analgesics

•Local Anesthetics▫Lidocaine- stabilizes the neuronal

membrane by inhibiting the ionic fluxes▫used intravenously, spinally, or topically

Bupivacaine (Marcaine) EMLA cream or Lidoderm

Pharmacological Therapies for Pain ManagementAdjuvant 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

ANXIOLYTICS

•used for the treatment of anxiety, & its related psychological and physical symptoms

•minor tranquilizers

Anxiolytics/Benzodiazepines Rx:CIII*Generally used on as needed basis*• Alprazolam (Xanax) 0.25-0.5 mg every 6 to

8 hours• Clonazepam (Klonipin) 0.125-2 mg every 12

hours **Long half-life**• Clorazepapte (Tranxene) 3.75-15 mg every 8

hours• Lorazepam (Ativan) 0.5-2mg every 6 to 8

hours• **SE of class: ataxia, memory impairment,

hypotension, falls, tremors, hallucinations• Non narcotic alternative: Buspirone (Buspar) 5-15

mg tid

HYPERACTIVITY

Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder generally characterized by the following symptoms:

•Inattention•Distractibility•Impulsivity•Hyperactivity

HYPERSOMNIA

•excessive daytime sleepiness or prolonged night-time sleep

STIMULANTS•Psychoactive drugs which induce temporary improvements in either mental or physical function or both•Also known as Stimulants

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

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)

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)

Insomnia Management

•Sleep Hygiene•Melatonin 0.3mg daily•Melatonin Receptor Agonists (Non-

Scheduled) ramelteon 8 mg hs

Non Benzodiazepinescyclopyrrolones 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

Benzodiazepinesestazolam 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 15-30 mg hs 15 mg hs in elderly or debilitated

WEIGHT MANAGEMENT

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.

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 27 24 22 20 19

160 31 28 26 24 22 20

170 33 30 28 25 23 21

180 35 32 29 27 25 23

190 37 34 31 28 26 24

200 39 36 32 30 27 25

210 41 37 34 31 29 26

220 43 39 36 33 30 28

230 45 41 37 34 31 29

240 47 43 39 36 33 30

250 49 44 40 37 34 31

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.

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

RISKS OF DIET PILLS•Abuse of, or dependence on diet pills -•Development of tolerance to diet pills

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).

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

CONTRACTS

•Informs on rules of obtaining controlled substance prescriptions

•Prevent misunderstandings

Controlled Substance ContractsKEY 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

Opiate Contract Pain Management AgreementThe purpose of this agreement is to prevent misunderstandingsabout certain medications you will be taking for pain management.This is to help you and your doctor to comply with the law regardingcontrolled pharmaceuticals._____ I understand that this Agreement is essential to the trust andconfidence necessary in a prescriber/patient relationship and that mydoctor undertakes to treat me based on this Agreement._____ I understand that if I break this Agreement, my prescriber willstop prescribing these pain control medicines._____ In this case, my prescriber will taper off the medicine over a periodof 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 deemsnecessary.______ I will communicate fully with my prescriber about the character andintensity of my pain, the effect of the pain on my daily life, and howwell the medicine is helping to relieve the pain.

______ I will not use any illegal controlled substances, including marijuana,cocaine, etc., nor will I misuse or self-prescribe/medicate with legalcontrolled substances. Use of alcohol will be limited to time whenI 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, includingopiod pain medications, controlled stimulants, or anti-anxietymedications from any other prescriber.______ I will safeguard my pain medication from loss or theft. Lost orstolen medications will not be replaced.______ I agree that refills of my prescriptions for pain medications will bemade 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 mypain medicine.

______ I authorize the prescriber and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state’sBoard of Pharmacy, in the investigation of any possible misuse, sale,or other diversion of my pain medication. I authorize my prescriber toprovide a copy of this Agreement to my pharmacy, primary carepractitioner and local emergency room. I agree to waive any applicableprivilege or right of privacy or confidentiality with respect to theseauthorizations.______ I agree that I will submit to a blood or urine test if requested by myprescriber to determine my compliance with my program of pain controlmedications.______ I agree that I will use my medicine at a rate no greater that theprescribed rate and that use of my medicine at a greater rate will resultin 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.

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:__________________________________________________

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

Substance Abuse: Street Drugs

•Younger addicts who have grown old•Expanded drug experimentation from the

1960s▫Marijuana▫Opiates▫Cocaine▫Crack ▫Heroin ▫Other

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)

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

References• ADHA (2012). The Basics. Retrieved January 30, 2012 @

http://www.healthcentral.com/adhd/understanding-adhd-000030_1-145.html?ic=506048

• Choy (2007). Managing Side Effects of Anxiolytics. Primary Psychiatry. 14(7). 68-76.

• 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. 2007 April; 22(4): 485–490; Published online 2007 January 5. doi:  10.1007/s11606-006-0084-1

• MPR (2011). Haymarket Media Publications: New York.• NINDS (2011). Hypersomnia. Retrieved December 5, 2011 @

http://www.ninds.nih.gov/disorders/hypersomnia/hypersomnia.htm • Pubmed (2012)

Retrieved December 11, 2011 @ www.nlm.nih.gov • St. Marie, B. (2nd Ed.).(2010). Core curriculum for pain

management nursing. American Society for Pain Management Nursing: Kendall Hunt Professional