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Controlled Substance Prescribing in the Geriatric Population

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Controlled Substance Prescribing in the Geriatric Population Lisa Byrd PhD, FNP-BC, GNP-BC Gerontologist * Meperidine (Demerol)-used to relieve moderate to severe pain. – PowerPoint PPT presentation

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Title: Controlled Substance Prescribing in the Geriatric Population


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 Speakers 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"

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

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

8
TREATMENT PLANPAIN 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

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

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 www.pmpalliance.org

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

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

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

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

16
DEFINITIONS
  • COMMON TERMS IN USE OF CONTROLLED SUBSTANCES

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

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

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

21
CPS-Pathophysiology
  • Multifactorial Complex
  • Some suggest-learned behavioral syndrome
  • External re-inforcers
  • Individuals prone
  • major depression, somatization disorder,
    hypochondriasis, conversion disorder

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

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

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

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

27
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/S
    MA12-4671.pdf

28
Pain Control
  • is every patients right

29
BASIC PRINCIPLES
  • Pain diagnosis based on
  • inferred pathophysiology
  • identification of contributing factors
  • identification of barriers

30
Principles of Pain Management
  • Anticipate, prevent, and treat pain
  • Anticipate, prevent, and treat adverse effects of
    pain management

31
Pain Assessment
  • Pain history
  • Location
  • Intensity
  • Quality
  • Pattern
  • Aggravating or alleviating factors
  • Medication history

32
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

33
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34
4 types of pain
  • Nociceptive
  • Mechanical
  • Inflammatory
  • Tissue destructive
  • Neuropathic
  • Muscular
  • Psychogenic

35
NOCICEPTIVE PAIN
  • Nociception implies active mechanical, thermal or
    chemical process

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

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

38
Psychogenic pain
  • is pain that originates through cognitive
    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

40
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41
Types of pain management agents
  • Analgesic agents
  • Nonsteroidal anti-inflammatory agents
  • Non-opioids
  • Opioids
  • Antidepressants
  • Anticonvulsants
  • Anxiolytic agents

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

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

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

46
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

47
Pharmacological Therapies for Pain Management
  • Nonopioids
  • Acetaminophen (Tylenol)
  • Action-analgesia, antipyretic
  • DOSAGE
  • Acetaminophen (Tylenol) 325500mg every 4 h or
    5001,000mg
  • 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

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 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

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

51
CODIENE CIII
  • Used to relieve mild to moderate pain
  • ADULT DOSE15 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)

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

53
MORPHINE CII
  • Immediate release 2.510mg 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 824 h
  • (Avinza, Kadian, MSContin, Oramorph SR)
  • see dosing guidelines in the package insert for
    each specific formulation

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.

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 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.

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

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

58
FENTANYL PAIN PATCH CONVERSION
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.

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)

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)

62
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.    Dosages, and ranges of dosages represented, are a compilation of estimated equipotent dosages from published references comparing opioid analgesics in cancer and severe pain.    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
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

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

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

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

67
Pharmacological Therapies for Pain
ManagementAdjuvant Analgesics
  • Tricyclic antidepressants
  • Amitriptyline (Elavil)
  • Nortriptyline (Pamelor)
  • Desiprmine (Norpramin, Pertofrane)
  • Action-Inhibition of norepinephrine and serotonin.

68
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

69
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

70
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

71
ANXIOLYTICS
  • used for the treatment of anxiety, its related
    psychological and physical symptoms
  • minor tranquilizers

72
Anxiolytics/Benzodiazepines RxCIIIGenerally
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

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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

76
STIMULANTS
  • Psychoactive drugs which induce temporary
    improvements in either mental or physical
    function or both
  • Also known as Stimulants

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

78
Methylphenidate Dosage
  • For children gt 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)

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)

80
Insomnia Management
  • Sleep Hygiene
  • Melatonin 0.3mg daily
  • Melatonin Receptor Agonists (Non-Scheduled)
    ramelteon 8 mg hs

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 15-30 mg hs 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.

85
BODY MASS INDEX (BMI), kg/m2
Height (feet, inches) Height (feet, inches) Height (feet, inches) Height (feet, inches) Height (feet, inches) 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
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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.

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

88
RISKS OF DIET PILLS
  • Abuse of, or dependence on diet pills -
  • Development of tolerance to diet pills

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).

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

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93
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

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.
95
______ 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_____________ Telep
hone number _____________ for filling my
prescriptions for all of my pain medicine.
96
______ I authorize the prescriber and my pharmacy
to cooperate fully with any city, state or
federal law enforcement agency, including this
states 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.
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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 __________
________________________________________ Prescribe
r signature _____________________________________
_____________ Witnessed by ______________________
____________________________
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

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
  • ADHA (2012). The Basics. Retrieved January 30,
    2012 _at_ http//www.healthcentral.com/adhd/understan
    ding-adhd-000030_1-145.html?ic506048
  • 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)
    485490 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 _at_ http//www.ninds.nih.gov/disorders/hypersom
    nia/hypersomnia.htm
  • Pubmed (2012) Retrieved December 11, 2011 _at_
    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
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