AOA Focus March 2018 AOA Focus March 2018 Opioid prescriptions per year per 100 persons History of Drug Control International International Opium Convention of 1912 Convention for Limiting the Manufacture and Regulating the Distribution of Narcotic Drugs of 1931 ID: 738898
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Slide1
Disclosures
The presenter has no financial interest in any products or services mentioned in the lecture.Slide2
AOA Focus, March 2018Slide3
AOA Focus, March 2018Slide4Slide5Slide6
Opioid prescriptions per year
per 100 personsSlide7
History of Drug Control
International
International
Opium Convention of 1912
Convention
for Limiting the Manufacture and Regulating the Distribution of Narcotic Drugs of 1931
Single
Convention on Narcotic Drugs of 1961Slide8
History of Drug Control
United States
Pure
Food and Drug Act of 1906
Federal
Food, Drug, and Cosmetic Act of 1938
Kefauver
Harris Amendment of 1962
Controlled
Substances Act of 1970Slide9
History of Drug Control
Oklahoma
Oklahoma
Oral Medication & Controlled Substance Act of 1994
10/6/2014
changes to schedule II controlled substances
Prescription
Monitoring Program went into effect November 1, 2015Slide10Slide11Slide12Slide13Slide14
JAMA April 2016Slide15Slide16
From
NBCNews.com
...
Opioid Crisis Batters Georgia as Suspicious Percocet Kills Two
http://www.nbcnews.com/storyline/americas-heroin-epidemic/opioid-crisis-batters-georgia-suspicious-percocet-kills-two-n768951?cid=eml_onsiteSlide17
Definitions
Narcotic
a
drug or other substance affecting mood or behavior and sold for nonmedical purposes, especially an illegal one.
a
drug that relieves pain and induces drowsiness, stupor, or insensibility.
The
term "narcotic" is believed to have been coined by the Greek physician Galen to refer to agents that numb or deaden, causing loss of feeling or paralysis. It is based on the Greek word να
ρκωσις
(narcosis), the term used by Hippocrates for the process of numbing or the numbed state.
(Wikipedia)Slide18
Definitions
Opioid
an
opium-like compound that binds to one or more of the three opioid receptors of the body.
Opiate
a
drug with morphine-like effects, derived from opium.Slide19
Drug Schedules Slide20
Schedules I
Schedule
I drugs, substances, or chemicals are defined as drugs with no currently accepted
medical
use and a high potential for abuse
.
Potentially
severe psychological or physical dependence
Heroin
,
LSD, marijuana, ecstasySlide21
Schedule II
Schedule
II drugs, substances, or chemicals are defined as drugs with a high potential for
abuse
Use
potentially leading to severe psychological or physical dependence
.
Vicodin,
cocaine, methamphetamine, methadone,
oxycodone
(OxyContin),
Adderall
, and RitalinSlide22
Schedule III
Substances
, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence.
Tylenol
with
codeine,
ketamine, anabolic steroids, testosteroneSlide23
Schedule IV
Schedule
IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence.
Xanax
, Soma
, Valium
, Ativan,
Talwin
, Ambien, TramadolSlide24
Schedule V
Schedule
V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes.
Cough
preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC),
Lomotil
,
Motofen
, Lyrica,
ParepectolinSlide25
Drugs
Opium has three main components:
Morphine
Codeine
ThebaineSlide26
Morphine
In
1803,
morphine
, the principal ingredient in opium, was extracted from opium resin
.
Morphine
is ten times more powerful than processed opium, quantity for quantity.
Morphine remains
the standard against which new pain relievers are measured.
Heroin
is synthesized from Morphine.Slide27
Codeine
Codeine
has less pain-killing ability than morphine and is usually taken
orally
As
a cough suppressant, it is found in a number of liquid
preparations
Hydrocodone
is a semi-synthetic opioid synthesized from codeineSlide28
Thebaine
Oxycodone
is synthesized from
thebaine
Like
morphine,
oxycodone
is used for pain
relief, and is taken orally
When
abused,
oxycodone
tablets are crushed and snorted, or dissolved in water and
injectedSlide29
Mechanism of Action
NSAIDs
work on the peripheral nervous system
Opioids
work on the central nervous systemSlide30
Dosage
Zohydro
ER (
hydrocodone
) 10, 12, 20, 30, 40, 50
Roxicet
,
Endocet
, Percocet (
oxycodone/acetaminophen
) 2.5/325, 5/325, 7.5/325, 10/325
Vicodin
,
Lorcet
, Lortab, Norco,
Xodol
,
Hycet
(
hydrocodone/acetaminophen
) 2.5/325, 5/300, 5/325, 7.5/300, 7.5/325, 10/300, 10/325
Ibudone
,
Reprexain
,
Vicoprofen
(
hydrocodone/ibuprofen
) 2.5/200,5/200,7.5/200,10/200
Tylenol
with Codeine (
acetaminophen/codeine
) 300/15, 300/30, 300/60
Ultram
(
tramadol
) 50mgSlide31
Prescribing
Schedule II
Hydrocodone/
acetominophen
5/325
#12
1 tablet PO q4-6
hrs
Schedule III
Tylenol #3 (
acetominophen
/codeine) 300/30
#12
1 tablet PO q4-6
hrs
Consult pharmacist for pediatric dosingSlide32
Contraindications
Use
of other acetaminophen-containing drugs
Acetaminophen
associated with acute liver failure include cases of liver transplant and death; most liver injury associated with acetaminophen doses >4000 mg per day and >1 acetaminophen-containing
product
Concurrent benzodiazepine useSlide33
Side Effects
Serious
Respiratory
depression
Hepatotoxicity
Common
Constipation
Drowsiness
Nausea
and vomitingSlide34
Relative Strength
(weakest to strongest)
Tramadol
Codeine
Morphine
Hydrocodone
OxcycodoneSlide35
Pricing
Zyhydro
ER
($7.78 brand only
)
Percocet
5/325 ($11.95 brand,
$0.49
generic
)
Lortab
5/325 ($0.31 brand,
$0.23 generic
)
Vicoprofen
7.5/200 ($15.60 brand,
$0.24 generic
)
Tylenol
III ($1.44 brand,
$0.36 generic
)
Ultram
($2.77 brand,
$0.07 generic
)Slide36
Definitions
Addiction
: a medical condition characterized by compulsive engagement in rewarding stimuli despite adverse consequences
Dependence
: an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
Tolerance
: the diminishing effect of a drug resulting from repeated administration at a given doseSlide37
DEA Rules for
Prescribing Controlled Substances
All
controlled
substances
Schedule II
Schedules
III-VSlide38
All Controlled Substances
Must have a DEA numberSlide39
All Controlled Substances
A
prescription
must
be dated on the date when
issued
Must
include the patient’s full name and address, and the practitioner’s full name, address, and DEA registration
number
Must
be manually signed by the practitioner on the date when
issuedSlide40
Schedule II
No
refills
May
transmit
facsimile
.
However, the
original
prescription
must be presented to the pharmacist
prior
to the actual
dispensing.
Exceptions:
Long
Term Care Facilities (
LTCF)
Hospice Care Program.
The practitioner or agent will note on the prescription that it is for a hospice patient.
Slide41
Schedule II
In an emergency, a practitioner may call-in a
prescription
The
quantity prescribed and dispensed is limited to the amount adequate to treat the patient during the emergency period.
The
prescribing practitioner must provide a written and signed prescription to the pharmacist within
seven days
. Further, the pharmacist must notify DEA if the prescription is not received.Slide42
Schedules III-V
Prescriptions may
be transmitted by
facsimile
from the practitioner or an employee or agent of the individual practitioner to the dispensing pharmacy. The facsimile is considered to be equivalent to an original prescription.
A
pharmacist may dispense
an
oral prescription
made by an individual
practitioner. It must contain all
information required for a valid prescription, except for the signature of the practitioner.Slide43
www.dea.govSlide44Slide45Slide46
CDC Guidelines Summary
Non-opioid
therapy is preferred for chronic pain
outside of active cancer, palliative, and end-of-life care. Opioids should only be used when their benefits are expected to outweigh their substantial risks.
When
opioids are used, the
lowest possible effective dosage should be prescribed
to reduce risks of opioid use disorder and overdose. Clinicians should start low and go slow.
Providers
should always exercise caution when prescribing opioids and
monitor all patients closely
. Clinicians should minimize risk to patients—whether checking the state prescription drug monitoring program, or having an ‘off-ramp’ plan to taper. Slide47
Drug Seeking Behavior
Patient-described
pain level not matching what’s observed or reporting a 10-out-of-10 pain
threshold
Requesting
medication by
name
Requesting
a
specific dosage
Reporting
lost or stolen
medications
Requesting
a
refill
.
AOA Focus, March 2018Slide48
Patient Resources
The
Substance Abuse and Mental Health Services Administration (SAMHSA) has a National Helpline,
1-800-662-HELP (4357)
, for those with a possible opioid use disorder. The Helpline is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders.
To
find an authorized Opioid Treatment Program dispensing methadone or buprenorphine to treat opioid dependency in your state visit:
http://dpt2.samhsa.gov/treatment/directory.aspx
To find an authorized DEA Registered Practitioner to treat opioid dependency with buprenorphine in your state visit:
https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator