Controlled Substance Prescribing in the Geriatric Population

1
Controlled Substance Prescribing in the Geriatric
Population

• Lisa Byrd PhD, FNP-BC, GNP-BC
• Gerontologist

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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

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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

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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

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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"

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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

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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

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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

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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

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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

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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

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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

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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

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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

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DEFINITIONS

• COMMON TERMS IN USE OF CONTROLLED SUBSTANCES

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PAIN

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

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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

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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

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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

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CPS-Pathophysiology

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

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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

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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

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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

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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

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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

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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

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Pain Control

• is every patients right

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BASIC PRINCIPLES

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

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Principles of Pain Management

• Anticipate, prevent, and treat pain
• Anticipate, prevent, and treat adverse effects of
  pain management

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Pain Assessment

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

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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

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4 types of pain

• Nociceptive
• Mechanical
• Inflammatory
• Tissue destructive
• Neuropathic
• Muscular
• Psychogenic

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NOCICEPTIVE PAIN

• Nociception implies active mechanical, thermal or
  chemical process

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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

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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

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Psychogenic pain

• is pain that originates through cognitive
  emotional processing
• examples are conversion disorder, factitious
  disorder, somatization disorder

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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

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Types of pain management agents

• Analgesic agents
• Nonsteroidal anti-inflammatory agents
• Non-opioids
• Opioids
• Antidepressants
• Anticonvulsants
• Anxiolytic agents

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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

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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

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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

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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

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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

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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

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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

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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

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Pharmacological Therapies for Pain Management

• Opiods-Agonists
• Codiene
• Morphine (MS Contin, Oramorph, Kadian, Roxanol)
• Hydrocodone (Vicodin, Lortab)
• Methadone (Dolophine)
• Oxycodone (OxyContin, Roxicodone, Roxifast)

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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)

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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

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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

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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.

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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.

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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

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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

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FENTANYL PAIN PATCH CONVERSION
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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.

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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)

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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)

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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
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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

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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

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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

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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

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Pharmacological Therapies for Pain
ManagementAdjuvant Analgesics

• Tricyclic antidepressants
• Amitriptyline (Elavil)
• Nortriptyline (Pamelor)
• Desiprmine (Norpramin, Pertofrane)
• Action-Inhibition of norepinephrine and serotonin.

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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

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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

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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

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ANXIOLYTICS

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

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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

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HYPERSOMNIA

• excessive daytime sleepiness or prolonged
  night-time sleep

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STIMULANTS

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

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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

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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)

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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)

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Insomnia Management

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

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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
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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
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WEIGHT MANAGEMENT
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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.

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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.

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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

92
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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.
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______ 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.
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______ 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 ______________________
____________________________
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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