Opioid Addiction from the Words of a Patient

Opioid addiction and misuse has been around since the earliest civilizations. Certainly when I graduated from Dalhousie College of Pharmacy 24 years ago and started working as a Pharmacist in Baddeck, we were all aware of such addiction. Based on what we were taught at the time, anyone who took an opioid dose of only the required amount for their pain and no more, would almost certainly avoid opioid misuse. This theory, largely fed to the medical community by the industry making these medications, has now proven to be untrue. The corporate deception has gone as far as to be prosecuted at a criminal level. Based on our centuries of using this class of medication it’s really a wonder it took us this long to figure out the truth.   Although the story behind that deception is too long to go into here, one thing is for sure, the opioid epidemic which has been gradually marching entirely across this continent eastward has become one of the most urgent medical crises of our time.

 

A few years ago I became involved with a group of medical professionals concerned with this topic called the Atlantic Mentorship Network, which has a focus on pain and addiction. It has turned out to be the best alignment in my career. Headed by Dr.’s Peter MacDougall and John Fraser, it is undeniably the best resource for anyone in working with pain or addiction treatment. They recently held a one day conference in September in Inverness that focused on the Challenges and Opportunities in the Delivery of Pain & Addiction Care in Rural Communities. Held this year at the beautiful Inverness County Centre for the Arts, it was a great collection of a dozen speakers that really educated and inspired those in attendance to take back to work helping those with pain and addiction and preventing addiction. All did an amazing job at educating from their own standpoint of doctor, pharmacist, counselor or Nurse.

 

Without a doubt, the absolute highlight of the day for me came not from any healthcare professional, but from a guest invited to speak on the topic of addiction by the name of John MacDonald. Accompanied by Laura Chapman MPH and Chera Clements RN, John quietly and modestly approached the podium as undoubtedly the bravest person in the room. Not used to speaking in front of the 60 plus people that were in attendance, he stated his name and openly announced himself as a recovering drug addict. John spoke for about 10 minutes, which probably seemed like an eternity for him. Little did he know the grasp he had on this group. In a day filled with Powerpoint presentations and laser pointers, he quietly stood in front of a group of strangers holding a hand written note in a simple scribbler and delivered an address that I don’t think I’ll ever forget. It took an experience like this to reinforce to me that the few brief interactions with patients I see every day at my work who have addiction issues did not choose to become that way. I later asked Laura for a transcript of his presentation so I could include it in the words he wrote with his permission, which he was happy to supply
. Without this, most of his effect would have been lost here. In listening and watching him that day, I was reminded of my own healthy children and how easily it is to have your life nearly destroyed by opioids. Remember that rescue Naloxone kits are provided free from pharmacies in Nova Scotia. If you are misusing opioids or are in regular contact with someone that is, you owe it to yourself to have a kit and learn how to use it. It may almost certainly help save a life.

Here is a transcript of John’s presentation:

 

Hello Everyone. My name is John MacDonald. I’ve been asked to speak to you today about substance abuse and addiction.

I’ve been using drugs since I was 13 years old. And in that 17 year period, myself, as well as our communities, went through different drug fads. First – it was cannabis, LSD, mushrooms, ecstasy and amphetamines and any other upper available. Then when I was 14, I started using oxys, cocaine, and crystal meth when available. Not all that long after, I found myself physically dependent on oxycontin and at that point, I had no idea what I was going through. I was never told before you could get sick without it. After a few days of waking up sick but getting better after I used, I googled side effects of oxys and that’s how I learned I was physically dependent. When I was a teen, we never learned about this kind of staff and never had programs at school geared toward drug prevention.

I started injecting drugs around the age of 15 and pretty soon, my addiction became even more out of control. I found myself becoming someone I couldn’t recognize. You see I didn’t set out wanting to become addicted to drugs or to be a junkie. No one does. It happens slowly over time. I experienced a lot of trauma in my early life and because it offered an escape from the horror of my home and public life while I was high nothing or no one could hurt me. However, after a while, it did more harm than good. Even today, I’m trying to reverse the damage drug addiction and substance abuse caused as I’m sure I will always have to do the rest of my life.

I spent years in and out of Detox but because I was there so often, when I would go, they would fast track me and turn a short time even shorter. I’d be discharged in the first week often leaving in withdrawal, which in turn would make my decision to use easy. The times I managed to stay off drugs for a few days after getting out, I would have everyone I used with constantly offering me free drugs and dealers calling trying to get me to use free stuff. They did it because they couldn’t clean up so they didn’t want me to but, whatever the reason, I always ended up giving in.

Drugs took everything from me, my dignity, health, family and friends. It made me homeless, sleeping under stairs, in ditch coverts, on benches. I even slept under the band shell in New Waterford one winter but more importantly, it made me lose myself and my love for myself and my happiness as it does and will continue to do to anyone that comes in contact with these substances.

Over the past 17 years, I have overdosed more than 20 times. I’ve witnessed more than anyone would be able to comprehend and I just lost my 28th friend from an overdose.

The Naloxone training program, I feel, is a god send because there are people alive today that probably wouldn’t be if Naloxone wasn’t readily available. I, myself, administered Naloxone on two separate occasions. The friends of those individuals were too scared to call 911 because they thought they would get arrested or in trouble with the police in other ways, so a person there knew I had a kit so he called me. I feel everyone who uses opiates should carry one and if someone you live with or a loved one uses them, you should also have one at hand in case they are using alone and overdose then you would be trained to administer the life-saving injection.

Anyway, thank you for listening and I hope you all have a great day.

 

This was followed by the largest round of applause we had heard all day, not to mention some encouraging support during his talk from those in attendance. Thanks again John for your insightful words and the best of luck with your future, which I am thinking might result in more than a few saved lives if he continues appearances such as this one.

 

Graham MacKenzie Ph.C.

Stone’s Pharmasave

Baddeck, NS

@grahamcmackenzi

graham@stonespharmasave.com

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Dispensing Pain Meds as a Specialty Service
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I have seen many changes happen to pharmacy in the last 24 years. One of the most career-shifting has been the change in the reimbursement model that has forced pharmacy to revisit how it makes money to remain afloat while continuing the important work of patient care. The traditional work I am referring to is not something that carries the business for most independent pharmacies.

Even before this adjustment to our financial model, we were criticized for not charging for other everyday services. Now, not only are many of us leaving money on the table for uncharged services that would easily have been charged by other professions and accepted by the public, but we are charging for dispensary services in unsustainable ways that fail to reimburse the business. Specialty services like methadone, travel clinics, injections, med reviews, compounding, nursing home filling, and others have helped relieve some of the financial strain on some pharmacy businesses. Some day soon I am sure medical marijuana will be one of those services.

Take two of these programs: methadone and medical marijuana. One currently runs in many Canadian pharmacies and one is on the horizon. Both of these have and will continue to gain popularity for the pain patient that has been prescribed opioids. In the case of methadone, it becomes a specialty rescue plan to give the patient back at least a small part of normalcy, even if there is no projected hard endpoint in sight. It can allow patients to stay off of street drugs and steer away from opioid addiction, and in addition keep their family, hold a job (at least one that allows them to go for a witnessed ingestion daily), keep some financial stability and make plans for the future. While this system has its share of abusers, the theory is sound.

In the case of medical marijuana, we try to remove opioids in a less proven method perhaps, and use a CBD/TCH combination to deal with pain in a way that has shown to work, even though we still have much to learn about long-term effects. Compounding can be included here as well, as studies have demonstrated and I have personally seen a regular pattern of reduced oral medications for pain when topical compounded products are introduced.

These demonstrate a practise we have shown in modern medicine for “a pill for every ill.” This is your symptom so this is your medication. In our defense we do try to project wellness campaigns into our profession surrounding eating right and physical activity—both with huge potential benefits. We actively run screening programs for cholesterol and blood glucose—again, often in free clinic formats without much evidence to back up clinical outcomes, such as death rate or disease prevention. This is all in the hope of reminding people to think about their health.

We have all pursued prevention programs in our pharmacies in one way or another. I removed sugary beverages a few years ago (a public health campaign that still resonates with my store today). I filmed a 40-minute healthy grocery shopping tour for YouTube for anyone to watch for free, and I have also done the blood pressure and glucose/cholesterol clinics in my store. In an era where evidence-based practitioners are claiming random screening in healthy populations proves questionable benefit, we push on despite costs to our businesses in both time and money.

What about the patient with either an acute need for a strong pain reliever or the one who is the long-term pain patient? You must be living under a rock if this hasn’t caused you to stop and think about where this patient will be in a few years (especially if they are not handled properly by both you and their doctor). Every time you fill a methadone prescription should make you think even harder. Why do we go through the trouble to screen for other diseases and prevent health complications while at the same time filling an opioid prescription while thinking “is this patient early for their refill?” Most of us have spent more time talking to a diabetic patients about their health than an oxycodone user about where their health is going. Is the potential impact of where that opioid patient could be headed any less drastic than the diabetic patient if not monitored properly? Even the patient on regular naproxen is probably not on our radar as someone who may get switched to an opioid and develop misuse issues down the road.

There are many responsible narcotic users out there who just don’t seem to be heading for any addiction or misuse problems. These patients are no less important when it comes to our vigilance though. We have tools available to us to help screen out those who are more likely to misuse. None of these tools are scientifically proven but they are based on our experience with various patient groups with opioids.

Realistically, any pain patient requires more time than the average patient even from day one. As specialized as methadone is today, it has become a regular fill commodity where a hundred or more patients come in for a witnessed ingestion and leave. With these numbers, there isn’t much time for a ”sit down” with each and every one. In stores with a more realistic number of patients, such as 10-20, it is conceivable that pharmacy staff is able to discuss how therapy is going each time, if they are showing subtle signs of drug use. A more one-on-one environment that isn’t rushed might bring out other signs of sub par therapy, drug diversion and other misuse.

If third-party payers reimbursed for such a specialized service, it would improve health outcomes in the long run. Each patient should be interviewed with each renewal of their opioid and as an initial consultation.  Pharmacists are in the best place to detect misuse. A patient that is yawning or restless in front of you, or perhaps agitated during the med review, may be showing signs of withdrawal from an opioid and could be a patient who is taking other sources of opiates along with their prescription. Urine drug testing should be discussed as a possibility early on with treatment as well so that it doesn’t offend patients later on when they are suspected of misuse.

It is estimated that 22% of patients will discontinue opioid therapy due to side effects. This may involve dose-limiting side effects that would require a dose reduction or even a discontinuation of the medication. This may include sedation, which should be assessed with high opioid doses (especially more than 200mg oral morphing equivalents) and with each dose increase. Although this will often resolve itself with tolerance, if suspected it should be monitored closely. Asking a patient to return to the pharmacy within a few hours after a dose may help.

Cognitive dysfunction follows the same warnings of dose increase and high dose as with sedation but can be trickier to pick out unless you take time to speak to the patient for a few minutes. It involves cloudy thinking, poor memory and diminished concentration. As with sedation, reducing the dose, discontinuing the drug or opioid rotation can help. Opioid-induced hyperalgesia is a side effect where this specialty service proves its worth. Again it tends to occur at higher doses and is a phenomenon where the pain threshold seems to drop, giving an increased sensitivity to pain as the opioid dose increases. Instead of a knee jerk increase in opioid dose, the dose should actually be tapered or a COX-2 inhibitor can be given concurrently. It has also been recommended that an NMDA receptor antagonist like Ketamine be tried. Quite often this molecule is used in our pain compounding.

A potentially serious side effect that can occur with opioids is sleep apnea, possibly due to the effect on sleep architecture. This may affect up to 30% of all patients on chronic opioid therapy and can significantly exacerbate a pre-existing sleep apnea condition. This is why it can be helpful for the partner of the patient to come with them to the interview with each fill. Extra information may be gleaned from this type of environment. Respiratory depression is a commonly known side effect of opioid use, however tolerance develops rather quickly and is often a problem only with patients with pulmonary disease like COPD or asthma. It can result in limiting the dose in these patients especially at higher doses.

Constipation, nausea, vomiting, dry mouth, pruritis, urinary retention, myoclonus, hormonal effects, immune suppression, and weight gain/sugar craving are all important side effects that should be addressed and monitored. It is difficult to do all of this with a typical prescription handout at the counter. Of course, the most important effect to monitor is addiction. Although the risk of this is low, it is still a real possibility and constant vigilant monitoring is important to cover your bases.

Tapering doses has become popular with recent warnings to keep patients below 90 oral morphine equivalents. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain strongly recommends a coordinated multidisciplinary collaboration approach that involves several health professionals that are readily accessible to the physician. The Nova Scotia College of Pharmacists’ registrar Bev Zwicker released a communication to its members on June 26 explaining that the College of Physicians and Surgeons of Nova Scotia warning that the tapering of opioids needs to be done sensitively, collaboratively and with realistic expectations. It also confirmed that rapid withdrawal could be dangerous if done too quickly and that these high- -dose patients cannot be abandoned. These guidelines need to be reviewed by all involved especially pharmacists. Tapering should be considered if there are dose-limiting side effects that are intolerable, if the opioid trial is failed, if the pain has resolved itself, or if there is evidence of addiction or diversion. Most of these tapers are voluntary but the decision may be made by the physician unilaterally. Assessing the patient during the taper requires close monitoring for withdrawal symptoms.

This year, The Journal of the American Pharmacist Association published a paper where a pharmacist-led opioid exit plan for acute postoperative pain management can  have benefits when involved at the point of admission, during the post operative recovery period and on discharge. A 2013 BMJ Open paper outlined an RCT where regular GP care was compared to pharmacist-led management of chronic pain and demonstrated improved pain outcomes with the pharmacist-led management.

A 2014 study involving a pharmacist-initiated intervention trial in osteoarthritis showed that patients experience quantifiable benefits from interprofessional collaboration among pharmacists, physicians and physiotherapists. We have also seen pharmacists’ involvement in the co-management of acute pain and substance use disorder improves patient safety and pain control.

Creating your own niche market where you are the go to pharmacy for beneficial outcomes in acute and chronic pain patients becomes key where you are trying to prevent opioid misuse and abuse. It starts with one on one time with the pharmacist and patient each time they come into your pharmacy. It can make your pharmacy the safe place for patients, from their initial prescription for pain to managing a chronic condition while avoiding addiction. Hopefully a patient or their third-party plan would pay for that service.

References:

Ware et al CMAJ 2010; 182(4)

AMN The Prescribing Course—Safe Opioid Prescribing for Chronic Non-Cancer Pain 1st Ed Oct 2014 MacDougall/Fraser

Bruhn H, Bond CM, Elliott AM, et al. Pharmacist-led management of chronic pain in primary care; results from a randomized controlled exploratory trial. BMJ Open 2013;3:e002361

Marra, CA et al Cost-Utility Analysis of a Multidisciplinary Strategy to Manage Osteoarthritis of the Knee: Economic Evaluation of a Cluster Randomized Controlled Trial Study. Arthrit Care Res. 2014 June; 66 (6): 810-816

Andrews LB, et al, Implementation of a pharmacist-driven pain management consultation service for hospitalized adults with a history of substance abuse. Int J Clin Pract. 2013 Dec; 67 (12): 1342-9.

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Thank you Marijuana for taking the bad press off of bioidentical hormone therapy.
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  June 17, 2017 : looking back hardly a day or two goes by since this year began when a question about medical marijuana or as we call it out here “marijuana” and what is going to happen next July … Continue reading

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Preventing Medication Errors and the ISMP

One evening in late October of this year I sat down with a rep from a compounding pharmacy supply company to discuss how our compounding business was going.

One of the first topics he brought up was a story of a young Mississauga boy, Andrew, who had died from an apparent mix-up with a compounded medication.

The boy died of an overdose of baclofen after taking a prescription that was alleged to contain tryptophan for sleep. It was the first I had heard of the tragic story.

It is a scenario that mimics the worst possible case in the back of our heads each time we as pharmacists go to work each day.

As fallible human beings I consider us the strongest and weakest link in the chain of what has largely become an automated day—automated with humans that are capable of a momentary lapse of attention that can kill someone.

It not only focuses directly on errors but on almost any conceivable reason for them occurring

Almost exactly a month later, I am reading in Halifax’s Chronicle Herald of Ontario’s Health Minister Eric Hoskins desire to tighten the safety of his province’s pharmacy dispensing in the wake of this tragedy.

As part of that process he’s looking at how Nova Scotia has dealt with this issue (thechronicleherald.ca/novascotia/1416107-nova-scotia-pharmacies-lead-in-safe-medicine-practices, namely through an initiative called SafetyNET-Rx. ( http://www.safetynetrx.ca)

This story, of course, grabbed my attention, not only because I am a community pharmacist, but also because I also compound and live and practice in Nova Scotia.

I am further pulled into this story because the SafetyNET-Rx initiative mentioned was started at a former alma mater (St. Francis Xavier University in Antigonish, Nova Scotia), in part by a former classmate of mine from Dalhousie University College of Pharmacy (now Dean Neil MacKinnon at U of Cincinnati Winkle College of Pharmacy).

As a practising Nova Scotia pharmacist, I am fully involved with SafetyNET-Rx. Our pharmacy in Baddeck was part of the pilot project in 2010.

The Nova Scotia College of Pharmacists’ Standards of Practice (www.nspharmacists.ca/?page=standardsofpractice ) now outline that every pharmacy in the province must have a Continuous Quality Improvement (CQI) plan in place.

This is a requirement in the Practice Regulations to the Pharmacy Act of Nova Scotia.  For the first time we now have a monitored, effective QCI process that tracks quality related events (QREs).  It is the SafetyNet-Rx model we use now.

So what does this involve in our day-to-day work in the pharmacy? Mainly, anytime there is a QRE, we note it in a scribbler to be entered later into an online recording system.

These errors encompass everything that can go wrong, such as a prescription handed out for the wrong drug or directions or doctor (even if it exactly follows the actual prescription but was an unintended change).

Most of the recorded errors include mistakes made before the prescription actually gets to the patient’s hands. Every time we enter the wrong doctor, drug, strength or directions, it gets marked down. In a busy day we do the best we can to record these events but in reality some do get fixed and aren’t recorded.

These events are formally recorded online on the Community Pharmacy Incident Reporting site—ISMP (Institute for Safe Medication Practices).

Each pharmacy has its own username and login and can search based on several metrics the types of errors that occur, the days of the week they occur the most, who detected the error, contributing factors, degree of harm from the incident and what the error was—both for your pharmacy and combined aggregate of all pharmacies on the system.

It’s quite interesting to see these comparisons. All of this data is invaluable in helping to prevent future errors. Quarterly staff meetings are required and helpful in sharing this information.

Through this reporting system, we are keenly aware now of the most common source for errors, who is most likely to catch the error, why the error occurred and even when it is most likely to occur.

This allows us to plan staffing and make corrections that we would have normally made after a mistake is made; except now we can do it before the incident occurs.

We can see how we compare with all other community pharmacies and if a discrepancy occurs we can immediately make changes.

Knowing the most common errors prompts one to be extra careful in that field. For example, if you know your store has an inordinately high number of errors that involve number of doses dispensed compared to the aggregate, it becomes a focus until it is normalized.

If we find that many errors occur with incorrectly written prescriptions at the physician level, we would have that conversation with the physicians.

Along with this reporting system, there are several other checks in place.  Many of these are done by any other pharmacy in the country.  Staff emergency contacts are recorded, as are the numbers for all services used by the store from police and fire down to insurance, electrician, plumber, computer data and storage in case they are needed by any staff member.

Regular audits are done that range from removing outdated stock, adverse drug reaction reporting, monthly narcotic drug inventory reconciliation, equipment and facilities certification, adherence to standards of practice are recorded and annual staff performances.

Confidentiality agreements are signed, pandemic planning is completed, robbery and break-in procedures are made and reviewed and emergency response plans of all types are done (staff and customer accidents, fire, leaks, toxic spills and power outages).

For our pharmacy in Baddeck there were a few changes we made as a direct response from all of this monitoring.  We determined the time of day and day(s) of week that we were most likely to see an error and we adjusted staffing levels to be heavier at those times.

We also determined a certain physician that had a higher probability of making an error when writing a continuation prescription for a drug that the patient was already on. This alerted us to pay extra attention to this occurring with this physician.

We also added another satellite computer in the pharmacy, not only as a reminder to document but to allow easier, daily documentation of events.  When it wasn’t possible to do this we jotted them down for later entry.

Another interesting thing that came out from this was through the stringent narcotic self audits.  We started noticing that a certain brand of medication was short one tablet in each bottle we were getting so these bottles were counted upon opening and the rep was alerted to the problem.

We also realized that the most common “near miss” incidents were incorrect quantity and incorrect dose. Special attention was brought to this during the quarterly meetings so extra attention on filling the script would prevent the problem again.

Future reports of quality assurance demonstrate the effect of these changes, new problem areas are found and new targets are made. Regular Medication Safety Self Assessments are done. This is a valuable tool that assesses the pharmacy’s overall ability to function safely based on many parameters and is done on a regular basis.

It is really an environment full of information that was floating there unharnessed before that monumentally helps to improve the safety of our patients when acted on.

If it seems like a lot of extra work in an environment that has very little down time, then you are correct.  Personally though, I have always found a huge sense of calm knowing something extra was done to double check that a patient got what they were supposed to get when they leave my pharmacy.

The time involved though blends in with our work and is worth it.  Time management is a skill that becomes greater as a result.

Getting back to the original patient we spoke of, Andrew, would this event had occurred if all of this were in place?  It is difficult to speculate as the cause is before the courts right now.

One thing though is for certain, making an error is an opportunity to explore why that error occurred and make corrections so it won’t happen again.

In the December 1989 issue of the CAPSIL (The Canadian Association of Pharmacy Students and Interns), I wrote one of my first public articles (without the internet) on the topic of Medication Errors (http://capsi.ca/wp-content/uploads/2015/01/CAPSIL-JACEIP-1989-Dec.pdf ).

It is a subject that will never completely go away. It is a disservice to our patients to not act on each error as a learning experience. SafetyNET-Rx is an invaluable tool that really turbo charges your incident prevention and kudos to the Nova Scotia College of Pharmacists for implementing this requirement into their standards.

It not only focuses directly on errors but on almost any conceivable reason for them occurring. Hats off to my friend and Colleague Dean Neil MacKinnon for his role in its development.  This standard is a huge leap forward that has caught the attention of the rest of the country.

I had the pleasure of corresponding with Andrew’s Mom earlier this year who contacted me ahead of a meeting with the Ontario College of Pharmacists Task Force where a proposal for medication error reporting was on the agenda. The College also contacted me ahead of this meeting to share ideas on the ISMP and my experience with it. Andrew’s Mom was glad to see movement on this system and its potential introduction in Ontario and thanked me for writing about this topic for the national audience of Canadian Pharmaicsts on the Canadian Healthcare Network. Hopefully some good comes out of this tragedy.

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Essay on the life of J. Esmonde Cooke (1990)


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Pharmacy Starts Healthy Cooking Class for Its Patients Families
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In 2015 I took four months to film a healthy grocery shopping tour with the help of a local filmmaker where I went through all areas of the grocery store to help people make healthy choices for themselves and their … Continue reading

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Why Your Pharmacy Should Stop Selling Sugary Beverages

Two of the most common questions I get about my discontinuing of selling sugary beverages in September of 2014 is A) Did I notice a drop in income because of the lost sales of this line and B) Did I notice an increase in sales because of this move.

Before I stopped selling this line I would see perhaps $1000 on a good month in sales of these products. I don’t have a number of the extra sales made when customers came in to buy pop, juice, vitamin water, chocolate milk, or iced tea. This might be picked up by measuring a drop in sales beyond the regular amount of these beverages sold. Since there really wasn’t a drop in sales though, it is difficult to tell if these ancillary sales dropped or not.

One thing is for sure, the unexpected volume of free advertising it gave the store more than made up for anything lost on pop or any other extra product not being purchased with it. It elevated the reputation of the store to a destination where customers knew we were willing to try something bold to further their health, even if it meant less revenue.

One great offshoot of this event was the introduction it brought us to a key Canadian researcher, Leia Minaker at the University of Waterloo’s Propel Centre for Population Health Impact. She took notice of the activity in Baddeck and started a natural study to determine the effect this had in the selling of pop in Baddeck after that day in September. She collected sales data not only from us but from the two other major sellers in the Village and determined that there was no switching behavior in purchasing to these other outlets. The study was published in BMC Public Health in 2016. (Minaker LM, Olstad DL, MacKenzie G, et al. An evaluation of the impact of a restrictive retail food environment intervention in a rural community pharmacy setting. BMC Public Health. 2016;16:586. doi:10.1186/s12889-016-3281-9).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947263/

Another great find for me was Dr Yoni Freedhoff, one of this country’s most prominent voices not only on unhealthy marketing practices to everyone (especially children) but also on the larger topic of obesity.

After two and a half years I look back on this move as the best one I could have done for my Pharmacy. When I think of the doubt I had in the months or weeks leading up to this I now realize the worry was for nothing. In this day and age, we try to rock the boat as little as possible in our pharmacy models for fear of going out of business. I can assure you if by some stretch your pharmacy would close based on the lost sales of sugary beverages, then maybe you should be in a convenience store type of setting instead. If you know for a fact that the small amount of profit made on this loss leader (if any at all) won’t affect your store adversely, and you realize the huge price tag that the consumption of these beverages costs your country long term, what is the holdback in removing them from your business?  After all, shouldn’t we be partly responsible for this cost to the healthcare system by continuing to sell liquid calories and in effect promoting them? When asked about other snack foods, which we have overhauled as well at Stone’s, my response is that this is my contribution to educating the public on one of the most common sources of extra calorie consumption starting with children and moving right on up to older adults. If you own a pharmacy, make a mark by taking your own stand on something that you know is causing harm to your patients. You’ll feel better for it and so will your business.

 

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Why the Pharmacy OTC Section Will Be a Growing Target for Evidence Based Medicine Trolls
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The front store of the pharmacy has traditionally been where the pharmacist and patient relationship grows to a level beyond where it would be with just prescription counseling alone. It affords to pharmacists a selection of products that empowers the … Continue reading

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Going forward with the opioid crisis as a health practitioner.

If you’re a prescriber or pharmacist, you owe it to yourself to check out the Atlantic Mentorship Network’s Prescribing Course – Safe Opioid Prescribing for Chronic Non-Cancer Pain. I had the pleasure of attending this course this weekend in Halifax, Nova Scotia. Although I had been trying to get to this amazing course for quite some time, my schedule finally permitted me to get there this year. In fact it was such an incredible learning experience I felt I should share it with you. As a disclaimer: I am a pharmacist, I have presented for the Mentorship program before, I have no financial interest in the program although I am involved with the planning of the program’s Fall Conference in Inverness Cape Breton this year. Other than that I’m just a fan of the Network.

Chaired by Dr. Peter MacDougall and Dr. John Fraser, this day-long event goes through pearls on what best practices are to deal with the average person with pain. This is not end of life pain or cancer pain, where boundaries are much wider. It is the tough world of dealing with pain at a time that threatens the potential of addiction more than we were aware of at any other time. It threatens safety of prescriber, patient, and the public. Even Dr. MacDougall claimed what many of us were told years back when dealing with narcotics: that we used to think that as long as there was still pain, the chance of addiction was extremely rare. The Nova Scotia College of Physicians and Surgeons are quite active now in reducing the narcotic load in our patients, as are the other provinces in Canada as the wave of overdoses washes eastward. They have adopted the CDC guidelines for treating this type of pain, which includes more of an emphasis on non-narcotic and non-drug.

As someone who feels the burn of the “online” world of alternative treatments and skeptics’ treatment of them, believe me it was refreshing to be in an entire room full of 40 legitimate practitioners embrace whatever works for their patients. I have commented on this phenomenon before and it was evident here again. Terms like physiotherapy, chiropractic, massage, TENS, acupuncture, qigong, yoga and other terms used side by side are embraced by physicians as treatments that have clinical results that they may or may not have success with. I have been working as a pharmacist for almost 24 years and the most important clinical pearls I picked up were:

-If someone claims to be travelling away and needs their Narcotics early ask them when, how are they getting there and where are they staying. This allows you to call contacts (landline) while the patient is sitting in front of you in the office and gives an opportunity to ask (demand) to see plane/bus/train tickets.

– There are many Addiction Risk Assessment tools that really don’t have any evidence to back them up but they can be clinically effective tools in seeing who might be at the highest risk for addiction in the future and who may require special attention going forward with their therapy.

– Although many patients in our patient records claim to be allergic to morphine, this “allergy” may actually be a normal pruritis side effect from the morphine and not an allergy at all.

-An increased request for more narcotic dosing may occur after a previous increase in dose for many reasons. It may be from hyperalgesia from the narcotic causing more pain. It may be from the increased activity that the pain relief allowed – which causes more pain. The concepts of pseudoaddiction, tolerance, pseudotolerance, opioid withdrawal, failed opioid trial and chemical coping are all important factors to consider.

-One way to realize if an aberrant behavior more serious or less serious is to ask yourself,   “I would never think to do that” or “I wouldn’t even know how to do that”. If the answer is “yes”, then it is most likely a more serious behavior.

– Safety of the prescriber is paramount

– UDT or Urine drug testing (preferably onsite) and a patient contract should be a standard practice for your opioid patients. It should be kept in mind that not only is UDT an important piece to the overall puzzle, its limitations should be kept in mind.

– “It is the information and not the story” that should be considered with abberant behavior. Why you ran out early is less important than the fact that you ran out early.

– Evidence on opioid rotation is primarily anecdotal but it can be an important method to reduce narcotic load after a failed opioid trial.

– As much as the goal of no narcotics beyond 3 months for this pain is ideal, we will always see these medications given. The goal of “no pain” is not a concept we entertain, and function should always come before pain relief. PRN doses of narcotics on top of long acting narcotics only focuses on the pain relief and not the function. Long acting narcotics are perfectly ok for initiation of narcotics rather than the tried and tested method of “start with short acting meds then convert to long acting”. Patients will not feel the same on these two types of meds and it might be counter productive to have the patient switch to long acting and not feel as well as the short acting med made them feel.

– Determining the goals of the patient and the expectations of treatment are important.

If you can’t make it to this annual event (now in its 18th presentation), you should get to a similar program in your area. This one gets definite kudos from me. Well done!

 

Graham MacKenzie Ph.C.

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How Open Minded Your Physician is May Determine Your Pain Relief

When I graduated from Pharmacy school in 1993, topically applied preparations for pain relief were limited to lidocaine and capsaicin, or so I was told up to that point. I was also taught that narcotics were safe not only for short term pain relief but also for long term pain that was non palliative and non cancer related and that addiction was rare in cases where total pain relief had not been reached yet. Medication is a constantly evolving and changing world. 23 years has passed and all of this has changed in a drastic manner.

It’s difficult to know exactly how it all started, but many in the medical community like to lay blame on the shoulders of a company called Purdue that had its beginnings in New York City as a relatively small pharmaceutical firm in the early 1950’s when it was purchased by two psychiatrist brothers, Mortimer and Raymond Sackler. The success of OxyContin from this company generated billions of dollars in revenue and made the Sacklers one of the wealthiest families in the country. Unfortunately, we began to see a trend happening where claims of this company and the aggressive and inappropriate marketing practices resulted in the alarming abuse and trafficking of this medication over decades of use. The company had to pay 635 million dollars after executives plead guilty.

You’d think that would have been the end of it. However the Mundipharma associated foreign corporations are agressively marketing this same medication worldwide with no plans to scale back. They also are running training programs to physicians in these countries urging them to overcome “opiophobia” and to just go ahead and write for these painkillers. They also have campaigns urging patients to take what their doctors prescribe to them.

The issue now is we have created an entire continent of addicts who would not normally have been there without these recommendations. For example, Jane Doe gets in a car accident. She has undeniable pain from this and it is not handled with NSAIDS. She is given a narcotic based on the recommendations from companies like Purdue who claim their studies show this is a safe medication to prescribe in this patient. In a little while Jane needs a higher dose of the medication and after not too long, despite her repeated denials, is addicted to painkillers. She then is unable to get a continuous supply of the drug from her doctor who now recognizes the problem. She starts to purchase the medication off the street. Her addiction becomes stronger as her supply and quality of the medication becomes more and more questionable. She then finds herself injecting to keep up with her addiction. In the last number of years, she has lost her job, her husband, her children, her home, car, money, friends, and everything she owns is in a small bag that she uses as a pillow because she lives on the streets with a sole purpose of seeking her next supply of fentanyl.

Is this scenario typical of everyone on narcotics? Of course not. If you walked down Vancouver’s downtown Eastside and asked random passersby what their story is, you might hear this one. Canada has recognized this in a west – east manner this year. Canada’s largest mental-health/addictions hospital, the Centre for Addiction and Mental Health in Toronto called on Ottawa in November to remove these high dose opioids from the market and to launch a review of prescription painkillers across Canada.

In fact, in the last 4 years, the number of opioid prescriptions dispensed per 1000 population has decreased in the United States whereas in Canada the number has more or less remained the same over that time frame. The provinces in Canada have been steadily spending more and more each year on opioid addiction. Not surprisingly, BC has lead this spending. PEI and NB are 2nd and 3rd behind them surprisingly. NS is near the bottom of the list. Towards the end of the year, Nova Scotia’s chief medical officer, Dr. Robert Strang, made a statement where he wanted the provinces’ physicians to ween patients back from current prescribed levels of narcotics exceeding the 90 mg per day of morphine and to keep to max of 50 mg if possible. He also wants long-term fentanyl patients backed off this drug in an effort to fit in with upcoming guidelines. The Nova Scotia College of Physicians and Surgeons is endorsing the CDC guidelines for prescribing opioids.

Lately in the news on the west coast we had a story in the news of 13 overdose deaths in one day making emergency kits a necessity. Nova Scotia Pharmacists are now able to dispense rescue kits of naloxone for overdose and these kits are becoming more available as the awareness of the antidote and education spreads.

The CDC promotes the prescreening of patients to avoid addiction. Overdose concerns are more prevalent with those over 65 years of age, history of overdose, substance abuse disorder (including alcohol), history of depression, renal or hepatic impairment and sleep-disordered breathing. Any patient may be considered at risk for overdose if they combine opioids with benzodiazepines, on a longterm formulation or especially just starting this medication, on an opioid for longer than 3 months, or on more than 100 morphine mg equivalents. Addiction is more prevalent with this level of morphine equivalents as well as being on the opioid longer than 3 months.

Nova Scotia’s Dr. Mary Lynch has gone on the record as not being in favour with these strict guidelines and claims that there are many of her patients where there simply is no alternative drug for them. Many physicians are unclear as to what they are supposed to use to control the pain of their patients.

Unfortunately later this year we heard of a list of Doctors flagged by Ontario’s Ministry of health because they were prescribing the equivalent opioid dose of 150 Tylenol 3’s daily for some patients. 86 physicians were the target of this probe.

The recommendations include such non pharmacologic modalities as cognitive-behavioral therapy, exercise therapy, complimentary medicine (like yoga, meditation and acupuncture). Nonopioid analgesics recommended include acetaminophen, NSAIDS, Cox-2 inhibitors, anticonvulsants like gabapentin or pregabalin, and antidepressants like tricyclics and serotonin and norepinephrine reuptake inhibitors. Other therapies involve epidural injection and biofeedback.

With such a sense of urgency and recommendations of treatments not normally seen by physicians in general medicine, one would expect that physicians would be open to topical pain relief. In speaking to physicians I have found a friendly acceptance but a definite hesitance in writing for these compounds. These compounds are new to them and contain such familiar oral ingredients as ketamine, ketoprofen, clonidine, gabapentin, and lidocaine. They may also use lorazepam, carbamazepine, baclofen, cyclobenzaprine, dextromethorphan, and others. A recent article written by myself and a local palliative care doctor covers these ingredients.  Check it out here.

This is a tremendous opportunity to reduce opioid use and improve pain relief. As I have seen from physicians that have tried this and seen it working in their patients, confidence comes with numbers and experience. The lack of side effects, interactions and lowered dose is something they like. Contact a compounding pharmacy and ask them more.

 

Graham MacKenzie

Owner/Compounding Pharmacist

Stone’s Pharmasave

Baddeck, N.S.

www.stonesphamasave.com

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