Understanding Controlled Substances & Opioid Therapy: Drug Schedules & Prescriptions, Exercises of Nursing

Download Understanding Controlled Substances & Opioid Therapy: Drug Schedules & Prescriptions and more Exercises Nursing in PDF only on Docsity!

Week 1

• Drug Schedules
  • Descriptions of each schedule
• Examples of drugs in each schedule:
• Schedule I: high potential for abuse: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ectstasy), methaqualone, and peyote.
• Schedule II: high potential for abuse, potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous; combination products with less than 15 milligrams of hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin
• • Schedule III: Moderate to low potential for physical psychological dependence; producets containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone Shedule IV: Low potential for abuse and low risk of dependence; Xanax, Soma, Darvan, Darocet, Valium, Ativan, Talwin, Ambien, Tramadol Schedule V: low potential for abuse and contain limited quantities of certain narcotics; antidiarrheal, antitussive, and analgesic purposes. (focus on schedule 2,3, and 4 per tutor)
• Which ones can and cannot be prescribed by nurse practitioners?
  • Prescriptive Authority Understand what prescriptive authority is and who mandates it. : Practice authority and prescriptive authority together are described as practice “enviornments” according to state laws and regulations.

o Full-practice scope: Nurse practitioners have the autonomy to evaluate patients,

diagnose, order and interpret tests, initiate and manage treatments and prescribe medications, including controlled substances without physician oversight.

o Reduced -Practice scope: Nurse practitioners are limited in at least one element of

practice. The state requires a formal collaborative agreement with an outside health

discipline for the nurse practitioner to provide patient care.

o Restricted practice scope: Nurse practitioners are limited in at least one element of

practice by requiring supervision, delegation, or team management by an outside health discipline for the nurse practitioner to provide patient care. ▪ What problems arise when prescriptive authority is limited? Limited prescriptive authority creates numerous barriers to quality, affordable,

and accessible patient care. For example a requirement to obtain the physician’s cosignature on prescription can increase patient waits.

- Know the responsibilities of prescribing : The ability to prescribe medications is both a Privilege and a burden. The best way to keep your patients and yourself safe is to be prudent and deliberate in your decision making process. Have a documented provider- patient relationship with the person for whom you are prescribing. Do not prescribe for family or friends or for yourself. Document a thorough history and physical examination in your records.

• Know patient reasons for medication non-adherence: - Forgot to take it - Ran out - Was away from home - Was trying to save money - Didn’t like the side effects - Was too busy - The medicine wasn’t working
• Know how what type of evidence prescribers should use to make treatment recommendations: -
• Be familiar with physiological changes of aging that impact pharmacological treatments: - Drug accumulation secondary to reduced renal function - Polypharmacy (the use of 5 or more medications daily) - Greater severity of illness - Presence of comorbidities - Use of drugs that have a low therapeutic index (e.g., digoxin) - Increased individual variation secondary to altered pharmacokinetics - Inadequate supervision of long-term therapy - Poor patient adherence - - Be familiar with Beer’s Criteria : The Beers Criteria include five lists that describe certain medications and situations and include: - Potentially inappropriate Medication (PIM) use in older adults - Potentially Inappropriate Medication (PIM) use in older adults due to medication-disease or medication-syndrome interactions that may exacerbate the disease or syndrome - Medications to be used cautiously in older adults. - Clinically significant drug interactions that should be avoided in older adults - Medications to be avoided or dosage decreased in the presence of impaired kidney function in older adults -

•

•

•

•

•

• Know CYP450 inducers and inhibitors: - Inducers Inhibitors (decrease medication metabolism) Carbamazepine Rifampin Alcohol Phenytoin Griseofulvin Phenobarbital Sulfonylureas Sertraline (Zoloft)50mg worse 200mg Erythromycin Terbinafine (Lamisi) Valporate Isoniazid Sulfonamides Amiodarone Chloramphenicol Ketoconazole Grapefruit Juice Quinidine -
• Be familiar with opioid agonists :
• Know the outcome of having a poor metabolism phenotype
• Know the role of the government agencies when it comes to prescription drugs

Week 2

• Know black box warning for various pain medications.
• Be familiar with patient indicators that would put them at risk for developing substance abuse disorder.
• Be familiar with conditions that do and do not warrant opioid therapy.
• Know what a morphine milligram equivalent is and when to use it.
• Be familiar with Prescription Drug Monitoring Program (PDMP) o What it is o When to use it
• Know the outcomes of renal and hepatic insufficiency with opioid therapy.
• Know the risk factors of opioid use disorder.
• Know the signs of drug diversion.
• When is it appropriate to prescribe naloxone?

• Be familiar with drugs that are not safe to take with opioids.
• Be familiar with the PEG Assessment Scale.
• Patient and provider responsibilities in opioid drug therapy
• How to approach conversations about Opioid Use Disorder
• What types of pain can be treated by psychotropic medications?

Week 3

• Lifespan considerations including pregnancy o Statins o Warfarin o Blood pressure medications
• Drug interactions to be mindful of, avoid, or adjust dosing with
  • Warfarin
  • Carbamazepine
  • Digoxin
  • Quinidine
  • Anticoagulants in general
• Treatment strategy for angina
  • Goals of treatment
  • Drugs to accomplish goals
• Monitoring
  • Labs related to blood pressure medications
  • Appropriate intervals for medication adjustments (4-6 WKs is ideal/appropriate)
• Heart Failure
  • Role of aldosterone and how to manage those effects - Who is at risk for severe rebound hypertension?
• Be familiar with treatment guidelines of hypertension.
  • When one medication would be preferred over another based-on patient factors
• Mechanism of action and related physiological outcomes
  • Cardiac glycosides
  • Verapamil
  • Organic nitrates
  • Calcium channel blockers
• Contraindications
  • Beta-blockers
  • ACE Inhibitors
  • Ranolazine
• Be familiar with clinical tools used to determine how to treat hyperlipidemia
• Alternative treatment strategies for statin intolerant patients

Week 4

• Be familiar with the treatment for osteoarthritis: asymptomatic patients are usually not treated. Mild pain can be managed with analgesics and anti-inflammatory agents. When the disease is more severe, a bisphosphonate is the treatment of choice. Benefits derive from suppressing bone resorption.

• Treatment of gout: o When to use which medication
• o Contraindicated medications o Side effects of medications o Medications requiring dosage adjustments based on renal or hepatic insufficiency o Medications typically co-administered with gout treatment o Complications of untreated gout
• Treatment of osteoporosis o Patient education for common osteoporosis medications: advise patients against switching to a different preparation. Advice patients to take oral calcium salts with a large glass of water. Taking with or shortly after meals promotes absorption. Don’t take calcium with spinach, swiss chard, beets, bran and whole-grain cereals it suppresses absorption. Inform patients of hypercalcemia (n/v, constipation, frequent urination, lethargy and depression). If patient taking tetracycline take 30 minutes apart. Calcium interferes with thyroid hormone absorption, take several hours in between. o Blackbox warnings o Drug Interactions : Glucocorticoids (e.g., prednisone) reduces absorption of oral calcium, leading to osteoporosis with long-term use. Calcium reduces absorption of several drugs when administered together. These drugs include tetracycline, and quinolone antibiotics, thyroid hormone the anticonvulsants phenytoin and bisphosphonates. Thiazide diuretics decrease renal calcium excretion and thus may cause hypercalcemia; however, loop diuretics increase calcium excretion and may cause hypocalcemia. o NSAIDs: Anti-inflammatory drugs
• Mechanism of action o NSAIDs: will help with joint discomfort as wella s the flu-like symptoms that occur with some bisphosphonates
• DMARDs : are drugs that reduce joint destruction and slow disease progression. They accomplish this by interfering in immune and inflammatory responses. D
• o o Examples : methotrexate, sulfasalazine, Lefluomide, Hydroxychloroquine.

o Baseline data needed for drugs in this class : All DMARDs: CBC with WBC differential; assess for s/s of infection (esp. TB and Hepatitis) and malignancies (including skin examination). Rule out pregnancy for women of childbearing age. Screen for TB. A complete history of physical exam needed to establish pretherapy stauts. Emphasis should be placed on risks to

immunocompetence and on liver and renal status. Also ALT, AST and serum creatinine. o o Baseline diagnostics needed for drugs in this class :

• Methotrexate: consider chest CXR. Emphasis on pulmonary and GI status
• Hydrochloroquine: ophthalmologic exam; cardiac exam with electrocardiopraphy (ECG) if indicated
• Leflunomide: consider CXR. Emphasis on BP and pulmonary status.
• Sulfasalazine: consider CXR. Emphasis on pulmonary and neurologic status. o o Patient teaching for drugs in this class
• Inform patient about the risk for infection and myelosuppression. Advise them to avoid close contact with people have a communicable disease. Instruct them to seek medical attention for s/s of infection or evidence of myelosuppression (bruising, bleeding, pallor, fatigue, fever). Advise pt. to report signs of heart failure, such as sob and orthopnea, fatigue and edema. For DMARDs that can cause liver injury, instruct pt. to report fatigue, jaundice, anorexia, right-sided abdominal pain and dark brown urine. Patient should also know about the risk of cancer and other drug- specific adverse effects.
• Inform pt. that vaccinations should be current before therapy with a DMARD is begun. Before therapy begins, live virus vaccines must be avoided. o Instruction needed regarding RA treatment and oral contraceptives :
• As a CYP3A4 inducer, tocilizumab increases the rate of meaabolism and can therapy decrease serum drug levels of CYP3A4 substrates such as oral contraceptives and HMG-CoA reductase inhibitors. Dosages for all of these agents may have to be increased. o o Pregnancy considerations
• Pregnancy Risk Category B. Rituximab and abatacept are pregnancy risk category C.
• Nonbiologic DMARDs: Azathioprine is teratogenic. Both leflunomide and methotrexate can cause fetal death and congenital abnormalities. Hydroxychloroquine may cause

fetal ocular toxicity; however in some conditions, such as maternal lupus or malaria, the drug decredases fetal risk

associated with the condions it treats. Sulfasalazine is pregnancy risk category B.

Prescription Writing

• Medications you will need to know for the prescription writing questions include:
  • Lortab
  • Lisinopril
  • Losartan
  • Amlodipine
  • Codeine
  • Alendronate
  • Colchicine - MID TERM REVIEW WITH SARAH THE TUTOR

1. What is a typical dose of Alendronate? 5 mg
2. What is a typical dose of codeine? 15 mg
3. What is a typical starting dose of amlodipine? 5 mg/daily
4. What schedule is Vicodin? Schedule 2

5. How many milligrams are colchicine tabs? 0.6 mg
6. What is the typical dosage of Lortab? 5/325 mg
7. What is the typical starting dose of Lisinopril? 10 mg
8. What is the typical starting dose of Losartan? 25-50 mg/daily
9. What are the treatments of osteoarthritis? NSAID, Cox2 inhibitors 10.First choice drug for acute gout? NSAIDs or colchicine 11.For a patient with hepatic or renal impairment what medications are contraindicated for colchicine? Cyclosporine, ranolazine, ketaconazole, clarithromycin, HIV protease inhib

12.What are some possible adverse effect of colchicine? Nausea, vomiting, diarrhea and abdominal pain and bone marrow suppression. 13.What are some of the potential adverse effects of allopurinol? Nausea, vomiting, diarrhea, abdominal discomfort, neuro effects, cataracts. 14.What gout medications require dosage adjustments based on renal and hepatic insufficiency? Colchicine, Allopurinol. 15.What medications are typically co-administered with gout treatment? NSAIDs and cortisone 16.What are some complications of untreated gout? Tophi may form in joint and urate crystal deposits may cause renal damage. 17.All of the following are treatments for osteoporosis except? Vitamin D, calcium (preventative not a treatment). 18.What patient education should we provide for bisphosphonate? Swallow whoe with a full glass of H20, stay upright for 30-60 minutes. 19.What is one rare but serious potential adverse effect of bisphosphonate? Osteonecrosis of the jaw. 20.What are some drugs that may interact with celecoxib? Warfarin, ACEI, furosemide, lithium. It has blood thinning property to it. 21.What is the MOA of NSAIDS? Inhibits cox-1 and COX-2. 22.Examples of disease-modifying antirheumatic drugs (DMARDS) include all of the following except? Diclofenac (Cambia, Cataflam, Voltaren XR, Zipsor, Zorvolex)

23.How should we educate our patients regarding DMARDs and contraceptive use? DMARDs are teratogenic so OC (oral contraceptive) is very important. 24.What is the black box warning for estrogen? Endometrial cancer and increased risk for venous thromboembolic events. 25.What is the black box warning for Bisphosphonates? Long-term use may lead to endometrial cancer. 26.What range is considered stage 1 hypertension? Systolic 130-139 or diastolic 80- 27.What are some contraindications of beta-blockers? Bradycardia, persistent hypotension, advanced heart block.

28.What are some contraindications of ACE inhibitors? Hypotension, renal failure, hx of ACEI- induced cough or angioedema 29.What are some contraindication of Ranolazine? Pre-existing QT prolongation 30.What clinical tools are used to determine how to treat hperlipidemia: ASCVD risk calculator , CPGs, AAC/AHA. 31.What range is stage 2 hypertension? > 140 mm Hg or > 90 mm Hg 32.What BP medication should be avoided in African-Americans? ACEIs **** 33.What medication is approved for htn in pregnancy? Labetalol and methyldopa 34.What is the mechanism of action MOA of digoxin? Increase myocardial contractility and CO by inhibiting Na+ K+ 35.What is the mechanism of action of verapamil? Blocks calcium channels in blood vessels and in the heart and causes dilation. 36.What is the mechanism of action of Nitro? Acts on vascular smooth muscle to cause vasodilation and decreases O2 demand. 37.Angina, goals of treatment include? Prevent MI and death, reduction of cardia ischemia and associated pain. 38.Drugs to treat angina include all of the following except? Loop diuretics and ARBs 39.What labs should we order for bp medication monitoring? Serum electrolytes 40.What is the appropriate intervals for medication adjustments? 4-6 weeks.

41.All of the following are true regarding aldosterone and how we manage the effects except: H2O retention is mediated in part by aldosterone through retention of Ca+ All this is true: o We manage with ACE inhibitors and ARBs o We manage with direct renin inhibitors and aldosterone antagonist o H2O retention is mediated in part by aldosterone through retention of Na+ 42.Patient who abruptly stop taking clonidine are at risk for what? **Severe rebound hypertension. 43.Drug interactions to be mindful of, avoid, or adjust dosing with Warfarin include all of the following except? Penicillin, vitamin D, vancomycin, antiviral agents. 44.Drug interaction to be mindful of, avoid with Warfarin area: o Drugs that increase or decrease anticoagulant effect or promote bleeding.

o Amiodarone, Azole antifungal agents, Cimetidine, cephalosporin, o Clopidogrel, aspirin, apixaban, OCS, Vitamin K. 45.Drug interaction (pg. 159) to be mindful of with Carbamazepine include: Oral contraceptives, warfarin, grape fruit juice, phenytoin, phenobarbital. 46.Drug interaction (pg. 332) to be mindful of with Digoxin include all except: Calcium channel blockers, penicillin, fenofibrate, Lamictal, abilify. 47.Quinidine can double the levels of what antidysrhythmic? Digoxin. 48.Prescribing and lifespan consideration for the elderly include? Renal dosing may be needed and some meds may have an increased effect. 49.All of the following are contraindications in pregnancy except? Labetalol-renal failure (fatal injury) 50.All of the following are the patient and provider responsibility in opioid drug therapy except? Discuss the PDMP and counsel the patient on “provider hoping”. 51.How would we approach conversation about Opioid use Disorder? Ask the pt. about their drug and alcohol use with open ended questions, (don’t be judgmental). 52.What type of pain can be treated by psychotropic medications? Fibromyalgia, chronic pain, peripheral neuropathy (SSRI, Benzo, TCA). What are some risk factors of opioid use disorder? Recreational use and being prescribed opioids after surgery. 53.The risk factor for overdose and reasons to prescribe Naloxone include all except: concurrent use of any prescription drugs. 54.What is the PEG assessment scale in regards to chronic pain and opioid use? Reasses functionality and pain control, if <30% improvement than wean off

55.What condition do not warrant opioid therapy? Mild to moderate pain. 56.What is a morphine milligram equivalent? Value that represents the potency of an opioid in comparison to MS04. 57.What is the PDMP and when should we use it? Electronic database with patients prescription hx of controlled substances. 58.What are the outcomes of renal and hepatic insufficiency with opioid therapy? Metabolize is affected and drug stays in body longer. 59.In regards to CYP450 inducers what does CRAP GPS stand for? *** carbamazepine Rifampin Alcohol phenytoin griseofulvn phenobarb sulfonylurea

60.CYP450 inhibitors include all of the following except: Rifampin, ETOH. Inhibitors include: o Amiodarone, chloramphenicol, ketoconazole, grapefruit juice, Quindine, Valproate, isoniazid, sulfonamides. 61.What is the most common CYP450 subtypes?*** CYP3A4, CYP2C9 62.What is an opioid agonists? Activate u receptors and k receptors 63.What is an example of an opioid agonist? Morphine, Fentanyl, Oxycodone 64.What is the outcome of having a poor metabolism phenotype? Genetic variations can influence an individual’s response to drugs.*** 65.What is the role of the government agencies when it comes to prescription drugs? DEA regulates drugs based on their potential for abuse/dependency 66.What is the black box warning for opioids like Fentanyl? Respiratory depression or arrest 67.What is the black box warning for methadone? Prolong QT interval 68.The risks for developing substance abuse disorder include all except… High socioeconomic status, strong family support physical abuse only. 69.What conditions warrant opioid therapy? Moderate to severe pain, cancer pain. 70.What schedule is Tylenol with Codeine? Schedule 3. What does part of codeine convert to? 10% of codeiene turns into morphine. 71.What schedule is Fentanyl, Diluadid and Oxycodone? Schedule 2

72.What schedule is Adderall and Ritalin? Schedule 2 73.What class of Meds are schedule 5? Antidiarrheal, antitussive. 74.Which schedule of meds cannot be prescribed by NPs? Schedule 1. Really has no medical purpose example: heroine, LC. Illicit drugs. 75.What is prescription authority? The right to prescribe independently without limitations. 76.Who mandates prescription authority? The state law and health professional boards. 77.What problems arise when prescriptive authority is limited? Barriers to quality, affordable, and accessible

78.What are some of the responsibilities of prescribing? Safe and competent practice. 79.We can keep patients safe by doing all of the these things except? Don’t consult additional providers. 80.All of these are reasons for medication non-adherence except? Dr. Google said to stop taking it. 81.What type of evidence should prescribers use to make treatment recommendations? CPGs (Clinical Practice Guides) those are go to. 82.All of these physiological changes of aging have an impact on med absorption except.. Increased splanchnic blood flow. These have an impact: -delayed gastric emptying -increased gastric pH -Decreased absorptive surface area 83.All of these physiological changes of aging have an impact on Med distribution except: Increased serum albumin will decrease. These will increase: Increased body fat Decreased lean body mass Decreased total body water 84.All of these physiological changes of aging have an impact on Med metabolism except.. Increased hepatic mass.

These have an impact on med metabolism: -Decreased hepatic blood flow -decreased activity of hepatic enzymes -decreased hepatic mass 85.All of these physiological changes of aging have an impact on med excretion except… Increased number of nephrons. These have physiological change in excretion: Decreased renal blood flow Decreased tubular secretion Decreased glomerular filtration rate

86.What is the BEERs criteria?*** A list of Drugs with a high likelihood of causing adverse effects in older adults 87.What schedule is Ativan, valium? Schedule 3 88.What schedule is Tramadol? Schedule 4 89.What schedule is Xanax? Schedule 4 90.What is included in the black box warning for hydrocodone? Hepatotoxicity due to Tylenol in it. WEEK 2 REVIEW WITH SARAH TUTOR What kind of analgesics should we give for mild to moderate acute pain? NSAIDS, acetaminophen, COX-2 inhibitors. What kind of analgesics for moderate to severe pain? Norco, Tramadol and opioids in general. When should we use short acting opioids? After surgery, post- surgical pain. Opioid naïve? Means someone who has never taken opioids. What adverse effect can opioid cause? Constipation, respiratory depression, urinary retention, hypotension, vomit, delirium agitation. What are some of the CDC suggestions for prescribing opioids for chronic pain? Essential consideration for Safe Pain Management: