Use & Abuse of Pain Killers : Focus on Mehthadone

Prescription painkiller overdoses were responsible for more than 15,500 deaths in 2009. While all prescription painkillers have contributed to an increase in overdose deaths over the last decade, methadone has played a central role in the epidemic. More than 30% of prescription painkiller deaths involve methadone, even though only 2% of painkiller prescriptions are for this drug. Six times as many people died of methadone overdoses in 2009 than a decade before.

Methadone has been used safely and effectively to treat drug addiction for decades. It has been prescribed increasingly as a painkiller because it is a generic drug that can provide long-lasting pain relief. But as methadone’s use for pain has increased, so has nonmedical use of the drug and the number of overdoses.

Methadone use poses risks

Methadone is frequently prescribed for pain.

Methadone, like other painkillers, is commonly prescribed for chronic problems like back pain even though it might not help these problems in the long run.

More than 4 million methadone prescriptions were written for pain in 2009, despite US Food and Drug Administration warnings about the risks associated with methadone.

Methadone is available as a low-cost drug. It is often listed as a preferred drug by many physicians.

Methadone's risks include:

The difference between appropriate prescribed doses and dangerous doses of methadone is small.

Methadone has special risks as a painkiller. For example, taking it more than 3 times a day can cause the drug to build up in a person’s body, leading to dangerously slowed breathing.

Methadone can seriously disrupt the heart’s rhythm.

Methadone can be particularly risky when used with tranquilizers or other prescription painkillers.

In one study, four in ten overdose deaths involving single prescription painkillers involved methadone, twice as many as any other prescription painkiller.

What can we do:

Follow guidelines for prescribing methadone and other prescription painkillers correctly, including

Screening and monitoring for substance abuse and mental health problems.

Prescribing only the quantity needed based on the expected length of pain.

Using prescription drug monitoring programs to identify patients who are misusing or abusing methadone or other prescription painkillers.

Monitor patients on high doses for heart rhythm problems.

Educating patients on how to safely use, store, and dispose of methadone and how to prevent and recognize overdoses

Source: CDC
by
Akshaya Srikanth
Hyderabad, India

Serious Post-Discharge Medication Errors Are Common

A study in two academic hospital centers in the U.S. finds that medication errors after discharge for treatment of cardiovascular disease are common and that a pharmacist-based intervention to address the problem may have little benefit. The study appears in the Annals of Internal Medicine.

Researchers studied 850 patients hospitalized with acute coronary syndrome or heart failure. Participants were randomized to usual care or to an intervention consisting of medication reconciliation by a pharmacist, counseling, provision of aids (like pill boxes) to increase adherence, and telephone follow-up. The incidence of medication errors at 30 days did not differ significantly between the groups (about 50% in each). Roughly 75% of errors were characterized as "significant" in severity, 23% as "serious," and 2% as "life-threatening."

Examples of adverse drug events included a patient found to have an INR higher than 14 at 8 days after discharge, and a patient whose insulin dose was poorly managed, resulting in several episodes of hypoglycemia.

In conclusion, they found that clinically important medication errors commonly occur during the 30 days after a cardiac hospitalization, and we report a much higher incidence than previously shown for preventable or ameliorable ADEs, as well as potential ADEs. A health-literacy–sensitive pharmacist intervention that included postdischarge telephone follow-up did not improve medication safety overall. Reducing ADEs and potential ADEs in the postdischarge period is becoming more critical as hospitals have increasing financial penalties tied to rehospitalization rates. Further work is needed to develop and test interventions in this setting, including strategies for higher-risk populations, as well as additional methods, such as postdischarge medication reconciliation (33) or closer postdischarge surveillance.

This study was published in 

Annals of Internal Medicine. 2012 Jul;157(1):1-10. CLICK HERE
BY
Akshaya Srikanth
Pharm.D Intern
Hyderabad, India

PPI Overuse: A Role in Gastric Cancer

Proton pump inhibitors (PPIs) have become one of the most commonly prescribed medications in both the Worldwide. Although PPIs have been proven to be effective in treating numerous disease states, recent data indicates that inappropriate use of PPIs is rampant and is leading to detrimental outcomes. The consequences associated with inappropriate PPI use include pneumonias, Clostridium difficile-associated diarrhea, osteoporosis, and delayed diagnosis of gastric cancer. Gastric cancer is often diagnosed late, so a further delay could potentially lead to a fatal outcome.

Between 60% to 80% of PPIs have been reported to be inappropriately prescribed during inpatient hospital stays internationally. Previous studies have also shown that between 50% to 70% of patients begin PPI therapy during a hospital stay and are subsequently discharged on these medications, with many continued on them for more than 6 months. As a result, many patients do not know why their physician prescribed these medications.

When they need recheck, their primary care physician or specialist often refills the prescription based on the assumption that PPIs are relatively safe. In recent years, several new PPIs have also been made available to the public. Consequently, it is important to note that if such a high percentage of physicians are incorrectly prescribing PPIs, then it would be fair to assume that the common layperson would have an even more difficult time evaluating their need for an PPI. 

Gastric cancer is rare, with approximately 23,000 new diagnoses each year. It is associated with a relatively high mortality rate, with an overall 5-year survival of less than 15%. The high mortality risk is partly due to the delay in diagnosis, as many patients are not formally diagnosed until metastases are present. Gastric cancer is most common in patients between the ages of 50 and 69 years. Risk factors for gastric cancer include cigarette smoking, obesity, H. pylori infection, and a diet consisting of smoked, processed, and salty foods.

H. pylori infection and GI symptoms associated with the aforementioned diet represent very common “indications” for patients started on PPIs. Along with a thorough history and physical examination, “alarm” symptoms such as unintentional weight loss, early satiety, and signs and/or symptoms of GI bleeding in an otherwise healthy patient can warrant, at minimum, the consideration of an endoscopy. 

The overuse of PPIs could theoretically lead to a delay in the patient receiving the appropriate diagnosis, since their symptoms could easily be masked or attenuated by a PPI. Aside from symptomatic relief delaying the diagnosis, changes also occur on the molecular level that could predispose a patient taking a PPI to gastric cancer. Several studies have shown chronic PPI use leads to hypergastrinemia and atrophic gastritis, which themselves are risk factors for gastric cancer. Not all studies have shown this link; therefore, the final verdict on whether chronic PPI use poses an increased risk of gastric cancer still needs to be determined.

As with many issues in medicine, the exact role of chronic PPI use in the diagnosis and development of gastric cancer needs to be clarified through well-controlled clinical trials. Regardless of the available data, patients on long-term PPIs should be evaluated for the correct indication and length of therapy.

Source: CH.T.A

by

Akshaya Srikanth

Hyderabad, India

Mechanical and Electrical Events of the Cardiac Cycle

Cardiac cycle is the all events related to the flow or blood pressure that occurs from the beginning of one heartbeat to the beginning of the next.Each beat of the heart involves five major stages: The first, "late diastole", is when the semilunar valves close, the atrioventricular (AV) valves open, and the whole heart is relaxed. The second, "atrial systole", is when the atrium contracts, the AV valves open, and blood flows from atrium to the ventricle.The third, "isovolumic ventricular contraction", is when the ventricles begin to contract, the AV and semilunar valves close, and there is no change in volume. The fourth, "ventricular ejection", is when the ventricles are empty and contracting, and the semilunar valves are open. During the fifth stage, "Isovolumic ventricular relaxation", pressure decreases, no blood enters the ventricles, the ventricles stop contracting and begin to relax, and the semilunar valves close due to the pressure of blood in the aorta.

The cardiac cycle is coordinated by a series of electrical impulses that are produced by specialized heart cells found within the sino-atrial node and the atrioventricular node.

Atrial systole is the contraction of the myocardia of the left and right atria.Normally, both atria contract at the same time.70% of the blood flows passively down to the ventricles, so the atria do not have to contract a great amount.Electrical systole of the atria begins with the onset of the P wave on the ECG.Ventricular systole is the contraction of the myocardia of the left and right ventricles.Cardiac Diastole is the period of time when the heart relaxes after contraction in preparation for refilling with circulating blood. Ventricular diastole is when the ventricles are relaxing, while atrial diastole is when the atria are relaxing.Together they are known as complete cardiac diastole.

by

Akshaya Srikanth

Pharm.D Resident

Hyderabad, India