Paved with Good Intentions

Community Assessment Referral & Education(CARE)

Chippewa Valley Coalition for Youth and Families16 September 2010

Jim Middleton, Pharmacist and EducatorCalhoun/Kalamazoo Counties

Paved with Good Intentions

Back in the dark days of college.....

Paved with Good Intentions

Free Speech and Marketing

Paved with Good Intentions

Convenient life

Effortless life

--The unasked question – for whom?

--Stimulants for children? or teachers?

– Haldol for parents? or caregivers?

Growth Markets in Health

Mental Illness – DSM IV

Diabetes – a consequence of obesity

And, to make things interesting, many of the drugs used to treat mental illness can result in a weight gain leading to type 2 diabetes

Growth Markets in Health

Treating mental illness – take a pill

Treating hyperactivity – take a pill (what did we do before 1955?)

Treating diabetes – take a pill, several pills

Treating obesity – take a pill

Growth Markets in Health

Attention Deficit Disorders – sponsorship of societies and research

Prepping children into the drug culture

Paved with Good Intentions

The Duty to Warn

The Right to be Pain-Free

Medical Marijuana

Control of Pseudoephedrine (Sudafed)

A Marginalized Profession

A “challenged” system of health care

The Duty to Warn

Ancillary labels

HIPAA challenges

The Right to be Pain Free

A JCAHO mandate

A State of Michigan mandate

Question: What is the definition of pain?

Sources for pain management

Is a dental office an appropriate starting point?

Medical Marijuana

Who is in control here?

Is the program designed to fail?

“Faux marijuana” – K2 or “Spice”

Control of Pseudoephedrine (Sudafed)

The first regulation: Public Acts 86 and 87 of 2005 in Michigan – 18 year old limit and signature log

2006 – Federal level – quantity of 3.6 grams daily or 9 grams in 30 days – mail order of 7.5 grams in 30 days – signature log and a photo ID required

Note: 3.6 grams equates to 120 tablets of 30mg pseudoephedrine

Control of Pseudoephedrine (Sudafed)

The Problem:

– no requirement for general oversight

– county-by-county monitoring of logs and usage varies wildly

– monitoring often gets cut with budget challenges (Kalamazoo county)

– user can hop from one pharmacy to the next

A Marginalized Profession

Tied to a product, not a service

By one vote on the US Supreme court, pharmacists are allowed to compound prescriptions

Evaporation of the independent “drug store”

A “challenged” system of health care

“Health Systems” and not “Hospitals”

Management by UPS? Marketing over medicine?

Ancillary and unprofitable programs are cut – patient education generally among the first to be eliminated, and among those, diabetes patient education

Health care insurance driven – decisions at clinical help desks by “Certified Pharmacy Technicians”

A “challenged” system of health care

– Pharmacists are timed for every function in a chain setting

– Pharmacists are rewarded – not for patient education or clinical encounters, but for volume and encouraging higher profit margin prescriptions

The Consequences

– Increase in prescription drug availability (however, we have a drop in illegal drug use!)

– Increase in fraud/Gaming the system

– Increase in overdosing cases

– Competing with peer groups and the media for the public's attention and education

– Less time for professionals to educate the public

Drugs We Watch

– Narcotics – Vicodin, Norco, Lortab, Lorcet (drugs that contain hydrocodone), Stadol NS

– Strong Narcotics – Oxycontin (oxycodone based), Percodan, Percocet, Morphine, Dilaudid (hydromorphone), Methadone

– Sedatives – Xanax, Ativan, Valium, Librium “benzodiazepines”

– Antipsychotics and Antidepressants – Seroquel, Topamax

Drugs We Watch

– Stimulants – Adderall, Ritalin, Concerta

– Cough Syrups – Robitussin (guiafenesin) and Robitussin DM (with dextromethorphan)

– OTCs – Sudafed, products with pseudoephedrine (Zyrtec D, Claritin D)

How we know things are a problem

– Talwin was very popular before Talwin NX

– Oxycontin before and after the “reformulation”

General side effects and adverse effects

– Amplification of therapeutic activity

– CNS depressants – more sedation

– Stimulants – focus becomes agitation

– Antidepressants – weight loss and increased suicide ideation

Think in Terms of Historic Personalities

– Cocaine use – paranoia, risky behaviors, grandiose ideation; weight loss

– Dexedrine use – paranoia, agitation, hypervigilence; weight loss

– Narcotic use – hearing loss, constipation, respiratory depression, sedation, need for external stimulation to counter sedation

Consequences of overdoses

Death

Death always reported as a drug reaction?

– not in Battle Creek

– homicides labeled “result of a gunshot wound”, not “individual, while on meth, attempted to rob a crack house and was shot in the process”

Drugs We Watch

– The opiate-heroin evolution – just what is a gateway drug?

Once you get past the notion of a fire 2 inches from your face, does it matter what's being burned?

Supply and demand, dropping costs, NAFTA among smugglers?

– Meth, cocaine, and prescription stimulants

– Impairment from medicine – medical marijuana, but also general prescription drugs (and not the usual suspects, either)

What We Look For

1. Patients who know more about prescription drugs than I do

2. Patients who know more about insurance coverage than I do, or insist they have no prescription coverage but like particular brands of drugs

3. Very thin, asymptomatic, agitated, toothless 20-somethings wanting Sudafed 24-hour capsules

4. And sadly, incoming patients who are perhaps a bit too friendly

What We Look For

6. Elaborate Excuses, generally involving trips to Tennessee, an ex-spouse, neighbor's dog, a funeral, a bathroom sink, a kitchen sink, a neighbor's spouse, a neighbor's dog, a neighbor's ex-spouse from Tennessee with a dog....

7. A phone call that starts with “OK, it's like this....”

What Parents and Educators Should Look for

– Sedation or erratic behavior of sudden onset

– Constipation and stomach complaints

– Loss of weight, loss of teeth, bleeding or infected gums

– Sudden interest in who in the family is ill, perhaps with cancer

– A need to refill your prescription meds early, especially if they have a sticker that reads “May Cause Drowsiness or Sedation”

And

...we're just getting started...