DOCSLIB.ORG

Respect Reason Recognition Resolution Referral Respect

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Respect Reason Recognition Resolution Referral Respect 7/10/2019 #FSHP2019 Disclosure #FSHP2019 I do not have (nor does any immediate family member have): Shining Light on the MATter: – a vested interest in or affiliation with any corporate organization offering financial support or grant monies Emergency Department Management of Opioid Withdrawal for this continuing education activity – any affiliation with an organization whose philosophy Nick Scaturo, PharmD could potentially bias my presentation Sarasota Memorial Hospital 12 #FSHP2019 #FSHP2019 Pharmacist Objectives Technician Objectives • Review the history of the opioid epidemic and the resulting implications for emergency departments (ED) • Explain the pathogenesis of AOW • Explain the pathogenesis of acute opioid withdrawal • List traditionally used treatments options for AOW (AOW) • Describe newer treatment options for AOW • Appraise literature surrounding different treatment options for AOW • Describe limitations to classical treatment modalities for AOW • Create evidence-based strategies for the treatment of AOW in the ED 34 #FSHP2019 #FSHP2019 The 5 R’s of Opioid Withdrawal Respect Reason Recognition Resolution Referral Respect 56 1 7/10/2019 #FSHP2019 #FSHP2019 “No one dies from opioid withdrawal” 78 #FSHP2019 #FSHP2019 Drug-Related Poisoning Death Risk by Intervention 2.5 2 Naloxone Administration by EMS 1.5 = 1 10% mortality within 1 year 0.5 Adjusted Hazard Ratio 0 No Treatment Psychological Psychological Intervention Only Intervention & Opiod Agonist Treatement Intervention Weiner SG et al. Ann Emerg Med 2017;70:S158. Pierce et al. Addiction 2015;111:298-308. 910 #FSHP2019 #FSHP2019 Timeline of Important Events NEJM letter Oxycontin CMS JACHO HCAHPS claiming low risk hits the institutes removes pain revision 2009 2007 1980 1997 of addiction market HCAHPS management 2017 with opioid use standards Reason 1980 1990 2000 2010 2015 JACHO 2007 1986 2012 2017 Portenoy’s 2001 institutes Purdue pleads Portenoy case report pain guilty to retracts Bibliometric published standards misbranding statements analysis NEJM: New England Journal of Medicine; JACHO: Joint Commission on Accreditation of Healthcare Organizations; CMS: Centers for Medicare and Medicaid Services; HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems 11 12 2 7/10/2019 #FSHP2019 #FSHP2019 NEJM Letter Bibliometric Analysis Porter J, Jick H. NEJM 1980;302(2):123. Leung P et al. NEJM 2017; 376:2194-2195. 13 14 #FSHP2019 #FSHP2019 Portenoy’s Case Series Purdue Pharma’s OxyContin • Aggressive marketing • Retrospective review of 38 non-malignant, chronic pain • All expenses paid conferences patients • Targeting highest opioid prescribers • 2/38 patients had problems with management, but noted • that these patients had a history of drug abuse Bonus system for sales reps • Branded promotional items • Conclusion: opioids are a safe and more humane alternative than surgery or no treatment in patients with • Misrepresentation of addiction risk intractable, non-malignant pain and no history of drug • “Risk of addiction less than 1%” abuse • Package insert: • “Delayed absorption is believed to reduce abuse liability of the drug” Portenoy RK et al. Pain 1986; 25(2):171-86. Van Zee, A. Am J Public Health 2009; 99(2):221-227. 15 16 #FSHP2019 #FSHP2019 Purdue Settlement Joint Commission • $634.5 million dollar settlement • Pain Management Standards introduced in 2001 • Estimated sales of OxyContin total $35 billion • Necessitated quantitative pain assessments in all patients • Additional settlement in 3/2019 with state of Oklahoma for $270 million • Unintended consequences • Increased opioid prescribing • 1600 additional cases have been filed against the • Fear of decreased federal funding if benchmarks not met company • Increased opioid over-sedation and fatal respiratory • Potential for bankruptcy of company depression • Standards removed in 2009 Van Zee, A. Am J Public Health 2009; 99(2):221-227. Jones MR. Pain Ther 2018; 7:13-21. https://www.npr.org/sections/health-shots/2019/03/26/706848006/purdue-pharma-agrees-to-270-million-opioid-settlement-with-oklahoma Baker DW. The Joint Commission 2017: 1-10. 17 18 3 7/10/2019 #FSHP2019 #FSHP2019 HCAHPS HCAHPS Revisions • Patient satisfaction survey required by CMS • Medication-based questions Old • Did you need medicine for pain? established in 2006 • How often was your pain well controlled? • How often did the hospital staff do everything they • Impacts (2006) could to help you with your pain? • Results are publically reported • Patient’s perception impacts institution’s reputation • Communication-based questions • CMS reimburses based on results • Did you have any pain? New • How often did hospital staff talk with you about • Valued-based purchasing how much pain you had? • How often did hospital staff talk with you about (2017) how to treat your pain? Thompson CA. Am J Health-Syst Pharm 2017; 74(23):1924-26. Thompson CA. Am J Health-Syst Pharm 2017; 74(23):1924-26. 19 20 #FSHP2019 #FSHP2019 Roots of the Opioid Epidemic Definitions Tolerance Dependence Low-quality Misguided evidence regulatory Addiction perpetuated Aggressive pressure pharmaceutical industry marketing Withdrawal Kosten TR et al. Sci Pract Perspect 2002; 1(1):13-20. 21 22 Opioids in the Brain #FSHP2019 #FSHP2019 Opioid PFC PFC Addiction PFC: Prefrontal cortex Addiction VTA: Ventral tegmental area Simplified NAc: Nucleus accumbens VTA PFC: Prefrontal cortex (Psychological D: Dopamine Symptoms) VTA: Ventral tegmental area NAc: Nucleus accumbens NAc LC: Locus ceruleus LC Dependence NAc (Physical Symptoms) Kosten TR et al. Sci Pract Perspect 2002; 1(1):13-20. 23 24 4 7/10/2019 Opioid Withdrawal Simplified #FSHP2019 #FSHP2019 NE NE NE Mu NE NE NE NE NE NE NE Recognition NE NE NE NE NE NE NE NE NE NE NE 25 26 #FSHP2019 #FSHP2019 Screening: Opioid Dependence Signs and Symptoms Physiological RODS MINI Psychological - Restlessness -Pain - Nausea/Vomiting • Specific screen for opioid • Screens for 17 -Anxiety - Diarrhea dependence psychological disorders - Stress Intolerance - Autonomic • 11-question section specific • 8-item questionnaire - Irritability Hyperactivity to opioid use • Takes < 2 minutes - Drug Craving - Gooseflesh skin • Takes 15-20 minutes, if - Diaphoresis • Proven high sensitivity and whole MINI preformed - Yawning specificity compared to • Weeks to -Mydriasis Days to MINI Gold-standard • Used in most study protocols Months Weeks Wickersham JA et al. J Correct Health Care 2015;21(1):12-26. Herring AH et al. Ann Emerg Med 2019;18:S1482-1483. 27 28 #FSHP2019 #FSHP2019 COWS Score Signs or Symptoms Assessed Resting Pulse Rate (0-4) Sweating (0-4) Total Level of Withdrawal Restlessness (0-5) Score Pupil Size (0-5) <5 None Bone or Joint Aches (0-4) Add it Up 5-12 Mild Resolution Runny Nose or Tearing (0-4) 13-24 Moderate GI Upset (0-5) 25-36 Moderately Severe Tremor (0-4) >36 Severe Yawning (0-4) Anxiety or Irritability (0-4) Gooseflesh Skin (0-5) 29 30 5 7/10/2019 #FSHP2019 Supportive Care Measures #FSHP2019 Treatment Options Symptom Medication Common/ Dangerous Adverse Effects Abdominal Dicyclomine Anticholinergic, dizziness, nausea • Supportive Care Cramps Anxiety/ Diazepam, Over-sedation; use caution if giving mu agonists • Central Alpha2 Agonists Restlessness Hydroxyzine • Clonidine Diarrhea Loperamide QT-interval prolongation and cardiac arrest with • Lofexidine large doses Dyspepsia Famotidine QT-interval prolongation • Opiate Agonists Myalgias Methocarbamol Dysphoria, suicidal thoughts • Methadone Nausea/ Ondansetron QT-interval prolongation • Buprenorphine (BUP) Vomiting Pain APAP, Ibuprofen Allergic reaction Insomnia Trazodone Orthostatic hypotension Duber HC et al. Ann Emerg Med 2018; 72(4):420-431. 31 32 #FSHP2019 Lofexidine Study #FSHP2019 Clonidine/Lofexidine Study Design • 8-day, randomized, double-blind, placebo controlled, parallel group • Outcomes: subjective opiate withdrawal scale (SOWS) on Day 3 and time- • Central alpha agonists to-dropout 2 • Lofexidine 3.2 mg daily in four divided doses vs matching placebo days 1- • Decrease norepinephrine 5, followed by 2 days of placebo release Patient Population • 264 patients dependent on short acting opioids with withdrawal signs Exclusion: medical/psych illness, AIDS, dependence on other substances, • Address physiologic hyper- or hypotension, bradycardia, use of methadone or BUP in last 14 days, use of psychotropics, prescription analgesics, anticonvulsants, symptoms of withdrawal antihypertensives, antiarrythmics in last 4 weeks, pregnancy or lactation only Results • Day 3 SOWS: 6.32 vs 8.67 (p=0.0212) • Early Terminators: 59 vs 80 • Lofexidine FDA approved Limitations • Not compared to opiate agonist therapy for opioid withdrawal • Limited to those withdrawing from short acting opioids Conclusions • Lofexidine significantly decreased SOWS scores and demonstrated higher retention rates in participants undergoing opioid withdrawal Toce MS et al. J Med Tox. 2018;14:306-322 Gorodetzky CW et al. Drug and Alc Depend. 2017;176: 79-88 33 34 #FSHP2019 #FSHP2019 Effectiveness: Alpha2 Agonists Dosing • 26 RCTs1728 patients • Clonidine • Compared to placebo: • Higher success of completing • 0.1-0.2 mg every 6-8 hours titrated to symptoms treatment and less severe and blood pressure withdrawal symptoms • Maximum: 0.3 mg/dose or 1.2 mg/day • Compared to tapering methadone: • Lofexidine • As effective; similar treatment completion rates • 0.54 mg every 6 hours for peak withdrawal, then • More adverse effects and tapered based on symptoms by decreasing by withdrawal occurred earlier
Load more

Recommended publications
  • Background to the Celebration of Herbert D. Kleber (1904 -2018) by Thomas A
    1 Background to the Celebration of Herbert D. Kleber (1904 -2018) by Thomas A. Ban By the mid-1990s the pioneering generation in neuropsychopharmacology was fading away. To preserve their legacy the late Oakley Ray (1931-2007), at the time Secretary of the American College of Neuropsychopharmacology (ACNP), generated funds from Solway Pharmaceuticals for the founding of the ACNP-Solway Archives in Neuropsychopharmacology. Ray also arranged for the videotaping of interviews (mainly by their peers) with the pioneers, mostly at annual meetings, to be stored in the archives. Herbert Kleber was interviewed by Andrea Tone, a medical historian at the Annual Meeting of the College held in San Juan, Puerto Rico, on December 7, 2003 (Ban 2011a; Kleber 2011a). The endeavor that was to become known as the “oral history project” is based on 235 videotaped interviews conducted by 66 interviewers with 213 interviewees which, on the basis of their content, were divided and edited into a 10-volume series produced by Thomas A. Ban, in collaboration with nine colleagues who were to become volume editors. One of them, Herbert Kleber, was responsible for the editing of Volume Six, dedicated to Addiction (Kleber 2011b). The series was published by the ACNP with the title “An Oral History of Neuropsychopharmacology Peer Interviews The First Fifty Years” and released at the 50th Anniversary Meeting of the College in 2011 (Ban 2011b). Herbert Daniel Kleber was born January 19, 1934, in Pittsburgh, Pennsylvania. His family’s father’s side was from Vilnius, Lithuania, and the Mother’s side was from Germany. Both families came to the United State during the first decade of the 20th century.
    [Show full text]
  • Advances in Opioid Antagonist Treatment for Opioid Addiction
    Advances in Opioid Antagonist Treatment for Opioid Addiction a, a b Walter Ling, MD *, Larissa Mooney, MD , Li-Tzy Wu, ScD KEYWORDS • Addiction treatment • Depot naltrexone • Opioid dependence • Relapse KEY POINTS • The major problem with oral naltrexone is noncompliance. Administration of naltrexone as an intramuscular injection may be less onerous and improve compliance because it occurs only once a month (ie, extended-release depot naltrexone). • To initiate treatment with extended-release depot naltrexone, steps should be taken to ensure that the patient is sufficiently free from physical dependence on opioids (eg, detoxification). • Research on naltrexone in combination with other medications suggests many opportu- nities for studying mixed receptor activities in the treatment of opioid and other drug addictions. PERSPECTIVE ON OPIOID ANTAGONIST TREATMENT FOR ADDICTION Naltrexone, an opioid antagonist derived from the analgesic oxymorphone, was synthesized as EN-1639A by Blumberg and colleagues in 1967. Four years later, in 1971, naltrexone was selected for high-priority development as a treatment for opioid addiction by the Special Action Office for Drug Abuse Prevention, an office created by President Nixon and put under the leadership of Dr Jerome Jaffe. Extinction Model The rationale for the antagonist approach to treating opioid addiction had been advanced by Dr Abraham Wikler a decade earlier, based largely on the extinction model explored in animal behavioral studies. It was believed that by blocking the euphorogenic effects of opioids at the opioid receptors, opiate use would become Disclosures: Dr Ling has served as a consultant to Reckitt Benckiser Pharmaceuticals and to Alkermes, Inc. Dr Mooney and Dr Wu report no relationships with commercial companies with any interest in the article’s subject matters.
    [Show full text]
  • Flashbacks and HPPD: a Clinical-Oriented Concise Review
    Isr J Psychiatry Relat Sci - Vol. 51 - No 4 (2014) Flashbacks and HPPD: A Clinical-oriented Concise Review Arturo G. Lerner, MD,1-2 Dmitri Rudinski, MD,1 Oren Bor, MD,1 and Craig Goodman, PhD1 1 Lev Hasharon Mental Health Medical Center, Pardessya, Israel 2 Sackler School Of Medicine, Tel Aviv University, Ramat Aviv, Israel INTRODUCTION ABSTRACT Hallucinogens encompass a group of naturally occurring A unique characteristic of LSD, LSD-like and substances and synthetic substances (1) which may trigger a transient with hallucinogenic properties is the recurrence of some and generally reversible state of intoxication characterized or all the hallucinogenic symptoms which had appeared by perceptual disturbances primarily visual in nature, often during the intoxication after the immediate effects of the referred to as “trips” (2, 3). A unique characteristic of LSD substance had worn off. This recurring syndrome, mainly (lysergic acid diethylamide) and LSD-like substances is the visual, is not clearly understood. The terms Flashback total or partial recurrence of perceptual disturbances which and Hallucinogen Persisting Perception Disorder (HPPD) appeared during previous intoxication and reappeared in have been used interchangeably in the professional the absence of voluntarily or involuntarily recent use (1-3). literature. We have observed at least two different This syndrome is still poorly understood (2, 3). LSD is the recurrent syndromes, the first Flashback Type we refer prototype of synthetic hallucinogenic substances and it is to as HPPD I, a generally short-term, non-distressing, probably the most investigated hallucinogen associated benign and reversible state accompanied by a pleasant with the etiology of this condition.
    [Show full text]
  • Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes–Beyond Benzodiazepines
    Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes–Beyond Benzodiazepines José R. Maldonado, MD KEYWORDS Alcohol withdrawal Withdrawal prophylaxis Benzodiazepines Anticonvulsant agents Alpha-2 agonists Delirium tremens KEY POINTS Ethanol affects multiple cellular targets and neural networks; and abrupt cessation results in generalized brain hyper excitability, due to unchecked excitation and impaired inhibition. In medically ill, hospitalized subjects, most AWS cases (80%) are relatively mild and un- complicated, requiring only symptomatic management. The incidence of complicated AWS among patients admitted to medical or critical care units, severe enough to require pharmacologic treatment, is between 5% and 20%. Despite their proven usefulness in the management of complicated AWS, the use of BZDP is fraught with potential complications. A systematic literature review revealed that there are pharmacologic alternatives, which are safe and effective in the management of all phases of complicated AWS. BACKGROUND Alcohol use disorders (AUDs) are maladaptive patterns of alcohol consumption mani- fested by symptoms leading to clinically significant impairment or distress.1 Ethanol is the second most commonly abused psychoactive substance (second to caffeine) and AUD is the most serious drug abuse problem in the United States2 and worldwide.3 The lifetime prevalences of Diagnostic and Statistical Manual of Mental Disorders,4thedi- tion, alcohol abuse and dependence were 17.8% and 12.5%, respectively; the total life- time prevalence for any AUD was 30.3%.4 Alcohol consumption-related problems are the Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stan- ford, CA 94305-5718, USA E-mail address: [email protected] Crit Care Clin 33 (2017) 559–599 http://dx.doi.org/10.1016/j.ccc.2017.03.012 criticalcare.theclinics.com 0749-0704/17/ª 2017 Elsevier Inc.
    [Show full text]
  • ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update
    The ASAM NATIONAL The ASAM National Practice Guideline 2020 Focused Update Guideline 2020 Focused National Practice The ASAM PRACTICE GUIDELINE For the Treatment of Opioid Use Disorder 2020 Focused Update Adopted by the ASAM Board of Directors December 18, 2019. © Copyright 2020. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the fi rst page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material, require prior specifi c written permission or license from the Society. American Society of Addiction Medicine 11400 Rockville Pike, Suite 200 Rockville, MD 20852 Phone: (301) 656-3920 Fax (301) 656-3815 E-mail: [email protected] www.asam.org CLINICAL PRACTICE GUIDELINE The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update 2020 Focused Update Guideline Committee members Kyle Kampman, MD, Chair (alpha order): Daniel Langleben, MD Chinazo Cunningham, MD, MS, FASAM Ben Nordstrom, MD, PhD Mark J. Edlund, MD, PhD David Oslin, MD Marc Fishman, MD, DFASAM George Woody, MD Adam J. Gordon, MD, MPH, FACP, DFASAM Tricia Wright, MD, MS Hendre´e E. Jones, PhD Stephen Wyatt, DO Kyle M. Kampman, MD, FASAM, Chair 2015 ASAM Quality Improvement Council (alpha order): Daniel Langleben, MD John Femino, MD, FASAM Marjorie Meyer, MD Margaret Jarvis, MD, FASAM, Chair Sandra Springer, MD, FASAM Margaret Kotz, DO, FASAM George Woody, MD Sandrine Pirard, MD, MPH, PhD Tricia E.
    [Show full text]
  • Myrtle Beach, SC May 24, 2019 New Drug Update 2019* *Presentation
    New Drug Update 2019* *Presentation by Daniel A. Hussar, Ph.D. Dean Emeritus and Remington Professor Emeritus Philadelphia College of Pharmacy University of the Sciences Objectives: After attending this program, the participant will be able to: 1. Identify the new therapeutic agents and explain their appropriate use. 2. Identify the indications and mechanisms of action of the new drugs. 3. Identify the most important adverse events and other risks of the new drugs. 4. State the route of administration for each new drug and the most important considerations regarding dosage and administration. 5. Compare the new therapeutic agents with older medications to which they are most similar in properties and/or use, and identify the most important advantages and disadvantages of the new drugs. New Drug Comparison Rating (NDCR) system 5 = important advance 4 = significant advantage(s) (e.g., with respect to use/effectiveness, safety, administration) 3 = no or minor advantage(s)/disadvantage(s) 2 = significant disadvantage(s) (e.g., with respect to use/effectiveness, safety, administration) 1 = important disadvantage(s) Additional information The Pharmacist Activist monthly newsletter: www.pharmacistactivist.com Myrtle Beach, SC May 24, 2019 Erenumab-aooe (Aimovig – Amgen; Novartis) Agent for Migraine 2018 New Drug Comparison Rating (NDCR) = Indication: Administered subcutaneously for the preventive treatment of migraine in adults Comparable drugs: Beta-adrenergic blocking agents (e.g., propranolol); (fremanezumab [Ajovy] and galcanezumab [Emgality]
    [Show full text]
  • Phannacotherapy in the Treabnent of Drug Dependence: Options to Strengthen Effectiveness Sarah Welch & John Strang
    Advances in Psychiatric Treatment (1999), vol. 5, pp. 427-434 Phannacotherapy in the treabnent of drug dependence: options to strengthen effectiveness Sarah Welch & John Strang Treatment ofpeople with drug problems requires a consideration of those inviduals in their personal Dependence andsocialcontext, whilebeingmindfulofthecomplex interactionofgeneticand developmental influences. Approaches to treatment should reflect this often Identifying the presence or absence of the depen­ complex aetiology and phenomenology, and the dence syndromeis importantin planning treatment. totality of treatment will typically include social, Dependence is a spectrum, and the therapist needs psychological, educational and pharmacological to developexperience in recognising degrees ofsever­ therapies. Treatment should result in a health benefit; ity. The dependencesyndromeis a clusterof physio­ consequently thegoals oftreatmentshouldbetailored logical, behavioural andcognitive phenomena (leD­ to the health care needs ofthe individual. Thus, with 10; World Health Organization, 1992; see Box 1). many patients, treatment will includeabstinence as Apart from the management ofoverdose, which an explicit objective, whereas with other patients, may, ofcourse, affect those who misusedrugs only intermediate goals, such as reduction of harmful once, the majority of pharmacotherapies are injecting, maybe more realistic and achievable. designed for use by those who have, or have had, Enthusiasm for new pharmacotherapies mustbe some or all of the features of the dependence
    [Show full text]
  • Systematic Evidence Review from the Blood Pressure Expert Panel, 2013
    Managing Blood Pressure in Adults Systematic Evidence Review From the Blood Pressure Expert Panel, 2013 Contents Foreword ............................................................................................................................................ vi Blood Pressure Expert Panel ..............................................................................................................vii Section 1: Background and Description of the NHLBI Cardiovascular Risk Reduction Project ............ 1 A. Background .............................................................................................................................. 1 Section 2: Process and Methods Overview ......................................................................................... 3 A. Evidence-Based Approach ....................................................................................................... 3 i. Overview of the Evidence-Based Methodology ................................................................. 3 ii. System for Grading the Body of Evidence ......................................................................... 4 iii. Peer-Review Process ....................................................................................................... 5 B. Critical Question–Based Approach ........................................................................................... 5 i. How the Questions Were Selected ................................................................................... 5 ii. Rationale for the Questions
    [Show full text]
  • HHS Guide for Clinicians on the Appropriate Dosage Reduction Or
    This HHS Guide for Clinicians on the Appropriate Dosage HHS Guide for Clinicians on the Reduction or Discontinuation of Long-Term Opioid Analgesics provides advice to clinicians who are contemplating or initiating a reduction in opioid dosage or discontinuation Appropriate Dosage Reduction of long-term opioid therapy for chronic pain. In each case the clinician should review the risks and benefits of the or Discontinuation of current therapy with the patient, and decide if tapering is appropriate based on individual circumstances. Long-Term Opioid Analgesics After increasing every year for more than a decade, annual needs.2,3,4 Coordination across the health care team is critical. opioid prescriptions in the United States peaked at 255 million in Clinicians have a responsibility to provide or arrange for 2012 and then decreased to 191 million in 2017.i More judicious coordinated management of patients’ pain and opioid-related opioid analgesic prescribing can benefit individual patients as problems, and they should never abandon patients.2 More well as public health when opioid analgesic use is limited to specific guidance follows, compiled from published guidelines situations where benefits of opioids are likely to outweigh risks. (the CDC Guideline for Prescribing Opioids for Chronic Pain2 At the same time opioid analgesic prescribing changes, such and the VA/DoD Clinical Practice Guideline for Opioid Therapy as dose escalation, dose reduction or discontinuation of long- for Chronic Pain3) and from practices endorsed in the peer- term opioid analgesics, have potential to harm or put patients at reviewed literature. risk if not made in a thoughtful, deliberative, collaborative, and measured manner.
    [Show full text]
  • Development of Cocaine Hydrolase for Therapeutic Treatment of Cocaine Abuse
    University of Kentucky UKnowledge Theses and Dissertations--Pharmacy College of Pharmacy 2016 DEVELOPMENT OF COCAINE HYDROLASE FOR THERAPEUTIC TREATMENT OF COCAINE ABUSE Xiabin Chen University of Kentucky, [email protected] Digital Object Identifier: http://dx.doi.org/10.13023/ETD.2016.289 Right click to open a feedback form in a new tab to let us know how this document benefits ou.y Recommended Citation Chen, Xiabin, "DEVELOPMENT OF COCAINE HYDROLASE FOR THERAPEUTIC TREATMENT OF COCAINE ABUSE" (2016). Theses and Dissertations--Pharmacy. 59. https://uknowledge.uky.edu/pharmacy_etds/59 This Doctoral Dissertation is brought to you for free and open access by the College of Pharmacy at UKnowledge. It has been accepted for inclusion in Theses and Dissertations--Pharmacy by an authorized administrator of UKnowledge. For more information, please contact [email protected]. STUDENT AGREEMENT: I represent that my thesis or dissertation and abstract are my original work. Proper attribution has been given to all outside sources. I understand that I am solely responsible for obtaining any needed copyright permissions. I have obtained needed written permission statement(s) from the owner(s) of each third-party copyrighted matter to be included in my work, allowing electronic distribution (if such use is not permitted by the fair use doctrine) which will be submitted to UKnowledge as Additional File. I hereby grant to The University of Kentucky and its agents the irrevocable, non-exclusive, and royalty-free license to archive and make accessible my work in whole or in part in all forms of media, now or hereafter known. I agree that the document mentioned above may be made available immediately for worldwide access unless an embargo applies.
    [Show full text]
  • Clonidine, Lofexidine and Similar Medications for the Management of Opioid Withdrawal
    Cochrane Database of Systematic Reviews Alpha2-adrenergic agonists for the management of opioid withdrawal (Review) Gowing L, Farrell M, Ali R, White JM Gowing L, Farrell M, Ali R, White JM. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD002024. DOI: 10.1002/14651858.CD002024.pub5. www.cochranelibrary.com Alpha2-adrenergic agonists for the management of opioid withdrawal (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Review] Alpha2-adrenergic agonists for the management of opioid withdrawal Linda Gowing1, Michael Farrell2, Robert Ali1, Jason M White3 1Discipline of Pharmacology, University of Adelaide, Adelaide, Australia. 2National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia. 3School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia Contact address: Linda Gowing, Discipline of Pharmacology, University of Adelaide, Frome Road, Adelaide, South Australia, 5005, Australia. [email protected]. Editorial group: Cochrane Drugs and Alcohol Group. Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 5, 2016. Review content assessed as up-to-date: 7 January 2016. Citation: Gowing L, Farrell M, Ali R, White JM. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD002024. DOI: 10.1002/14651858.CD002024.pub5. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment.
    [Show full text]
  • Hydroxychloroquine (All Populations Monograph)
    3/17/2020 Clinical Pharmacology powered by ClinicalKey Hydroxychloroquine (All Populations Monograph) Indications/Dosage expand all | collapse all Labeled malaria rheumatoid arthritis malaria prophylaxis systemic lupus erythematosus (SLE) Off-Label, Recommended coronavirus disease 2019 (COVID-19) † severe acute respiratory syndrome coronavirus lupus nephritis † 2 (SARS-CoV-2) infection † polymorphous light eruption † † Off-label indication Per the manufacturer, this drug has been shown to be active against most strains of the following microorganisms either in vitro and/or in clinical infections: Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale, Plasmodium vivax. NOTE: The safety and effectiveness in treating clinical infections due to organisms with in vitro data only have not been established in adequate and well-controlled clinical trials. This drug may also have activity against the following microorganisms: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). NOTE: Some organisms may not have been adequately studied during clinical trials; therefore, exclusion from this list does not necessarily negate the drug’s activity against the organism. For the treatment of malaria due to susceptible strains of P. falciparum, P. knowlesi†, P. malariae, P. ovale, and P. vivax https://www.clinicalkey.com/pharmacology/monograph/print?cpnum=300&type=0&printSections=monindi&printSections=monsup&printSections=mon… 1/87 3/17/2020 Clinical Pharmacology powered by ClinicalKey Oral dosage Adults 13 mg (10 mg base)/kg/dose [Max: 800 mg (620 mg base)/dose] PO, then 6.5 mg (5 mg base)/kg/dose [Max: 400 mg (310 mg base)/dose] PO at 6, 24, and 48 hours after the initial dose.[41806] [64059] For P.
    [Show full text]