Paved with Good Intentions

1. Community Assessment Referral & Education (CARE) Chippewa Valley Coalition for Youth and Families 16 September 2010 Jim Middleton, Pharmacist and Educator Calhoun/Kalamazoo Counties Paved with Good Intentions

2. Paved with Good Intentions Back in the dark days of college.....

3. Paved with Good Intentions Free Speech and Marketing

4. Paved with Good Intentions Convenient life Effortless life --The unasked question – for whom? --Stimulants for children? or teachers? – Haldol for parents? or caregivers?

5. 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

7. 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

8. Growth Markets in Health Attention Deficit Disorders – sponsorship of societies and research Prepping children into the drug culture

13. 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

14. The Duty to Warn Ancillary labels HIPAA challenges

15. 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?

16. Medical Marijuana Who is in control here? Is the program designed to fail? “Faux marijuana” – K2 or “Spice”

17. 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

18. 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

19. 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”

20. 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”

21. 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

22. 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

23. 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

24. 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)

25. How we know things are a problem – Talwin was very popular before Talwin NX – Oxycontin before and after the “reformulation”

26. 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

27. 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

28. Consequences of overdoses Death

29. 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”

30. 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)

31. 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

32. 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....”

33. 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”

34. ...we're just getting started... And