1. Disclosures
The presenter has no financial interest in any products or services mentioned in the lecture.

2. AOA Focus, March 2018

3. AOA Focus, March 2018

4. In the Fall of 2017, 90 people per day were dying in the U. S
In the Fall of 2017, 90 people per day were dying in the U.S. from opioid overdoses. In 34 days, more people die than in the 9/11 attacks.

5. Highest was West Viginia, 52. 0 deaths per 100,000 people in 2016
Highest was West Viginia, 52.0 deaths per 100,000 people in Alabama was Oklahoma was 21.5

6. Opioid prescriptions per year per 100 persons
Alabama 121, Oklahoma 97.9

7. History of Drug Control
International
International Opium Convention of 1912
Convention for Limiting the Manufacture and Regulating the Distribution of Narcotic Drugs of 1931
Single Convention on Narcotic Drugs of 1961

8. History of Drug Control
United States
Pure Food and Drug Act of 1906
Federal Food, Drug, and Cosmetic Act of 1938
Kefauver Harris Amendment of 1962
Controlled Substances Act of 1970

9. History of Drug Control
Oklahoma
Oklahoma Oral Medication & Controlled Substance Act of 1994
10/6/2014 changes to schedule II controlled substances
Prescription Monitoring Program went into effect November 1, 2015

12. CPD – controlled prescription drug

14. JAMA April 2016
61% of teens age had an opioid Rx filled after tooth extraction

16. From NBCNews.com...
 Opioid Crisis Batters Georgia as Suspicious Percocet Kills Two  heroin-epidemic/opioid-crisis-batters-georgia- suspicious-percocet-kills-two- n768951?cid=eml_onsite
Fentanyl is 50 to 100 times more powerful than morphine. When prescribed by a physician, fentanyl is often administered via injection, transdermal patch, or in lozenges. However, the fentanyl and fentanyl analogs associated with recent overdoses are produced in clandestine laboratories. This non-pharmaceutical fentanyl is sold in the following forms: as a powder; spiked on blotter paper; mixed with or substituted for heroin; or as tablets that mimic other, less potent opioids. People can swallow, snort, or inject fentanyl, or they can put blotter paper in their mouths so that fentanyl is absorbed through the mucous membrane.

17. Definitions
Narcotic
a drug or other substance affecting mood or behavior and sold for nonmedical purposes, especially an illegal one.
a drug that relieves pain and induces drowsiness, stupor, or insensibility.
The term "narcotic" is believed to have been coined by the Greek physician Galen to refer to agents that numb or deaden, causing loss of feeling or paralysis. It is based on the Greek word ναρκωσις (narcosis), the term used by Hippocrates for the process of numbing or the numbed state. (Wikipedia)

18. Definitions Opioid Opiate
an opium-like compound that binds to one or more of the three opioid receptors of the body.
Opiate
a drug with morphine-like effects, derived from opium.
-oid = form

19. Drug Schedules

20. Schedules I
Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse.
Potentially severe psychological or physical dependence
Heroin, LSD, marijuana, ecstasy

21. Schedule II
Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse
Use potentially leading to severe psychological or physical dependence.
Vicodin, cocaine, methamphetamine, methadone, oxycodone (OxyContin), Adderall, and Ritalin

22. Schedule III
Substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence.
Tylenol with codeine, ketamine, anabolic steroids, testosterone
Ketamine is a drug used for general anesthesia

23. Schedule IV
Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Xanax, Soma, Valium, Ativan, Talwin, Ambien, Tramadol
Xanax – anxiety, Soma – acute musculoskeletal pain, Valium – anxiety, preop sedation, Ativan (lorazepam) – anxiety, Talwin – pain, Ambien – insomnia, Tramadol - pain

24. Schedule V
Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes.
Cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin

25. Drugs
Opium has three main components:
Morphine
Codeine
Thebaine

26. Morphine
In 1803, morphine, the principal ingredient in opium, was extracted from opium resin.
Morphine is ten times more powerful than processed opium, quantity for quantity.
Morphine remains the standard against which new pain relievers are measured. Heroin is synthesized from Morphine.

27. Codeine
Codeine has less pain-killing ability than morphine and is usually taken orally
As a cough suppressant, it is found in a number of liquid preparations
Hydrocodone is a semi-synthetic opioid synthesized from codeine

28. Thebaine Oxycodone is synthesized from thebaine
Like morphine, oxycodone is used for pain relief, and is taken orally
When abused, oxycodone tablets are crushed and snorted, or dissolved in water and injected

29. Mechanism of Action NSAIDs work on the peripheral nervous system
Opioids work on the central nervous system

30. Dosage Zohydro ER (hydrocodone) 10, 12, 20, 30, 40, 50
Roxicet, Endocet, Percocet (oxycodone/acetaminophen) 2.5/325, 5/325, 7.5/325, 10/325
Vicodin, Lorcet, Lortab, Norco, Xodol, Hycet (hydrocodone/acetaminophen) 2.5/325, 5/300, 5/325, 7.5/300, 7.5/325, 10/300, 10/325
Ibudone, Reprexain, Vicoprofen (hydrocodone/ibuprofen) 2.5/200,5/200,7.5/200,10/200
Tylenol with Codeine (acetaminophen/codeine) 300/15, 300/30, 300/60
Ultram (tramadol) 50mg
Zyhydro was approved by the FDA in 2014, even though the agency’s own advisory committee overwhelmingly voted against it.

31. Prescribing Schedule II Schedule III
Hydrocodone/acetominophen 5/325
#12
1 tablet PO q4-6 hrs
Schedule III
Tylenol #3 (acetominophen/codeine) 300/30
Consult pharmacist for pediatric dosing
Both are available in elixir form

32. Contraindications Use of other acetaminophen-containing drugs
Acetaminophen associated with acute liver failure include cases of liver transplant and death; most liver injury associated with acetaminophen doses >4000 mg per day and >1 acetaminophen- containing product
Concurrent benzodiazepine use

33. Side Effects Serious Common Respiratory depression Hepatotoxicity
Constipation
Drowsiness
Nausea and vomiting

34. Relative Strength (weakest to strongest)
Tramadol
Codeine
Morphine
Hydrocodone
Oxcycodone

35. Pricing Zyhydro ER ($7.78 brand only)
Percocet 5/325 ($11.95 brand, $0.49 generic)
Lortab 5/325 ($0.31 brand, $0.23 generic)
Vicoprofen 7.5/200 ($15.60 brand, $0.24 generic)
Tylenol III ($1.44 brand, $0.36 generic)
Ultram ($2.77 brand, $0.07 generic)

36. Definitions
Addiction: a medical condition characterized by compulsive engagement in rewarding stimuli despite adverse consequences
Dependence: an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
Tolerance: the diminishing effect of a drug resulting from repeated administration at a given dose

37. DEA Rules for Prescribing Controlled Substances
All controlled substances
Schedule II
Schedules III-V

38. All Controlled Substances
Must have a DEA number
$731 for 3 years

39. All Controlled Substances
A prescription must be dated on the date when issued
Must include the patient’s full name and address, and the practitioner’s full name, address, and DEA registration number
Must be manually signed by the practitioner on the date when issued

40. Schedule II
No refills
May transmit facsimile. However, the original prescription must be presented to the pharmacist prior to the actual dispensing.
Exceptions:
Long Term Care Facilities (LTCF)
Hospice Care Program. The practitioner or agent will note on the prescription that it is for a hospice patient.

41. Schedule II In an emergency, a practitioner may call-in a prescription
The quantity prescribed and dispensed is limited to the amount adequate to treat the patient during the emergency period.
The prescribing practitioner must provide a written and signed prescription to the pharmacist within seven days. Further, the pharmacist must notify DEA if the prescription is not received.

42. Schedules III-V
Prescriptions may be transmitted by facsimile from the practitioner or an employee or agent of the individual practitioner to the dispensing pharmacy. The facsimile is considered to be equivalent to an original prescription.
A pharmacist may dispense an oral prescription made by an individual practitioner. It must contain all information required for a valid prescription, except for the signature of the practitioner.

45. CDC issued this guideline in 2016

46. CDC Guidelines Summary
Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care. Opioids should only be used when their benefits are expected to outweigh their substantial risks.
When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. Clinicians should start low and go slow.
Providers should always exercise caution when prescribing opioids and monitor all patients closely. Clinicians should minimize risk to patients—whether checking the state prescription drug monitoring program, or having an ‘off-ramp’ plan to taper.

47. Drug Seeking Behavior
Patient-described pain level not matching what’s observed or reporting a 10-out-of-10 pain threshold
Requesting medication by name
Requesting a specific dosage
Reporting lost or stolen medications
Requesting a refill.
AOA Focus, March 2018

48. Patient Resources
The Substance Abuse and Mental Health Services Administration (SAMHSA) has a National Helpline,  HELP (4357), for those with a possible opioid use disorder.  The Helpline is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. To find an authorized Opioid Treatment Program dispensing methadone or buprenorphine to treat opioid dependency in your state visit:
To find an authorized DEA Registered Practitioner to treat opioid dependency with buprenorphine in your state visit:
treatment/physician-program-data/treatment-physician-locator