NR565 Advanced Pharm Midterm | 79 questions and answers

What is used to calculate a patient's overdose risk? (An actual calculation won't be done

on the exam)

Which schedule drugs can APRNs prescribe?

DEA license will allow for prescribing of Schedules 2-5. There can be restrictions as noted in collaborative agreement. May be facility/state dependent.

Who determines and regulates prescriptive authority?

Determines: Also known as independent prescribing. APRNS can prescribe without limitation and is state dependent. Includes "legend" (prescription) and controlled drugs, health/medical services, DME, etc.

Regulates: State board of nursing, regulated by health professional board. Federal government controls drug regulations but has no control over prescriptive authority.

How does limited prescriptive authority impact patients within the healthcare system?

Limited prescriptive authority creates numerous barriers to quality, affordable, and accessible patient care. For example, restrictions on the distance of the APRN or PA from the physician providing supervision or collaboration may prevent outreach to area of greatest need. An increase in patient waits.

What are the key responsibilities of prescribing?

The ability to prescribe medications is both a privilege and a burden. Have a documented provider-patient relationship, do not prescribe medications to family or friends or yourself, Document a thorough history and physical examination, include any discussions you have with the patient about risk factors, side effects, or therapy options, have documented plan regarding drug monitoring or titration, if you consult additional providers not that you did so. Use the references provided in the following boxes to assist in safely and rationally choosing one medication over another.

Be sensible, accept responsibility, do not fear it, know constraints and limitations, always learn and update, keep Rx pads in safe place, confirm allergies, verify medication list with patient, do not let insurance dictate quantity of Rx, Charting is key (particularly with off label use), Provide use and rationale.

What should be used to make prescribing decisions?

The best way to keep your patients (and yourself) safe is to be prudent and deliberate in your decision-making process. Cost, availability, current practice guidelines, medication interactions including interactions with food, side effects, need for monitoring, how drug is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)

Be familiar with pharmacokinetic and pharmacodynamic changes of older adults and how that would translate to baseline information needed to prescribe

Pharmacokinetic is the study of drug absorption, distribution, metabolism, and excretion in the body. The ability of older adults to metabolize drugs is commonly decreased. Drug dosages may need to be reduced to prevent drug toxicity.

Beer's criteria

Guidelines for prescribing medications to patients 65 & older. Drugs on the list should be avoided in patients over 65 expect when the benefits significantly outweigh the risks. The Beers Criteria includes five lists that describe certain medications and situations and include: potentially inappropriate medication (PIM) us in older adults, PIM use in older adults due to medication-disease or medication-syndrome interactions that may exacerbate the disease or syndrome, medications to be used cautiously in older adults, clinically significant drug interactions that should be avoided in older adults, medications to be avoided or dosage decreased in the presence of impaired kidney function in older adults.

Why is Beer's criteria important?

It provides a list of medications that are potentially harmful in elderly. List that identifies drugs with a high likelihood of causing adverse effects in older adults. Beers Criteria are recommendations; ultimately prescribers must determine whether a medication is appropriate for use or not. These guidelines are not intended to limit the use of medications or apply to all older adults. Safe and judicious prescribing is crucial in the older adult to optimize pharmacotherapy.

Impacts/outcomes of polypharmacy

Polypharmacy greatly increases the risk for interactions. Drug interactions with mild side effects to life-threatening consequences. Elderly is at a higher risk of polypharmacy due to taking five or more medications daily.

CYP450

metabolic pathway, involved in metabolism of drugs in the liver. Metabolism can be inhibited or induced by drugs and once this happens drug-drug interaction can occur.

What are the CYP450 inhibitors?

Liver enzymes. It's not just a single molecular entity but rather a group of 12 closely related enzyme families.

Examples: Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol, Ketoconazole, Grapefruit juice, Quinidine

What do they do? Slows down metabolism of medications. Inhibitors are medications that inhibit activity of one or more of the CYP450 enzymes. Medications that inhibit an enzyme can potentially slow that enzymes activity required for metabolism of other medications, thereby increasing the levels of medications dependent on that particular enzyme for biotransformation. This inhibition prolongs the pharmacalogical effects, which may result in toxicity. Factors that affect the inhibition include the dose and the capacity to bind to the enzyme

What do they cause if not used correctly (CYP450)?(aka:What would the patient experience?)

Toxicity. drug build up

Examples of CYP450 inducers?

barbiturates, St Johns wart, carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas

What do CYP450 inducers do?

Increase medication metabolism.

Inducers are xenobiotics that elevate the CYP450 enzyme activity by increasing the enzyme synthesis. This action leads to additional sites available for biotransformation. The increased number of sites enhances the medication metabolism, decreasing the concentration of the "parent drug" while increasing the metabolite production. The half-life of the inducing drug may cause a delay before enzyme activity increases. A decease in concentration of a medication metabolized by CYP2C9 (responsible for 10% of drug metabolism) usually occurs within 24 hours after the administration of the medication.

What happens when someone has a poor metabolism phenotype?

Slow or increase absorption, slow the metabolism, keep drug in body longer and increase toxicity. Poor metabolisms affect a high or low therapeutic index: increase drug toxicity, Ex: Plavix: Clots and increase platelets.

What does the U.S. Food and Drug Administration regulate when it comes to medications?

Regulates what the pharmacies can sell, requires special alerts and management guidelines, for drugs that cause serious adverse effects. Ensuring pharmaceutical companies thoroughly test new products for efficacy and safety with an aim towards minimizing side effects. They approve or disapprove drugs

Reasons for medication non-adherence

1. patient feels not needed

2. affordability

3. side effects

4. forgetfulness

5. lack of info

6. lack of disease concern

7. poor social support

8. low reaction satisfaction

9. poor physician relationship

What are black box warnings?

Concise summaries of adverse effects of concern in a box surrounded by a thick black line.

Why are black box warnings issued?

-Neonate and infant drug absorption

-Purpose is to alert the provider to potentially severe side effects and ways to prevent or reduce harm. Provides a concise summary of the adverse effects of concerns. The FDA requires a boxed warning on drugs with serious or life- threatening risks.

Be familiar with general development and when absorption would reach adult levels

The drug-metabolizing of infants is limited. The liver does not develop its full capacity to metabolize drugs until approximately 1 year after birth. During the time before hepatic maturation, infants are especially sensitive to drugs, and care must be taken to avoid injury.

Examples of pure opioid agonists

- agonist is a drug that binds to the receptor, producing a similar response to the intended chemical and receptor

How would you know when to refer someone to a pain specialist for pain management?

Prescription Drug Monitoring Program (PDMP)

What is it?

Why is it important?

are secure, online,

state-based databases that contain information about controlled substance

prescriptions written by clinicians and dispensed by pharmacists within a

state or jurisdiction

PDMPs store patient-specific prescription information in a central repository. The information

in accordance with state or jurisdictional laws.

PDMPs are valuable tools that facilitate safer opioid prescribing, inform clinical practice, and improve patient safety.

Schedule I Drugs: Opioids, Acetylmethadol, Heroin, Normethadone,marijuana, any otherso Schedule II Drugs: Opioids, Alfentanil, Codeine, Fentanyl, Hydrocodone,

Methamphetamine, Barbiturates, Cocaineo Schedule III Drugs: Opioids, Buprenorphine, Paregoric,Cannabinoids,Dronabinol (THC), Stimulants, Testosterone, Ketamineo

Schedule IV Drugs:Opioids,Benzodiazepines,Alprazolam,

Chlordiazepoxide, Clonazepam, Lorazepam, Midazolamo

Schedule V Drugs: Opioids, Diphenoxylate plus atropine, Pregabalin

Know how what type of evidence prescribers should use to make treatment recommendations

Cost, guidelines, availability, interactions, side effects, allergies

hepatic and renal function, need for monitoring, special populations

Schedule II drugs

-rules and prescribing

examples

Opioids, Alfentanil, Codeine, Fentanyl, Hydrocodone,

Methamphetamine, Barbiturates, Cocaine

-All prescriptions for

Alternatively, prescribers may submit prescriptions using an electronic prescribing procedure. Oral prescriptions may be called in but only in emergencies, and a written prescription must follow within 72 hours. Prescriptions for schedule II drugs cannot be refilled. However, a DEA rule allows a prescriber to write multiple prescriptions on the same day—for the same patient and same

drug.

Behaviors that predict controlled substance abuse

Illegal drug use; prescription drug use for nonmedical reasons. History of substance use disorder or overdose.

Mental health conditions (eg, depression, anxiety). Sleep-disordered breathing.

Concurrent benzodiazepine use.

When should naloxone be prescribed for a patient?

-Providers should consider offering naloxone to patients when the following

factors that increase risk for an opioid overdose are present

-history of nonfatal OD

-hx of substance abuse disorder

-higher opioid dosages (>50 MME/day)

-Concurrent benzo use

-high risk of returning to a dose to which tolerance is no longer expected, such as when a pt is released from jail

US Drug Enforcement Administration description of the scheduled drugs

Treatment of Chronic Pain

Example: How should something like OA be treated?

Education: weight loss, exercise, NSAIDS, steroid injections

OA; yoga, heat, compassion, relationship-building

Risk factors for opioid use disorder

-Risk Evaluation and Mitigation Strategy (REMS)-reinforces safe medication use. Goal of REMS is to ensure that medication is used according to FDA approved prescribing.

-Requires drug manufacturers to add recs about naloxone

The patient requests refills before the prescription runs out

The patient fails to disclose pertinent information, such as current

opioid prescriptions

The patient makes unreasonable excuses for losing medications

The patient may show physical signs of opioid withdrawal, such as

anxiety, nausea, vomiting, or abdominal pain. If any of the above

signs are noticed during a patient exam, you may need to assess

your patient for OUD.

Methadone:

black box warning

benefits of use in opioid use disorder

prolongs the QT interval and hence may pose a risk for potentially fatal dysrhythmia. Torsades de pointes has developed in patients taking 65 to 400 mg/day. To reduce risk, methadone should be used with great caution—if at all—in patients with existing QT prolongation or a family history of long QT syndrome and in those taking other QT- prolonging drugs. In addition, methadone causes severe respiratory depression that can be potentially fatal.

Buprenorphine and naloxone

benefits of using this combination

-Buprenorphine is an opioid partial agonist. The partial agonist effect relieves withdrawal symptoms resulting from cessation of opioids.

-Buprenorphine should be started at 6-12 hours after the last dose of heroin or immediate release opioids and longer after ER. At least 36 hours after the last dose of methadone

-providers must have board certification in addiction medication and complete special training to qualify for the federal waiver to prescribe Buprenorphine

NALOXONE; is an opioid antagonist. Is added with Buprenorphine to make the product less likely to be abused by injection. The naloxone component will have no effect if taken in tablet form. If injected then naloxone will precipitate withdrawal.

Treatment of chronic pain

Use of pregabalin

-sedation, dizziness, and ataxia are more linked to pregabalin

-GI bleeding may be caused by COX-2 inhibitors and and NSAIDs

- Use of pregabalin

-sedation, dizziness, and ataxia are more linked to pregabalin

-treats neuropathic pain

Tricyclics (TCAs) and SNRIs treats neuropathies pain

-contraindicated in severe cardiac disease, particularly conduction issues

-anticholinergic effects

Order HTN meds are typically prescribed

-Best for someone with diabetes

-Best approach or drug to use during pregnancy or someone wishing to become pregnant

-Therapeutic action of drug classification used

Ethnic groups impacted by certain drug classifications

Prescribing considerations when carbamazepine is prescribed with warfarin

Beta blockers:

-Their use with nitroglycerin and tachycardia

-know examples

-risk of stopping them abruptly

-what happens when given to someone with asthma?

Know the outcome of having a poor metabolism phenotype

slowed metabolism of a prodrug into an active drug, leading to accumulation go prodrug

Know the role of the government when it comes to rx drugs

Although the federal government controls drug regulation, However, several

organizations have appealed for changes that would place scope of practice and prescriptive authority under federal regulation in an effort to expand prescriptive authority and the scope of practice of advanced practice providers.

Fentanyl

Products containing fentanyl can cause fatal respiratory depression. Many of these products are only available through restricted distribution programs secondary to misuse and abuse

Methadone

prolongs the QT interval and hence may pose a risk for potentially fatal dysrhythmia. Torsades de pointes has developed in patients taking 65 to 400 mg/day. To reduce risk, methadone should be used with great caution—if at all—in patients with existing QT prolongation or a family history of long QT syndrome and in those taking other QT- prolonging drugs. In addition, methadone causes severe respiratory depression that can be potentially fatal.

Which of the following is NOT a potential harm/risk of pregabalin? Select the best answer.

GI bleeding

Alan Sayed has neuropathic pain. What nonopioid medications should be considered for his treatment? Select all that apply.

A)Tricyclic antidepressants (TCAs)

B)Topical lidocaine

C)Serotonin and norepinephrine reuptake inhibitors (SNRIs) D)Gabapentin

Answer: ABCD

Diuretics:

Action

Contradictions to thiazide diuretics

o Monitoring needs

-Thiazide diuretics are the preferred agent for treating stage 1 hypertension

-Preferred in African American with HTN

-All diuretics decrease blood volume, venous pressure, and preload

-thiazide diuretics block the sodium-chloride channel in the kidney, decreasing the cross of sodium over the luminal membrane, which in turn decreases the action of the sodium-potassium pump and sodium and water passage to the renal interstitium

-monitor K and electrolytes

- DO NOT GIVE IF SULFA ALLERGY

- can also be used to manage osteopenia or osteoporosis

Examples: HCTZ, Hygroton, Lozol

Side effects: hyperglycemia, hyperuricemia (can precipitate gout), hyperlipidemia, hypokalemia, hyponatremia, hypomangesium

Heart failure:

-What to prescribe in response to fibrotic changes?

-effects of cardiac glycosides

-Digoxin belongs to a class of drugs known as cardiac glycosides, agents best known for their positive inotropic actions—that is, their ability to increase myocardial contractile force. By increasing contractile force, digoxin can increase cardiac output. In addition, it can alter the electrical activity of the heart and can favorably affect neurohormonal systems. Unfortunately, although digoxin can reduce symptoms of HF, it does not prolong life. Used widely in the past, digoxin is considered a second-line agent today.

Quinidine and digoxin

What happens when they are combined?

Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score

What is it?

When is it used?

Statin drugs-- at what age are they preferred?

Exetimibe (Zetia) what is it?

When is it used?

Pharmacological option to minimize side effects

-In other words, how would you treat high cholesterol if someone was concerned about or experiencing side effects from other medications? Which drug classification would be a good choice?

Angina:

-therapeutic action of organic nitrates

-contraindication for ranolazine

-prevention of MI and death

-antiplatelet drugs, cholesterol-lowering drugs, angiotensin-converting enzyme inhibitors

-Reduction of cardiac ischemia and the associated pain-- nitrates, beta blockers, CCB, ranolazine

- CCBs and ACEI most expensive

- BB mid-range

-Nitrates cheapest

Most appropriate treatment approach for OA

-pharmacological and non-pharm

gout

o Complicationsofuntreatedgouto Treatmentofacuteflarewithcolchicine

Patient education

Adverse effects

o Long-term use of allopurinol

What condition can be developed?o Drug interactions with allopurinolo What should be

co-administered with febuxostat?

-Gout is a recurrent inflammatory disorder characterized by hyperuricemia (high blood levels of uric acid) and episodes of severe joint pain, typically in the large toe. Hyperuricemia

- Drugs are used in two ways in patients with gout. First, they are given short term to relieve symptoms of an acute gouty attack. Second, they are given long term to lower blood levels of uric acid.

In patients with infrequent flareups (less than three per year), treatment of symptoms may be all that is needed. Nonsteroidal antiinflammatory drugs (NSAIDs) are considered first-line agents for relieving the pain of an acute gouty attack. Glucocorticoids are an acceptable option. In the past, colchicine was considered a drug of choice for acute gout—even though it has a poor risk/benefit ratio. Today, colchicine is generally reserved for patients who are unresponsive to or intolerant of safer agents.

In patients with chronic gout, tophaceous gout, or frequent gouty attacks (three or more per year), drugs for hyperuricemia are indicated. Three types of drugs may be employed: agents that decrease uric acid production, agents that increase uric acid excretion (uricosuric drugs), and agents that convert uric acid to allantoin.

NSAIDS

o BlackBoxWarning

o Drug interactions

o Therapeutic action

o Mechanism of action

DMARDS

Black box warning

Drug interactions

therapeutic action

mechanism of action

-Conventional DMARD: Methotrexate

o immunosuppressant: inhibits dihydrofolate reductase; inhibits lymphocyte proliferation (folate antagonist)

- Biological DMARD: adalimumabo binds and inhibits tumor necrosis factor-alpha, reducing inflammation and altering

immune response

-Targeted DMARD: Tofacitinibo inhibits janus-associated kinases (JAK) 1, 2, and 3, leading to disruption of

cytokine and growth factor signaling pathways

Osteoporosis:

-Aldendronate- patient education

-Ibandronate- which dietary supplement can interfere with absorption?

- three agents are used...

1. Bisphosphates: alendronate, ibandronate

-first line tx for postmenopausal women with prior hip or vertebral fx. and/or DXA T-score of <2.5

-Mechanism of action: inhibits osteoclasts activity, reducing bone resorption and turnover.

2. Denosumab: prolix, Xgeva

-An alternative initial treatment in postmenopausal women with osteoporosis who are at high risk for osteoporotic fractures

-mechanism of action: Binds to receptor activator of nuclear factor kappa-B ligand (RANKL), inhibiting

osteoclast formation, maintenance, and survival and reducing bone resorption and turnover (RANKL inhibitor)

3. Raloxifene: Evista, raloxifene

-Approved for the treatment and prevention of osteoporosis in postmenopausal women and used in those who have contraindications for the prior two options

-mechanism of action: Selectively binds to estrogen receptors, producing estrogenic and anti-estrogenic

effects

RA

-treatment during pregnancy

- Which drugs have a higher risk vs which ones are the safest

hydrocodone/acetaminophen (Lortab)

Lisinopril

Amlopidine (Norvasc)

Colchine

Colchicine should be used with care in older adults and debilitated patients and in patients with cardiac, renal, hepatic, and GI disease.

As noted, combined use of colchicine with strong inhibitors of PGP

or CYP3A4 should generally be avoided. For both acute therapy and long-term prophylaxis, dosage should be adjusted on the basis of liver function, kidney function, and use of interacting drugs. Prescribing information for Mitigare but not Colcrys includes contraindications for hepatic or renal impairment.

Colchicine should be avoided during pregnancy unless the perceived benefits outweigh the potential risks

statins and colchicine

As noted, atorvastatin, simvastatin, and other statins can increase the risk for colchicine-induced muscle injury. If possible, combined use of statins and colchicine should be avoided.

Drugs that can increase colchine levels

Life-threatening reactions have occurred when colchicine

was combined with two classes of drugs: P-glycoprotein (PGP) inhibitors and inhibitors of CYP3A4. Recall from

o

diuretics and ACEIs. Hence even though aspirin has beneficial effects on coagulation, it should still be avoided unless clinically indicated for conditions such as myocardial infarction.

Be familiar with the treatment for osteoarthritis

Treatment of gout

39of47

Chapter 4 that PGP is a transporter protein that can reduce plasma drug levels through effects in the liver, kidney, and intestine. Hence, by inhibiting PGP, drugs such as cyclosporine and ranolazine can cause colchicine to accumulate to toxic levels. Similarly, by inhibiting CYP3A4, drugs such as ketoconazole, clarithromycin, and the HIV protease inhibitors (e.g., nelfinavir and ritonavir) can cause colchicine levels to rise. Accordingly, combined use of colchicine with strong inhibitors of either PGP or CYP3A4 should generally be avoided and is contraindicated in patients with hepatic or renal impairment

Medications typically co-administered with gout tx

Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first-

line agents for relieving the pain of an acute gouty attack.

Combo: Colchicine and probenecid (generic)

Antigout Anti-inflammatory Drug (colchicine)

Glucocorticoids (Prednisone (oral) (Deltasone), Triamcinolone

acetate (IM) (Aristospan and Kenalog)

Xanthine Oxidase Inhibitors (Allopurinol (Zyloprim))

Uricosuric Agents Probenecid (generic only)

Recombinant Uric Acid Oxidase Pegloticase (Krystexxa)- $$$

Complications of untreated gout

Untreated gout may cause erosion and irreversible joint damage, renal damage, and tophi.

Tophi (TOE-f-EYE) are telltale signs your gout is out of control. When uric acid levels remain high and gout is out of control, deposits of uric acid crystals can develop into hard visible lumps that damage your joints and bones. Tophi can be microscopic or large and, though rare, may need to be surgically removed.

Bisphosphonates (OA tx) pt education

Instruct patients to swallow the tablet whole, with a full glass of water, while sitting or standing upright. Remain upright for at least 30 min (60 min with ibandronate). These measures minimize the risk of esophagitis; Intake of food, even in small amounts, prevents absorption of this medication; Instruct patients to take these drugs in the morning before eating or drinking anything other than water; Postpone ingesting anything —including orange juice, coffee, antacids, and calcium, iron, or magnesium supplements—for at least 30 min (60 min with one drug in this class).

Denosumab (OA tx) pt education

Advise patients to ensure adequate intake of calcium and vitamin D. A dosage of 1000 mg of calcium with at least 400 IU of vitamin D daily is commonly recommended; Instruct patients that this drug may decrease their ability to fight infections. They should avoid contact with people who have a contagious disease and should practice good handwashing, especially when using public facilities; Explain the need to report plans to have dental surgery. Maintain a routine plan for excellent dental hygiene.

-Report symptoms such as jaw pain and signs or symptoms of infection; Emphasize the need to avoid stopping medication without first discussing this with the provider. The risk for bone fracture is increased after medication is discontinued.

Raloxifene (OA tx) pt education /black box warning!

Advise women taking this medication for osteoporosis to ensure adequate intake of calcium and vitamin D; Because this agent increases the risk for DVT, PE, and thrombotic stroke, advise patients to discontinue the agent at least 72 hours before prolonged immobilization (e.g., postsurgical recovery and extended bed rest) and to resume treatment only after full mobility has been restored. Instruct patients to avoid extended periods of restricted activity, as can happen when traveling

Baseline data needed for drugs in DMARDS class

Conventional DMARDS:

-ALT, AST, serum creatine

Methotrexate: CXR, check plum and GI status

Sulfasalazine: CXR, check pulm and neuro status

Hydroxychloroquine: eye exam, cardiac exam with ECG

Leflunomide: CXR, Check pulm status, BP

Gayle has RA and takes leflunomide and an oral contraceptive. She reports that she would like to get pregnant. Which of the following is the best course of action for Gayle?

Discontinue the leflunomide and begin an 11-day course of cholestyramine.

-Leflunomide is teratogenic; therefore, it is contraindicated in pregnancy. Patients desiring pregnancy must follow a three-step protocol that includes stopping leflunomide, taking cholestyramine to chelate the leflunomide, and ensuring that leflunomide drug levels are below 20 μg/L before getting pregnant.

Hydrocodone black box warning

All forms of hydrocodone contain a black box warning. Products that contain acetaminophen (Vicodin) are associated with hepatotoxicity. The extended-release forms of hydrocodone can cause fatal respiratory depression and should only be prescribed by providers with additional education regarding chronic pain

Opioids

-moderate to severe pain

-dosing considerations: opioid naive vs chronic pain pt

-adverse drug reactions: sedation, drowsiness, mental cloudiness, constipation, nausea, worse if combined with alcohol or benzo

-clear instructions and education to pt about safety and ADRs, discuss length of treatment, discuss alternative therapy

-monitor pain

Acetaminophen

-mild to moderate pain

-children 10 mg/kg every 4-8 hrs

-maximum 4g/day

hepatic injury with OD

renal disease with chronic disease

drug interactions with alcohol

NSAIDs

-use for fever and/or pain, inflammation as an anti platelet

-Avoid in pregnancy and renal disease

-max dose: 3200 mg/day

-Naproxen max dose: 1250 mg/day

-ADRs: GI upset, dyspepsia, abdominal pain, GI bleed, fluid retention, edema, HTN, renal damage

Three main principles to improve opioid prescribing

-determining when to initiate or continue opioids for chronic pain

-opioid selection, dosage, duration, follow-up, and discontinuation

-assessing risk and addressing harms of opioid use

Assess potential harms of opioid therapy:

1. Assess

Evaluate for factors that could increase your patient's risk for harm from opioid therapy such as: Personal or family history of substance use disorder Anxiety or depression Pregnancy Age 65 or older COPD or other underlying respiratory conditions Renal or hepatic insufficiency

2. Check

Consider urine drug testing for other prescription or illicit drugs and check your state's prescription drug monitoring program (PDMP) for: Possible drug interactions (such as benzodiazepines) High opioid dosage (≥50 MME/day) Obtaining opioids from multiple providers

3. Discuss Ask your patient about concerns and determine any harms they may be experiencing such as: Nausea or constipation Feeling sedated or confused Breathing interruptions during sleep Taking or craving more opioids than prescribed or difficulty controlling use

4. Observe

Look for early warning signs for overdose risk such as: Confusion Sedation Slurred speech Abnormal gait

Determine whether to initiate opioids for chronic pain

strategies to improve pt safety

-use of morphine milligram equivalent (MME)

-use extra precautions when increasing to >50 MME per day

-Avoid or carefully justify increasing dosage to >90 MME/day

renal and hepatic consideration for opioid use

- pts with renal or hepatic insufficiency can experience greater peak effect and longer duration of action for medications.

- pts over 65 have smaller therapeutic window between safe dosages