Medication Safety: A

Prescription for Prevention

Chad Kawakami Pharm.D., BCPS, CDE

Assistant Professor of Pharmacy Practice

The Daniel K. Inouye College of Pharmacy

Jonathan Kataoka Pharm.D. Candidate

Robert McHugh Pharm.D. Candidate

Objectives

● Understand the definition of prescription drug misuse

● Know the risk factors involved in prescription drug misuse

● List misuse prevention tactics that help aid in proper drug use

● Understand the different disposal methods, and understand when each method is most

appropriate

● List the common problems associated with each medication form

Objective

● List devices that can help medication compliance

● Understand the pros and cons regarding OTC medications

● List common drugs that geriatrics tend to take, the adverse effects, and

cautions regarding these drugs

● Realize the dangers that may occur when taking combination or multi-

symptom products

● Be able to utilize and describe the drug facts label

Older Adults Take More

Medicine → Consume 1/3 of all prescription meds

→ One in four older adults has used

psychoactive meds with abuse potential

→ Prescription drug misuse and abuse

is a growing problem

→ May be as high as 11% of older adult

population

Definitions

Prescription Drug Misuse

→ The use of a medication other than as

directed

– May be accidental or willful

Prescription Drug Abuse

→ Intentionally taking medications that are not

medically necessary

Misuse can Lead to Abuse

→ Patient behavior

→ Prescriber behavior

→ Both

The pathway from appropriate use, through misuse to abuse can result from

Prescription Drug MisusePatient Behavior

→ Taking more of a drug than prescribed

→ Missing doses

→ Taking the wrong drug

→ Using a drug for other than the prescribed reason

→ Sharing or borrowing drugs

→ Using drugs that have expired

→ Combining drugs with alcohol or other substances

Prescription Drug MisusePrescriber Behavior

→ Medications w/o indication

→ Multiple drugs from same class

→ Dose too high; duration too long

→ High risk drugs or inappropriate for elderly

→ Inadequate instructions for taking meds

→ Failure to question about use of alcohol or other

drugs with abuse potential

Prescription Drug Misuse is UNSAFE

→ Treatment failure

→ Increased health resource utilization

– ER visits

– Hospitalizations

It might lead to prescription drug ABUSE

Prescription Drug Misuse

Risk Factors → Number of medications

→ Multiple prescribers

→ Inappropriate prescribing

→ Limited English language proficiency

→ Low health literacy

→ Memory problems

→ Hearing/Vision impairments

→ Treating symptoms and not the cause

How Much is Too Many?

Prevention Tactics→ Improving medication adherence.

→ Making sure that older adults understand how to take medications and what to avoid when taking a prescription medication.

→ Encouraging older adults to share concerns and ask questions about their medication.

→ Encouraging older adults to inform health care providers of all medications they take regularly.

→ Encouraging older adults to keep a current medication list.

Prevention Tactics

→ Provide medication aids

→ Address communication barriers

→ Community informational and intervention support programs

→ Educate prescribers

→ Adequate treatment of underlying conditions

→ Standardized screening

→ Transitional care and medication review

Quality of Prescribing“No man is an island”

Quality of Prescribing requires a team effort to avoid ADE and optimize therapy to improve a patient's QOL

In an article published by AAFP titled “Appropriate Prescribing of Medications: An Eight-Step Approach,” the

authors combined WHO suggested steps with their own to create a safer and more effective prescribing

strategy:

1. Evaluate and Define the patient’s problem

2. Specify the therapeutic objective

3. Select the appropriate drug therapy

4. Initiate therapy with appropriate details and consider

nonpharmacologic therapies

1. Give information, instructions, and warnings

2. Evaluate therapy regularly

3. Consider drug cost

4. Use Electronic Devices (RX software, and access to a

Electronic drug references)

BUT WHAT’S MISSING????

Quality of Prescribing

While these steps are thorough and address many of the potential pitfalls and mistakes in prescribing

medications to the elderly with chronic disease, the steps fail to mention the prescribers most valuable

resource: the whole medical team.

Every member of the medical team should contribute to the 8 steps.

● Nurses

● Pharmacists

● Specialist

● Mental Health Care Providers

● Social Workers

● Family Members TEAMWORK

Help fight

Prescription Drug Misuse & Abuse

CLEAN OUT THE

MEDICINE

CABINET!!

Safe Disposal of Medications

Importance of Safe Disposal

● Keeping medications when they are not needed also keeps unnecessary

health risks in the household

● Every year, more than 71,000 children (18 years old and younger) are seen in

the emergency room due to accidental overdoses of prescription and OTC

medications

● Ensuring proper disposal of medications can help reduce accidental exposure

(and also intentional misuse)

Accidental Exposure Cases

● 2-year old male taken to ER due to methadone intake. Was treated in the ER with

appropriate actions such as activated charcoal, and was discharged. Later that day,

child had no heartbeat and not breathing. Resuscitation attempts were not effective

and child died.

● 4-year old female not breathing at grandparents home. Resuscitation attempts were

not effective and child died. Autopsy showed that child ingested a transdermal fentanyl

patch. Child probably found a used patch in the house trash.

● 2-year old female was found staggering and rubbing mouth. Child also developed

tiredness and abdominal pain. Brought to ER, but found no signs of distress. The next

day under parent’s care, child was found unresponsive. Child pronounced dead at

hospital. Blood test was found positive for oxycodone.

Disposal Methods

Three Safe Methods:

● Drug Take-Back Programs or Authorized Collectors

● Household Trash

● Flushing in Sink or Toilet

Drug Take-Back Programs and Authorized Collectors

• Recommended for all medications allowed in the program when possible• DEA-authorized personnel receive prescription drugs and safely/securely

dispose of them• National Prescription Drug Take-Back events are periodically hosted by

DEA– Free and anonymous– Takes back solid dosage forms, such as tablets and capsules– Does not accept needles and syringes

• Some places are DEA-authorized to collect medications, and may include retail pharmacies, hospitals, clinics, and law enforcement

• Some authorized collectors may provide mail-back envelopes or have drop-boxes

Drug Take-Back Event

Where - Blaisdell Exhibition Hall

When - September 22-24, 2017,

8:30am-12:30pm each day

Who - Anyone

Cost - Nothing!

National Prescription Drug

Take-Back Day

https://www.deadiversion.usdoj.gov/

drug_disposal/takeback/index.html

● Occurs biannually (Around April

and October)

National Prescription Drug

Take Back Day

●Who: Everyone

●What: Unused or Expired

Medications

●When: Saturday, October 28th,

2017 from 10:00 am to 2:00 pm

●Where: visit www.dea.gov or call 1-

800-9539 for a collection site.

Controlled Substance Public Disposal Locator

https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1

Other Method: Disposal Envelopes

● $4.20 (Amazon price)

Disposal by Household Trash

● Recommended for most drugs if a drug take-back program is not available

● Usually not done for narcotics because a child or pet may still accidentally get

the disposed drug

Disposal by Flushing

● Recommended for certain controlled-substances (especially narcotics) if a

drug take-back program is not available

● The label or patient information sheet that came with the medication should

indicate if the medication can be flushed

● Flushing prevents accidental ingestion of these harmful and fatal medications

● Not done for all medications due to environmental concerns (water treatment

plants were not made to remove medicines in mind)

Disposal by Flushing

• Substances include:• Buprenorphine• Diazepam (rectal gel)• Fentanyl• Hydrocodone• Hydromorphone

• Methadone

• Methylphenidate

• Morphine

• Oxycodone

• Oxymorphone

• For a full list of brands please visit:

• https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm#medicines

Medication Disposal

DisposeMyMeds.org→ An online resource to help find medication disposal programs at the local

independent community pharmacy near you

Drug Take Back Network→ Information on permanent and regularly recurring drug take-back events

www.takebacknetwork.com/local_efforts.html

SMARxT Disposal→ http://www.mnsmartdisposal.net/

Medication Forms

Medication Forms● Oral

○ Multiple medications can make organizing and remembering when to take which meds difficult

○ Size of capsules and tablets can make swallowing difficult

○ Specifics with dosing (example: with or without food)

● Inhaled (Powder and Aerosolized)

○ Specific instructions for proper administration can be complicated

○ New devices may not be “user friendly” to the elderly

● Rectal

○ Stigma associated with insertion

○ Proper administration instructions must be given

● Topical (lotions, gels, ointments)

○ Variable absorption and application rates

○ Many medications are not transdermal

○ Application to hard reach areas may be very difficult

● Injections

○ Painful

○ Problematic dosing and process - requires extra equipment

○ Dexterity and cognitive issues

Devices

Blister Packing

• Pharmacare– Minimal to NO additional cost to patient– Free Home Delivery

• Contact:– Reece Uyeno, Pharm.D., BCPS– (808) 840-4126– ruyeno@pharmacarehawaii.com

Devices

There are many devices that can help elderly patients remain compliant to their medications:

● Pill Organizers - One of the oldest, most often-utilized methods

○ Pros: inexpensive, effective, simple

○ Cons: must be packed by hand, remember to take medications, can become confusing

● Bubble Packs - Can be completed by local pharmacies or other health care providers

○ Pros: packed at the pharmacy and approved by RPh, multiple packs for multiple times of day

○ Cons: cost, remember to take medications, cannot adjust medications mid-Rx

● Time Bottle Caps - Can be set to show when bottle was last opened or alarm each day to remind the

patient that it’s time to take his or her medication

○ Pros: will alarm when time to take medication, multiple settings available

○ Cons: hearing impaired, no idea if patient is over/under dosing him or herself

● Software/Apps - One of the newest items on the market to ensure safe and compliant use of

medications, involves portable electronics/smart phones

Software/Apps

Pros:

● Not Just for patient but for family

● Multiple apps for mobile devices

● Multiple alarms with images

● Can be set up by family members

● Integrated Bluetooth caps can keep track of what medications

have been taken and when

Cons:

● Learning curb for geriatrics

● Must maintain battery

● Keep device on and near Bluetooth caps

● Can not be sure if patient is over- or under-dosing him or herself

Over-The-Counter Medications

Over-The-Counter (OTC) Medications

● Can be found in many outlets over at the shopping aisles

● Can be purchased without a prescription

● Considered safe enough to use without supervision of a physician or other

health care professional

Over-The-Counter (OTC) Medications

Pros

● Convenient for the patient

● Cost-friendly for many common conditions

(allergy, cough, diarrhea, rash, etc.)

● Patients can purchase OTC products

independently based on their own judgment

Cons

● Common misconception that OTCs must

always be safe to use

● Dosing, adverse effects, and interactions

● Instructions are not always clear

● Possible unnecessary ingredients or even

unnecessary treatment

● Doctors not always informed on all OTC

products being taken

Over-The-Counter (OTC) Medications

Because of the risks still found in OTC products, it is good practice to remember:

● Common generics and examples of brands

● Indications as to why a medication should be taken

● Adverse effects that may happen when taking the product

● Interactions that may occur with a product

● Cautions regarding other existent conditions

NSAIDs

● Examples: ○ Aspirin (Bayer, Ecotrin)○ Ibuprofen (Advil, Motrin)○ Naproxen (Aleve, Midol ER)

● Indications: Pain, Headache, Fever, Inflammation

● Adverse Effects: Gastrointestinal Bleeding, Gastritis, Diarrhea, Nausea, Renal Failure, Tinnitus

● Interactions: ACEIs, Warfarin● Cautions: Cirrhosis, Renal Failure,

Congestive Heart Failure, Alcohol Use

● Note: Take with food to prevent upset stomach

Acetaminophen

• Example: Tylenol• Indications: Pain, Headache,

Fever• Adverse Effects: Liver Toxicity• Interactions: Azoles,

Macrolides, Warfarin• Cautions: Cirrhosis, Alcohol

Use• Note: Multiple Products with

Acetaminophen • Max total for geriatrics = 3

grams/day

Not just in Tylenol…

OTC Combination and Multi-Symptom Products

• Some OTC products contain more than one active ingredient (contain more than one drug)

• Reasoning:• More effective in treating a single symptom

(combination product)• Example: Excedrin

• Migraine• Acetaminophen + Aspirin +

Caffeine• More effective in treating various different

symptoms (multi-symptom product)• Example: Adult Robitussin Multi-

Symptom Cold (Cough, Nasal Congestion, Mucus)

• Dextromethorphan, Guaifenesin, Phenylephrine

Benefits and Safety Concerns

Benefits

● Convenience of less products

● Cost benefits

Safety Concerns

● Possible unneeded drug(s)

● Risk of taking one specific active

ingredient in multiple medicines at the

same time

Do You See Any Potential Problems?

Active Ingredients

Tylenol Cold (per caplet)

• Acetaminophen 325 mg

• Dextromethorphan 10 mg

• Guaifenesin 200 mg

• Phenylephrine 5 mg

• Recommended dose is 2 caplets every 4 hours

Robitussin Severe Multi-Symptom Cough Cold + Flu (per 20 mL)

• Acetaminophen 650 mg

• Dextromethorphan 20 mg

• Guaifenesin 400 mg

• Phenylephrine 10 mg

• Recommended dose is 20 mL every 4 hours (6 doses per day)

Acetaminophen Overdose

If both products taken together at the same time at the manufacturer’s

recommended dose:

● You would exceed the recommended maximum single dose of acetaminophen

● After three doses, you would exceed the recommended maximum daily dose of

acetaminophen

Always read the Drug Facts label on every OTC product!

Pseudoephedrine

• Example: Sudafed • Indications:

– Nasal Congestion

• Adverse Effects: – Hypertension, Vasospasm, Arrhythmia, Tremors, Stroke, Seizures, Insomnia, Headaches, Hallucinations

• Interactions: – Beta-Blockers, Digoxin, Monoamine Oxidase Inhibitors

• Contraindications: – MAO use

• Cautions: – Hypertension, Heart Disease, Diabetes Mellitus, Closed-Angle Glaucoma, Thyroid Disease, Prostatic Hypertrophy,

Urinary Retention

• Note: Doesn’t need prescription but is behind-the-counter

Topical Nasal Decongestants

● Examples: Oxymetazoline (Afrin),

Phenylephrine (Neo-Synephrine)

● Indications: Nasal Congestion

● Adverse Effects: Hypertension, Rhinitis

Medicamentosa

● Interactions: Beta-Blockers, Digoxin,

Monoamine Oxidase Inhibitors

● Cautions: Hypertension, Heart Disease,

Diabetes Mellitus, Closed-Angle

Glaucoma, Thyroid Disease, Prostatic

Hypertrophy, Urinary Retention

First-Generation Antihistamines

● Examples: Diphenhydramine (Benadryl)

● Indications: Symptomatic Relief of Cough,

Cold, and Allergy

● Adverse Effects: Arrhythmia, Diaphoresis,

Dry Mouth, Mydriasis, Constipation,

Urinary Retention, Cognitive Dysfunction,

Seizures, Hallucinations, Sedation

● Interactions: Oxybutynin, Phenothiazine

Medications, TCAs, Antiparkinsonian

Medications

● Cautions: Closed-Angle Glaucoma, BPH,

Asthma, Dementia

Laxatives

Surfactant Agents

● Examples:Docusate Sodium (Colace),

Mineral Oil

● Cautions: Aspiration (mineral oil)

Stimulant Agents

● Examples: Senna, Bisacodyl (Dulcolax)

● Adverse Effects: Cathartic Colon,

Electrolyte Imbalance

Osmotic Agents

● Examples: Magnesium Hydroxide,

Magnesium Sulfate

● Adverse Effects: Edema, Electrolyte

Imbalance

● Interactions: Digoxin, Thyroid Medications,

Quinolones, Azoles

● Cautions: Renal Failure, Bone Disease

Important Notes• Remember to always read the Drug

Facts found on the OTC product for important information. This label contains invaluable information regarding the product.

• Active Ingredient: Be aware of this, especially if multiple OTC products are being used simultaneously

• Uses: Make sure you are using the correct product for the certain condition

• Warnings: Be sure to understand when not to take the product, and what adverse effects may happen while taking the product

• Inactive Ingredients: May contain something that a patient may be allergic to

• Directions: Always follow this• Other Information: storage, expiration

date, overdose instructions, etc.

• Take steps to prescribe appropriately• Be aware of difficult to administer dosage forms

and take steps to mitigate errors• Use compliance aids as appropriate• Encourage proper medication disposal to prevent

accidental exposure

Directions: