From the front lines of pharmacy care
A virtual poison pill: Top 3 avoidable medication dangers
The life of a pharmacist is filled with horror stories — or near misses that have a potential for horror — when it comes to dispensing medications and patients taking (or mis-taking) them. A retail pharmacist is incredibly busy in the assembly line of filling medications all day long, and even with their extensive training and all of the safeguards, “stuff” can indeed happen.
I’ll share a few real-life stories in a related blog. But here, I’ll cover the top three drugs that have the greatest potential for not merely error, but abuse that can lead to serious complications…even death. In addition, I’ll give a few thoughts about how both patients and their loved ones can be prepared by their physician if an opioid overdose occurs.
Fentanyl: Big danger in small amounts
The artist Prince isn’t the only person who’s died from an overdose of fentanyl. In fact, a report posted in JAMA on May 1, 2018 noted that while prescription opioids have been the most common drug involved in overdose deaths, but heroin and synthetic opioids — primarily illicitly manufactured fentanyl (IMF) — are implicated in more and more overdoses. In addition, synthetic opioids such as fentanyl are increasingly found in illicit drug supplies of heroin, cocaine, methamphetamine and counterfeit pills, typically without the user’s knowledge. Fentanyl is an extremely powerful opioid, 50 to 100 times more potent than morphine. Studying six years of data beginning in 2010, by 2016 these fake synthetic opioids eclipsed prescription opioids as the most common drug involved in U.S. deaths by overdose.
One in every 16 surgical patients prescribed opioids becomes a long-term user. As the cited article notes, overprescribing opioids after surgery is common, and the lack of multidisciplinary procedure-specific guidelines contributes to the wide variation in opioid prescribing practices. The authors hypothesize — and I agree — that a single-institution, multidisciplinary expert panel can establish consensus on ideal opioid prescribing for select common surgical procedures.
Unfortunately, further limiting legal prescriptions for opioids has a blowback effect. Americans hard-pressed to get prescription refills are increasingly turning to street drugs to alleviate their pain or to get the high they’ve become accustomed to. These street drugs are laced with synthetic fentanyl and who knows what else. Most people don’t know they’re taking it, and even the smallest amount of fentanyl can be deadly…and very hard to detect.
In its prescription form, fentanyl is known by such brand names as Actiq, Duragesic, and Sublimaze. Street names for fentanyl or fentanyl-laced heroin include Apache, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, TNT, and Tango and Cash, no doubt among others.
Trust me…If you have an addictive personality or genetic makeup, talk to your doctor before you accept even a legal prescription. Worse, if you’re seeking it as a street drug, it’s potential for overdose and fatality is even more real. For more drug facts about fentanyl including how it’s delivered, see this resource from the National Institute on Drug Abuse.
Morphine: Elementary, Dr. Watson
When many of us think of morphine, we conjure up the old image of Victorian-era mythical detective hero Sherlock Holmes. In one of Arthur Conan Doyle’s immortal books, Mr. Holmes said he sometimes used morphine and cocaine to escape “the dull routine of existence.” Not a good idea; get a hobby (and a clue), Sherlock!
Morphine and morphine derivatives are powerful opium alkaloid narcotics long used to treat pain but can have significant addictive side effects. (An example of an opioid derivative is hydromorphone, brand names Dilaudid and Exalgo, a semi-synthetic opioid used since the 1920s). Morphine-based drugs can cause serious or life-threatening unmanageable adverse effects (especially when taken with alcohol) including breathing or swallowing problems, especially during the first 24 to 72 hours of treatment and any time the dosage is increased.
The fast road to heroin — Since they carry a high risk for dependence and addiction, opioids are often a gateway drug to heroin — another opium-based derivative — and physicians and clinical pharmacists work to find less-dangerous and less-addictive options. Using national data in the 2000s, nearly 80% of heroin users reported using prescription opioids prior to heroin, reported the National Institute on Drug Abuse.
Doing the math — For prescribers and pharmacists, morphine is an area where a simple math error can cause death. Quickly. Morphine is often prescribed for elderly patients that have difficulty swallowing — since it also comes as an oral liquid formulation. But there are two strengths of morphine that are 10 TIMES different, the only difference being a single zero: 10mg/5ml and 100mg/5ml. One handwriting or math slipup and death is likely.
An important safety measure: Narcan or Evzio (naloxone) — Before an opioid is prescribed, physicians and patients often sit down to the discuss the possibility of co-prescribing naloxone. For over nearly 50 years, it’s been effective in reversing the effects of opioid overdose when time is of the essence, saving tens of thousands of lives annually and as well as unnecessary and expensive ambulance trips, ED visits and hospitalizations.
Medical societies in nearly every state have helped enact naloxone access laws, with prescriptions nearly doubled in 2017 to 8,000 per week. Note that it’s vitally important the patient (and/or a close friend or family member) have the proper training to use naloxone in case of an overdose.
The American Medical Society and its Opioid Task Force have a website — End the Epidemic — full of facts and links to excellent resources that will help you learn more about the issue of opioid addiction, the use of naloxone and other life-saving information. (Here’s a short PDF to download on naloxone, for instance.) I highly recommend both patients and providers spend some time on the site.
A new method to treat addiction — One quick note: Opioid dependence and access to treatment are two of the biggest barriers to overcoming addiction. A related AMA article discusses a new alternative payment model — the Patient-Centered Opioid Addiction Treatment (P-COAT) model developed by the AMA and the American Society of Addiction Medicine (ASAM) — that combines not only medical care but coordinated psychological and social services for patients who need them. This is great additional valuable information about a coordinated-care approach for opioid-addicted patients, and something patients can ask their physicians about, especially if they’re participating in a patient-centered medical home (PCMH).
Warfarin: To bleed or stroke out
This used to be a tough one. When it was first FDA-approved in 1954, warfarin was one of few anticoagulants that could keep blood flowing smoothly by decreasing the amount of clotting proteins present in your blood. This is particularly vital for people who have had or run the risk of having blood clots due to deep-vein thrombosis (DVT) or pulmonary embolism (PE). Other conditions are an irregular heart rhythm known as atrial fibrillation, a recent heart attack, heart valve replacement, or surgeries such as a hip or knee replacement.
Unfortunately, it’s extremely tricky to get the dosage for warfarin (brand names: Coumadin and Jantoven) just right due to a person’s genetic makeup and how he or she might respond to the drug. Too much and a patient can bleed out internally; too little and they can have another stroke or heart attack. It’s challenging to change a frail patient over to another medication once they’ve been on warfarin for some time. And blood work for a patient on warfarin must be done regularly and consistently.
Worse yet in this teeter-totter balance, warfarin’s side effects can be much more challenging when a patient is taking any of a long list of meds and OTCs. These range from Cipro and erythromycin to Phenobarbital and others. Also, interactions are possible with the standard OTC meds we think are “safe” — Tylenol (acetaminophen), aspirin, Motrin or Advil (ibuprofen), Aleve (naproxen), Tagamet and Prilosec. Don’t get me started on herbal supplements (especially anything with too much Vitamin K), alcohol and diet. So for the late President George H.W. Bush, no worries about him being forced to eat the Brussels sprouts he so hated!
For reference, here’s the AMA’s “Patient’s Guide to Taking Warfarin.”
Options — Currently, there are four other medications approved for use, though as with anything else doctors, other prescribers and us as clinical pharmacists, a lot depends on your genetic makeup, overall health and lifestyle.
The newer meds are Apixaban (Eliquis), Dabigatran (Pradaxa), Edoxaban (Savaysa), and Rivaroxaban (Xarelto). You’ve undoubtedly see their commercials within your favorite TV shows. But in all honesty, there has yet to be accepted research that compares their effectiveness and side effects head to head. Like most options in medicine, “it’s not a one-size-fits-all choice” according to Bruce Lindsay, MD, from the Cleveland Clinic.
There remains a risk of bleeding using any of these meds. But since they wear off faster than warfarin, bleeding problems may not be as serious when they happen.
How PGx prevents deadly results
Pharmacogenomics (PGx for short) helps avoid many potentially deadly results. Testing your unique genetic profile and what type of phenotype you are (how you metabolize meds) can get you the relief you need much more quickly and minimize the likelihood of overdose or other side effects. Here at RxLive®, we’ve found it very effective for our clients in shortening the “therapeutic journey” of hit-or-miss prescribing…especially when the “miss” could be deadly.
In the case of pain relief, some people can do just fine with a higher dosage of Aleve or ibuprofen. Others tolerate hydrocodone versus the more powerful and potentially more addictive oxycodone just fine. PGx helps us avoid the medical disasters that meds such as these are causing each year.
Partner with a team of pharmacy professionals to promote patient safety
As I said, these issues can have deadly consequences. But somehow, we as clinical pharmacists sometimes come across an incidence in real life that we simply must laugh about and, of course, learn from. See this blog about a few of those “medication disaster” stories from the front lines.
RxLive clinical pharmacists are proud to help avoid medication errors, improve quality of life and save money in the process. As we say, “it’s good to check your meds.” And we’re always here to help do so.