Marie A. Abate

Doctor and pharmacy shopping for controlled substances.

Background:Prescription drug abuse is a major health concern nationwide, with West Virginia having one of the highest prescription drug death rates in the United States. Studies are lacking that compare living subjects with persons who died from drug overdose for evidence of doctor and pharmacy shopping for controlled substances. The study objectives were to compare deceased and living subjects in West Virginia for evidence of prior doctor and pharmacy shopping for controlled substances and to identify factors associated with drug-related death. Methods:A secondary data study was conducted using controlled substance, Schedule II–IV, prescription data from the West Virginia Controlled Substance Monitoring Program and drug-related death data compiled by the Forensic Drug Database between July 2005 and December 2007. A case-control design compared deceased subjects 18 years and older whose death was drug related with living subjects for prior doctor and pharmacy shopping. Logistic regression identified factors related to the odds of drug-related death. Results:A significantly greater proportion of deceased subjects were doctor shoppers (25.21% vs. 3.58%) and pharmacy shoppers (17.48% vs. 1.30%) than living subjects. Approximately 20.23% of doctor shoppers were also pharmacy shoppers, and 55.60% of pharmacy shoppers were doctor shoppers. Younger age, greater number of prescriptions dispensed, exposure to opioids and benzodiazepines, and doctor and pharmacy shopping were factors with greater odds of drug-related death. Conclusions:Doctor and pharmacy shopping involving controlled substances were identified, and shopping behavior was associated with drug-related death. Prescription monitoring programs may be useful in identifying potential shoppers at the point of care.

The Medication Assessment Program: Comprehensive medication assessments for persons taking multiple medications for chronic diseases

OBJECTIVE To describe the development, implementation, and evaluation of a pharmacist patient care program for persons taking multiple medications for chronic diseases. DESIGN Pilot study. SETTING Services were provided in Michigan within community pharmacies and through home and work-site visits, between October 2004 and September 2006. PARTICIPANTS 30 pharmacists and 67 patients 18 years of age or older who took four or more medications on a routine basis (three or more times per week). INTERVENTIONS The comprehensive medication assessments identified medication- and health-related problems. Pharmacists provided patient education supported by written educational materials and written recommendations for improving drug therapy and overall patient health. MAIN OUTCOME MEASURES Patient knowledge regarding medications, diagnoses, and healthy lifestyle practices; types of recommendations made; recommendation acceptance rates; pharmacist assessment of program effects. RESULTS The program was developed and implemented through a collaborative approach that included pharmacists, colleges of pharmacy, and employers. Pharmacists were supported by various administrative and clinical services offered by the colleges. Three employers adopted the program as a service for their employees, retirees, and dependents. A total of 67 patients received comprehensive medication assessments. Patients tended to be women, tended to be older, and took an average of 12.6 medications. Pharmacists provided 662 recommendations related to drug therapy, healthy lifestyle practices, and the need for medical evaluation. Recommendation acceptance rates, changes in patient knowledge, and pharmacist evaluation of program effects indicated that the program had a positive effect on patient health. CONCLUSION A collaborative approach to developing and implementing comprehensive medication assessments was found to be beneficial in improving patient understanding of medications, diagnoses, and healthy lifestyle choices. Written pharmacist recommendations resulted in actions that improved self-monitoring skills and drug therapy appropriateness. College of pharmacy administrative and clinical service support was instrumental in network participation and the provision of care.

Trends in drug use among drivers killed in U.S. traffic crashes, 1999-2010

OBJECTIVE Driving under the influence of drugs is a global traffic safety and public health concern. This trend analysis examines the changes in general drug usage other than alcohol, broad categories, and typical prescription and illegal drugs among drivers fatally injured in motor vehicle crashes from 1999 to 2010 in the U.S. METHODS Data from the Fatality Analysis Reporting System were analyzed from 1999 to 2010. Drug prevalence rates and prevalence ratios (PR) were determined comparing rates in 2009-2010 to 1999-2000 using a random effects model. Changes in general drug usage, broad categories, and representative prescription and illegal drugs including, methadone, oxycodone, hydrocodone, barbiturates, benzodiazepines, and cocaine, were explored. RESULTS Comparing 2009-2010 to 1999-2000, prevalence of drug usage increased 49% (PR=1.49; 95% confidence interval [CI] 1.42, 1.55). The largest increases in broad drug categories were narcotics (PR=2.73; 95% CI 2.41, 3.08), depressants (PR=2.01; 95% CI 1.80, 2.25), and cannabinoids (PR=1.99; 95% CI 1.84, 2.16). The PR were 6.37 (95% CI 5.07, 8.02) for hydrocodone/oxycodone, 4.29 (95% CI 2.88, 6.37) for methadone, and 2.27 (95% CI 2.00, 2.58) for benzodiazepines. Barbiturates declined in rate over the 12-year period (PR=0.53; 95% CI 0.37, 0.75). Cocaine use increased until 2005 then progressively declined, though the rate remained relatively unchanged (PR=0.94; 95% CI 0.84, 1.06). CONCLUSIONS While more drivers are being tested and found drug-positive, there is evidence that a shift from illegal to prescription drugs may be occurring among fatally injured drivers in the U.S. Driving under the influence of prescription drugs is a growing traffic concern.

Nifedipine-induced gingival hyperplasia.

Gingival hyperplasia, a condition characterized by increased amounts of gingival connective tissue, has most commonly been observed in patients receiving phenytoin, but has also been noted in patients receiving cyclosporine and, as in this case report, nifedipine. Patients receiving nifedipine should be advised to practice good oral hygiene to lessen the possibility of hyperplasia occurring. If gingival hyperplasia develops in a patient taking nifedipine, the drug should be suspected as being

Characteristics of alprazolam-related deaths compiled by a centralized state medical examiner

BACKGROUND AND OBJECTIVE Unintentional drug poisoning deaths represent a major health concern, particularly in rural areas. Although alprazolam is frequently detected in drug-related deaths, characterization of its involvement is limited. Our objective was to compare the characteristics of alprazolam-related deaths with nonalprazolam deaths in a predominantly rural state. METHODS A comprehensive forensic drug database (FDD) was developed in 2005 to compile demographic, toxicology, and co-morbidity information from all West Virginia (WV) drug-related deaths. All FDD data from 2005 to mid-November 2007 were analyzed. RESULTS Alprazolam contributed to 204 (17.0%) of the 1,199 drug-related deaths and was identified in 7.2% of the 363 deaths occurring during 2005 and in 27.5% of the 422 deaths entered in the database during 2007. At least one other drug, predominantly an opioid, was identified in 97.5% of the alprazolam cases, with concurrent benzodiazepines also found. Compared to nonalprazolam deaths, alprazolam decedents were significantly more likely to be obese and to have preexisting cardiovascular disease, but were less likely to have documented substance abuse. An alprazolam prescription existed in 52.5% of the alprazolam deaths, with 77.6% having a prescription for all drugs identified. CONCLUSIONS Alprazolam was a contributing cause of death in a substantial and increasing number of drug-related deaths. Prescriptions for alprazolam and the other drugs detected were often present in these cases. SCIENTIFIC SIGNIFICANCE Controlled substance monitoring programs should be routinely used as one mechanism to help prevent potential drug misuse/abuse. Our findings provide a baseline for ongoing alprazolam-related death surveillance.

Monooctanoin Use for Gallstone Dissolution

Monooctanoin (Capmul 8210), a digestion product of medium chain triglycerides, is a cholesterol solvent that has been used for the dissolution of retained cholesterol gallstones following cholecystectomy. Bile duct infusion of monooctanoin is associated with little toxicity, although potentially serious problems can result from absorption of the drug or tissue infiltration. Gastrointestinal side effects such as anorexia, nausea, vomiting, diarrhea, and abdominal pain have been reported most commonly. Complete gallstone dissolution has occurred in ∼50–75 percent of patients receiving monooctanoin. Although mechanical stone removal is still considered to be the treatment of choice for retained gallstones, monooctanoin use appears promising for stone dissolution in patients in whom mechanical removal has been unsuccessful or is impossible.

Buspirone Use for Smoking Cessation

The results of buspirone efficacy have been inconsistent and contradictory. The rate of smoking abstinence has been reported to range from 36% to 88% and 16% to 89% in buspirone and placebo treatment groups, respectively. Only one controlled study reported buspirone efficacy in reducing nicotine withdrawal symptoms, although it was based on a small sample population and only 4 weeks of follow-up. The most recent studies have been unable to demonstrate the efficacy of buspirone in smoking cessation or in the relief of withdrawal symptoms. A placebo-controlled, randomized trial with a large number of patients, relatively high doses of buspirone (30-60 mg/d), strict abstinence criteria, long-term follow-up, and the inclusion of smokers with general anxiety or anxiety reported in previous quit attempts is needed to further evaluate buspirone efficacy in smoking cessation and the reduction of nicotine withdrawal symptoms. The treatment effects of buspirone could then be specifically tested as a function of alleviating the anxiety component of the smoking withdrawal syndrome. Finally, buspirone may prove to be an alternative in patients unsuccessful with or unable to tolerate transdermal nicotine therapy. How buspirone compares with bupropion therapy for smoking cessation is also unknown.

Effect of Naproxen and Sulindac on Blood Pressure Response to Atenolol

Twenty-eight patients with mild to moderate essential hypertension well controlled by atenolol entered a five-week, double-blind, placebo-controlled trial of the effects of sulindac and naproxen on blood pressure (BP) control. Atenolol alone was administered during weeks 1, 3 5. Naproxen or sulindac was administered with atenolol during week 2, with crossover during week 4. Data were analyzed for 27 of the patients (one dropped out after developing a skin rash). Naproxen significantly increased the systolic BP compared with placebo (mean 4.0 mm Hg; 95 percent confidence interval, 1.1–7.0; p<0.05). There were no significant differences in systolic BP during sulindac administration compared with placebo or naproxen. No significant effects on diastolic BP were observed. Weight was increased by naproxen and sulindac compared with placebo (mean 0.6–0.8 kg, p<0.05), although not to a clinically significant extent. One-week therapy with naproxen has a greater potential than sulindac to increase systolic BP in well-controlled hypertensive patients receiving atenolol; however, the increase is minor and unlikely to be of clinical significance.

Perceptions of a Continuing Professional Development Portfolio Model to Enhance the Scholarship of Teaching and Learning

Objective: To obtain feedback about the potential usefulness of a continuing professional development (CPD) portfolio for enhancing a faculty or practitioner’s scholarship of teaching and learning (SoTL). Method: A CPD portfolio approach to the SoTL was distributed in advance to registrants of the 2011 Annual AACP Teacher’s Seminar. In an interactive workshop, faculty facilitators described a model for a CPD process applied to the development of an individual’s SoTL. During the workshop, participants were asked to complete the initial sections of the portfolio to develop a personal plan for success in the SoTL. Post workshop, an evaluation form was distributed to the participants to obtain feedback about the CPD approach. Completed evaluation forms were collected, collated, and summarized. Results: A total of 53 (14.1%) workshop participants completed the evaluation form of the 375 attendees. In all, 25 assistant professors, 14 associate professors, 4 full professors, 10 residents/students, 22 clinical, and 2 research faculty submitted evaluations. The proposed uses for the portfolio model selected most often by the responders were for personal development, faculty evaluation, increasing the SoTL, new faculty development, preceptor development, and residency training. Implications: A structured CPD portfolio model might be useful for the professional development of the SoTL.

Introduction of a Continuing Professional Development Tool for Preceptors Lessons Learned

Accreditation Council for Pharmacy Education (ACPE) guidelines state that preceptors should “have a systematic, self-directed approach to their own continuing professional development (CPD).” The objective of this study was to encourage preceptors to take advantage of the ACPE CPD resources and implement the concept of CPD (reflect, plan, act, evaluate, record) as a framework for guiding individual preceptor’s continuing development as educators and to determine their opinion regarding the usefulness, effectiveness, and obstacles to implementation of this approach. A total of 3713 preceptors from the participating schools were encouraged to undergo CPD training and invited to respond to a series of questions. Of the initial respondents, 48% represented health system/hospital preceptors, followed by community/independent pharmacists (64 of 236, 28%). Preceptor respondents often train students from multiple schools/colleges (average = 1.9 schools/colleges per preceptor) and 90% agreed or strongly agreed with the statement, “the CPD model, as learned in the webcasts, is beneficial for ongoing preceptor development.” The general consensus was that the preceptor portfolio provided motivation to reflect, plan, and set more defined and realistic goals for students, residents, and themselves as educators and could be a valuable starting point for promoting preceptors’ reflection, planning, and action related to rotation management, professional teaching, and student learning goals.