Dos and don’ts in responding to opioid overdose (SAMHSA, 2018) ● DO support the person’s breathing by performing rescue breathing. ● DO administer naloxone as prescribed in the kit. ● DO put the person in the recovery position (turn on the side) if they are breathing independently. ● DO stay with the person and keep them warm. ● DON’T slap or try to forcefully stimulate the person. This will only cause further injury. If you are unable to wake the person by shouting, rubbing your knuckles on the sternum, or lightly pinching her, they may be unconscious. ● DON’T put the person into a cold bath or shower. This in- creases the risk of falling, drowning, or going into shock. ● DON’T inject the person with any substance (speed, saltwater, milk, heroin). The only safe treatment is naloxone. ● DON’T try to make the person vomit drugs that they may have swallowed. Choking or inhaling vomit into the lungs can cause a fatal injury. Conclusion The source and pathophysiology of pain is as diverse as each pa- tient’s characterization of the misery that he or she is experiencing. It is important for the pharmacist to truly understand the underly- ing mechanisms of pain and then apply this knowledge by care- fully and comprehensively determining individual patient needs Bermas, B L. (2021). Safety of rheumatic disease medication use during pregnancy and lactation. Up to Date. https://www.uptodate.com/contents/safety-of-rheumatic-disease- medication-use-during-pregnancy-and-lactation Bystritsky, A. (2021). Pharmacotherapy for generalized anxiety disorder in adults. Up to Date. https://www.uptodate.com/contents/ generalized-anxiety-disorder-in-adults-management • References • Centers for Disease Control and Prevention (CDC). (n.d.). Calculating total daily dosage of opioids for safer dosage. https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_ dose-a.pdf • Chou, R. (2021). Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. Up to Date. https://www.uptodate.com/contents/subacute-and- chronic-low-back-pain-nonpharmacologic-and-pharmacologic-treatment Cleveland Clinic. (2020). Acute vs chronic pain. https://my.clevelandclinic.org/health/articles/12051-acute-vs- chronic-pain Cook, R. (2021). Subacute and chronic low back pain: nonpharmacologic and pharmacologic treatment. Up to Date. https://www.uptodate.com/contents/subacute-and- chronic-low-back-pain-nonpharmacologic-and-pharmacologic-treatment • DiPiro, J., Yee, G., Posey, L. M., Haines, S. T., Nolin, T. D., & Ellingrod, V. (2019). Pharmacotherapy: A pathophysiologic approach (8th ed.) McGraw-Hill. • Dowell, D., Haegerich, T. M., & Chou R. (2016). CDC guideline for prescribing opioids in pain—United States. JAMA, 315(15), 1624–1645. doi:10.1001/jama.2016.1464 • Food and Drug Administration (FDA). (2021). Kloxxado (naloxone hydrochloride) nasal spray. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/212045s000lbl.pdf • Food and Drug Administration (FDA). (2018). FDA Drug Safety Communication: Prescription Acetaminophen Products to be Limited to 325 mg Per Dosage Unit; Boxed Warning Will Highlight Potential for Severe Liver Failure. https://www.fda.gov/drugs/drug-safety-and- availability/fda-drug-safety-communication-prescription-acetaminophen-products-be- limited-325-mg-dosage-unit • Food and Drug Administration. (2016). FDA advisory committee on the most appropriate dose or doses of naloxone to reverse the effects of life-threatening opioid overdose in the community settings. https://www.fda.gov/downloads/AdvisoryCommittees/ CommitteesMeetingMaterials/Drugs/AnestheticAndAnalgesicDrugProductsAdvisoryCo Freeborn, D. (2021). OTC Pain Medicines and Their Risks. University of Rochester Medical Center. https://www.urmc.rochester.edu/encyclopedia/content. aspx?contenttypeid=134&contentid=130 • Fudin, J. (2018). Opioid Agonists, Partial Agonists, Antagonists: Oh My! https://www. pharmacytimes.com/contributor/jeffrey- fudin/2018/01/opioid-agonists-partial-agonists- antagonists-oh-my • Gerriets, V., Anderson, J., Nappe, T.M. Acetaminophen. (2021). Acetaminophen. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482369/ • Goodwin, J., & Bajwa, Z. H. (2016). Evaluating the patient with chronic pain. In C. A. Warfield & Z. H. Bajwa (Eds.). Principles and practice of pain medicine (3rd ed.) McGraw-Hill Companies, Inc. • Hirsch, M; Birnbaum, R. (2021). Tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects. Up to Date. https://www.uptodate.com/contents/tricyclic-and-tetracyclic-
Self-Assessment Quiz Question #4 If a patient were to experience an opioid overdose, which of the following symptoms would NOT be likely related to overdose? a. Slow or shallow breathing. b. Clammy skin. c. Fast heart rate. d. Blue or purple lips. Self-Assessment Quiz Question #5 Which of the following points should be emphasized when edu- cating a patient on the signs and symptoms of overdose? a. If his breathing becomes shallow and he cannot be aroused, call 911. b. Use only the prescribed naloxone for signs of an overdose. c. Do not put the patient in the shower. Keep him warm until emergency services arrive. d. All of the above. before contributing to their care. Pharmacists must be aware that because pain is so individualized, it is often necessary to combine treatment approaches, including non-pharmacological therapies such as acupuncture. drugs-pharmacology-administration-and-side-effects International Association for the Study of Pain (IASP). (2021). IASP Taxonomy. http://www.iasp-pain.org/Taxonomy • Knight, CL; Deyo, RA; Staiger, TO; Wipf, JE. (2021). Treatment of acute low back pain. Up to Date. https://www.uptodate.com/contents/treatment-of-acute-low-back-pain • Lind, J. N., Interrante, J. D., Ailes, E. C., Gilboa, S. M., Khan, S., Frey, M. T., Dawson, A. L., Honein, M. A., Dowling, N. F., Razzaghi, H., Creanga, A. A., & Broussard, C. S. (2017). Maternal Use of Opioids During Pregnancy and Congenital Malformations: A Systematic Review. Pediatrics, 139(6), e20164131. DOI: 10.1542/peds.2016-4131 • Mayo Clinic. (2019). Antidepressants: Another weapon against chronic pain. http://www. mayoclinic.com/health/pain-medications/PN00044 McAuley, D. (2017). Pain management, opiates. http://www.globalrph.com/pain.htm • Michigan State University College of Human Medicine. (nd). Pain relief for terminally ill patients. http://learn.chm.msu.edu/painmanagement/chooseopioid.asp • National Institutes of Health-National Center for Complementary and Alternative Medicine (NCCAM) (2016). Acupuncture: In Depth. https://nccih.nih.gov/health/acupuncture/ introduction • Nelson, C. (2021). Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects. Up to Date. https://www.uptodate.com/contents/serotonin- norepinephrine-reuptake-inhibitors-snris-pharmacology-administration-and-side-effects? search=depression&topicRef=1725&source=related_link • OSCE Skills. (2018). History taking. https://www.medistudents.com/en/learning/osce-skills/ other-skills/patient-history-taking/ • Portenoy, RK; Dhingra, LK. (2021). Assessment of cancer pain. Up to Date. https://www. uptodate.com/contents/assessment-of-cancer-pain Substance Abuse and Mental Health Services Administration (SAMHSA). (2018). SAMHSA opioid overdose prevention toolkit. HHS Publication No. (SMA) 18–4742. Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/system/files/sma18-4742.pdf • Solomon, DH. (2021a). Nonselective NSAIDs: Overview of adverse effects. Up to Date. https://www.uptodate.com/contents/nonselective- nsaids-overview-of-adverse-effects • Solomon, DH. (2021b). Overview of COX-2 selective NSAIDs. Up to Date. https://www. uptodate.com/contents/overview-of-cox-2-selective- nsaids • Tauben, D; Stacey, B. R. (2021a). Evaluation of chronic non-cancer pain in adults. Up to Date. https://www.uptodate.com/contents/evaluation-of-chronic-non-cancer-pain-in-adults • Tauben, D; Stacey, B. R. (2021b). Pharmacologic management of chronic non-cancer pain in adults. https://www.uptodate.com/contents/pharmacologic-management-of-chronic-non- cancer-pain-in-adults • Tauben, D; Stacey, B. R. (2020). Approach to the management of chronic non-cancer pain in adults. Up to Date. https://www.uptodate.com/contents/approach-to-the-management-of- chronic-non-cancer-pain-in-adults • U.S. National Library of Medicine. (2018). Pain. MedlinePlus. http://www.nlm.nih.gov/ medlineplus/pain.html • Zelaya, C. E; Dahlhamer, J. M; Lucas, J. W; Connor, EM. (2020). Chronic pain and high-impact chronic pain among US adults, 2019. NCHS Data Brief No. 390. https://www.cdc.gov/nchs/products/ databriefs/db390.htm y
PAIN MANAGEMENT AWARENESS FOR PHARMACISTS, SECOND EDITION Self-Assessment Answers and Rationales
1. The correct answer is C. Rationale: Since pain is patient specific, gathering information about pain that a patient’s relatives experience would not help characterize the patient’s pain. Finding out specifically where the pain is, what the pain is like, and what exacerbates or alleviates it can be helpful in developing a treatment plan.
2. The correct answer is A. Rationale: Mr. Johnson should receive a short-acting opiate. Long-acting opiates should be reserved for patients with severe chronic pain. This will help minimize the risk of oversedation, re - spiratory depression, and overdose. Injectable opiates would not be the most appropriate option for a patient discharging home.
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