Does the 'War on Drugs' belong in the nursing home?

My first memory of the country’s “war on drugs” was during Nancy Reagan’s campaign against the drug epidemic. I still remember Red Ribbon Week. As a pharmacist, I learned first-hand how the DEA tightly regulates prescription control substances. I learned the upmost importance of ensuring that every single control substance in the pharmacy is logged and accounted for, and rightfully so. Today, I read about how Fentanyl (a prescription pain medication) laced heroin deaths claim so many lives that paramedics run out of Narcan (narcotic antidote) to revive them.

As a consultant pharmacist, I see this drug war spill over into the nursing home. I’ve learned to never interrupt the nursing staff while “counting narcs.” I hear the panic when the count is “off.” I’ve heard the details of drug diversion by staff and even residents.

The result of all this regulation of control substances? Better safeguards against diversion, yes. An understanding of the utmost importance of regulating these agents, yes, but also an unmistakable perception by many nursing staff that narcotic medications, particularly pain medications are bad. I hear the remarks about residents who are just “drug seeking” because they frequently request pain medications, in one case, in reference to a 94-year-old woman with breast cancer. I hear the remarks to the residents “you just got your pain pill two hours ago and have to wait at least 2 more!” instead of saying, “let me call your doctor because you may need something stronger to treat your pain.” I see the residents wheel themselves away, rejected, still presumably, in pain.

I think we as a medical community treating nursing home residents have become so tight fisted about narcotic pain medications that we forget or don’t even bother to understand WHY someone might need them. It’s no wonder that it has been reported that 45-80% of nursing home residents have substantial pain that is undertreated. It’s no wonder that the Centers for Medicare & Medicaid Services developed a pain management quality measure for nursing homes.

What can we do as nursing home medical professionals? Remember the “both/and” approach. We need to BOTH ensure that control substances are properly secured and accounted for to keep them out of the hands of people who shouldn’t have them AND make sure that we get pain medication to those who should.

Pain is widely undertreated in our elderly and there is no reason that they should suffer because of our war on drugs. 

Alicia A. Timko, PharmD
Consultant Pharmacist
Long Term Care Rx Pharmacy
 

Prevnar 13 vs Pneumovax 23

As cough and cold season approaches, we’ve been seeing an uptick in the amount of pneumonia vaccine orders and questions. The CDC currently recommends that adults greater than 65 years old should get both the Prevnar 13 and Pneumovax 23.  It’s especially important to make sure the residents with high risk diagnoses (diabetes, COPD, heart failure, chronic liver disease) receive these vaccines.

In residents with no prior pneumonia vaccinations, Prevnar 13 should be given first. This helps to improve the body’s immune response to the vaccine. After one year, the Prevnar 13 should be followed by the Pneumovax 23.

If your resident has already received Pneumovax 23 but not the Prevnar 13, that is alright. The Prevnar 13 can still be given one year after the Pneumovax. If your resident can’t remember if they have ever been given either vaccine, then it will not hurt to assume no vaccination was given and to start the Prevnar 13.

A few more pneumonia vaccine facts:

1. Giving both of these vaccines in seniors is estimated to prevent 230 cases of invasive pneumonia and 12,000 cases of community-acquired pneumonia in their lifetime.
2. Medicare Part B covers both vaccines at zero cost to the resident.
3. It is okay to give these vaccines at the same time as many other vaccinations, such as their annual flu shot or a shingle vaccination.

As always, if you have any questions or would like more information regarding pneumonia vaccination (or any vaccination for that matter), please contact the pharmacy.

Thanks for reading!

Drew Curtis, PharmD
Pharmacist Manager
Consultant Pharmacist

When in Doubt, Write it Out

It seems like we as a society are always looking for ways to abbreviate our everyday lives.  Twitter shortens our thoughts to 140 characters or less. Shorthand makes taking notes during a lecture much easier. Emoji remove words completely to communicate a thought or feeling with just a smiley face. Abbreviations definitely serve a purpose in our day-to-day lives, but caution should be used when we are communicating medical information.

One of the most common causes of preventable medication errors is the improper use of abbreviations. Misinterpreted abbreviations or symbols can frequently lead to mistakes that can result in patient harm, delay the start of therapy, and waste time spent trying to clarify the original order. Abbreviations that seem obvious and make perfect sense to the person writing the order can still be misinterpreted by someone else. Take a look at the following examples:

Seems pretty self-explanatory, right? Potassium chloride 10meQ, 1 tablet by mouth daily. Or is it four times daily?

What about this one? Should we give 6 units of insulin, or 60?

Imagine coming across these two handwritten orders during the middle of your work day.  The phone is ringing off the hook. You have 2 residents having behavior issues in the dining room.  It’s time for shift change over and your replacement is running late. Can you say, with 100% certainty, that these orders will be interpreted correctly? Even under the best of circumstances, mistakes can happen.

When it comes to resident safety, it’s important to remember to slow down and do our best to communicate medical information safely and effectively. I’ll leave you with a list of commonly misinterpreted medical abbreviations. Are there any that you use?

Abbreviation	Misinterpretation	Instead Use
U (unit)	Mistaken for zero, number four, or cc	Write "unit"
IU (international unit)	Mistaken for IV or number ten	Write "international unit"
QD (daily)	Mistaken for QID (four times daily)	Write "daily"
QOD (every other day)	Mistaken for QID and QD	Write "every other day"
Trailing zero (X.0 mg)	Decimal point is missed (ex: 1.0 mg read as 10mg)	Write X mg
Lack of leading zero (.x mg)	Decimal point is missed (.1 mg read as 1 mg)	Write 0.X mg
MS	Can mean morphine sulfate or magnesium sulfate	Write out "morphine sulfate" or "magnesium sulfate"
MSO4 and MgSO4	Can be confused for one another	Write out "morphine sulfate" or "magnesium sulfate"

Healthcare is a very diverse field. An abbreviation that one person may have used for years will not necessary translate to everyone else who may come across it. With medical abbreviations, when it doubt, write it out!

Drew Curtis, PharmD
Pharmacist Manager
Consultant Pharmacist