Medication Overdose Research Articles

A retrospective chart review of opioid represcribing following nonfatal overdose at a Veterans Affairs hospital.

Introduction:Opioid-related overdoses have risen despite extensive media coverage and apparent awareness of this public health crisis. Emergency department visits related to opioid use nearly tripled from 2004 to 2011. Patients with mental illness are more likely to be prescribed opioids and have higher rates of overdose. This retrospective chart review sought to determine if opioid represcribing occurred after patients were treated for a nonfatal opioid overdose (NFO) at a Veterans Affairs hospital.Methods:Patients who experienced an NFO between 2009 and 2013 were included and charts reviewed until January 1, 2016. Review of the electronic medical record (EMR) was performed to determine if and when opioids were again prescribed after NFO.Results:Fifty-six veterans met the inclusion criteria. A new opioid prescription was issued to 82% of patients within 3 months following the index NFO date. The average daily morphine equivalent dose prescribed before (122 mg) and after (120 mg) NFO did not differ. A subsequent opioid overdose event occurred in 25% of patients, and there was 1 fatal event. Only 1 patient had medication overdose on the problem list of their EMR.Discussion:Despite experiencing NFO, veterans continued to be prescribed opioids without significant changes in the drug or dose; some experienced repeated overdose events, possibly due to poor communication and documentation of NFO. Pharmacists can play a key role in clinical interventions and education of patients and prescribers.

Assessing Bleeding Risk in Patients With Intentional Overdoses of Novel Antiplatelet and Anticoagulant Medications

In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications. This study is a retrospective study of acute ingestion of apixaban, clopidogrel, ticlopidine, dabigatran, edoxaban, prasugrel, rivaroxaban, and ticagrelor reported to 7 poison control centers in 4 states during a 10-year span. The prevalence of bleeding for each agent was calculated, and hemorrhage was classified as trivial, minor, or major. A total of 322 acute overdoses were identified, with the majority of cases involving clopidogrel (260; 80.7%). Hemorrhage occurred in 16 cases (4.9%), including 7 cases of clopidogrel, 6 cases of rivaroxaban, 2 cases of dabigatran, and 1 case of apixaban. Most cases of hemorrhage were classified as major (n=9). Comparing the novel anticoagulants with the P2Y12 receptor inhibitors, the relative risk for any bleeding with novel anticoagulant was 6.68 (95% confidence interval 2.63 to 17.1); the relative risk of major bleeding was 18.1 (95% confidence interval 3.85 to 85.0). Acute overdose of novel anticoagulants or antiplatelet agents is associated with a small risk of significant hemorrhage. The risk is greater with the factor Xa inhibitors and direct thrombin inhibitors than with the P2Y12 receptor antagonists.

Exposure to Medication Overdose as an Adversity in Childhood

PurposeTo determine the prevalence of youth exposure to medication or pill overdose by someone close to them, as well as how common this is within the spectrum of major stressful events and child victimization experienced by youth. Design and MethodsData were collected as part of the Third National Survey of Children's Exposure to Violence, a nationally representative telephone survey of youth, ages 2–17years (N=3738) conducted in 2013. The analytical subset for the current paper is youth ages 10–17years (n=1959). ResultsEstimates indicate that approximately 1 in 12 youth (8%), ages 10–17 have been exposed to medication overdose by someone close to them in their lifetimes. Overdose exposure is related to recent trauma symptoms, alcohol and other substance use. However, these relationships appear to be largely driven by the co-existence of major stressful events these youth are experiencing. Alcohol use is the exception; exposure to medication overdose continues to be related to past year personal alcohol use even after adjusting for other lifetime stressful events. ConclusionsHaving a close family member or friend overdose on a medication is a common experience among U.S. youth and related to high rates of co-occurring stressful events. Practice ImplicationsHealth care providers should be aware that youth exposure to medication overdoses likely indicates exposure to other recognized adversities. Youth with a caregiver who has had an overdose may require an urgent response including referral to crisis intervention through child and family services.

Oesophageal coins invisible on chest radiography: a case report

BackgroundCoins are made of metal, which is generally radiopaque, and so physicians often have the misconception that all coins are detectable by radiography. Here, we report a case of intentionally swallowed coins in the oesophagus of an adult; the coins could not be detected on chest radiography but were detected using computed tomography (CT).Case presentationA 46-year-old woman with a history of depression presented to the emergency department after an intentional medication overdose and ingestion of two Japanese 1-yen coins. She complained of persistent retrosternal discomfort. In order to confirm whether the coins were in the oesophagus or trachea, an anteroposterior chest radiograph was obtained; however, no coins were detected. Owing to her persistent symptoms, a chest CT was performed. On the initial CT scan, two 1-yen coins were observed in the oesophagus: one in the middle oesophagus and the other in the lower oesophagus. After the scanning, the patient drank water with permission, but vomited. No coins were found in her vomit, and the symptoms of retrosternal discomfort had completely disappeared. A subsequent CT scan revealed that the two 1-yen coins were in the patient’s stomach.ConclusionsJapanese 1-yen coins are made of 100% aluminium, which is less radiopaque than the metals that make up coins (nickel, bronze, and lead), and so, they were not visible via chest radiography in our case. Detecting very small or thin radiolucent foreign bodies is not possible using a chest radiograph or contrast oesophagram, but is possible via CT. CT is both increasingly convenient and non-invasive, unlike endoscopy or bronchoscopy, and so, the use of CT scans should be considered in cases of possible radiolucent foreign body ingestion.

Persistent Opioid Use Following Cesarean Delivery: Patterns and Predictors Among Opioid-naive Women

(Am J Obstet Gynecol. 2016;215(3):353.e1–353.e18) According to the US Centers for Disease Control and Prevention and other leading health care organizations, between 1999 and 2010 the rate of opioid medication overdose resulting in death among women increased 5-fold. With over a third of all deliveries in the United States being cesarean deliveries and opioids being prescribed as postsurgical analgesics to these patients, the risk of overdose increases. Hence, the purpose of this study was to identify the risks and behavior patterns of women with initial opioid exposure (opioid-naive women) in the setting of routine medical care (eg, postcesarean pain medicine prescriptions) associated with them becoming persistent opioid users.

Self-harm and suicide attempts in Schizophrenia.

The risk of suicide among persons with schizophrenia (SZ) is higher than in general population, with multiple contributory factors. We assessed the prevalence of risk of deliberate self-harm and suicide attempts, along with associated socio-demographic and clinical factors in a group of SZ outpatients (n=61) as part of a larger study on overall schizophrenia-associated risks. To investigate factors associated with risk of deliberate self-harm and suicide among persons with schizophrenia. Out of 270 SZ participants evaluated for various risks using Ram Manohar Lohia Risk Assessment Interview (RML-RAI), 61 reported risk of self-harm including suicide attempt/s. The factors associated with this risk were further evaluated on clinical details and Diagnostic Interview for Genetic Studies. Risk of reported self-harm was 22.59%. Among them, 10% had attempted suicide at least once. Current age and past month Global Assessment of Functioning score from DIGS (GAF) were significantly correlated with suicide attempt. Attempters had significantly lower current GAF score, indicating poorer functioning. Among 27 attempters, 9 attempted at the onset of illness while 6 others attempted suicide within one year. Most common method of attempt was ingestion of insecticides or overdose of medication, followed by hanging or jumping from height. In our hospital-based sample of suicide attempters, 10% had attempted suicide, among them over 55% within first year of illness. Attempters were significantly older than non-attempters and suffered from significantly more severe illness than non-attempters. Positive symptoms were significantly associated with attempt, irrespective of time at which suicide was attempted.

A review of the changing patterns of suicide and deliberate self-harm in Sri Lanka

Background In the mid 1990s, Sri Lanka had the second highest rate of suicide in the world, due to ingestion of pesticides. Since then, Sri Lanka has seen significant changes in the rates of suicide and self-harm by attempted or non-fatal self-poisoning. Aims The objective of this article is to examine the changes in rates and modes of suicide and attempted self-poisoning in Sri Lanka, from 1995 to the present, and discuss the significance of these changing patterns. Methods Electronic searches were carried out in Pubmed, using the following key words; suicide, deliberate self-harm, poisoning, attempted suicide and Sri Lanka. Results Since 1995 the rate of suicide in Sri Lanka has declined, with the annual suicide rate falling from 47.0 per 100,000 in 1995 to 19.6 per 100,000 in 2009. Self-poisoning still remains the most common method of suicide, with a relatively small increase in suicide by other methods, such as hanging. But after 1995, there has been increased hospital admissions due to attempted self-poisoning, with more medication overdoses. Conclusion The fall in suicide rates in Sri Lanka is a positive outcome of preventive measures taken, including restriction of access to toxic pesticides. These need to be continued, together with increased focus on management of psychological contributory factors, such as depression and alcohol use disorders. At the same time, innovative and culturally appropriate preventive strategies are needed to address the increasing public health problem of attempted self-poisoning.

Clinical Outcomes of Start-Low, Go-Slow Methadone Initiation for Cancer-Related Pain: What's the Hurry?

Methadone has been shown to be effective for cancer pain. Most published switching methods are complete in less than three days, requiring very close supervision, usually in an inpatient setting. This need for hospitalization is a barrier to access. We present a large retrospective study of slow outpatient methadone starts and describe our starting method. Charts were reviewed of patients referred to the Pain and Symptom Management/Palliative Care clinics at the six BC Cancer Agency's regional centers that underwent initiation of methadone for analgesia over a 14-year period. Patient characteristics, method of start, and outcomes of methadone treatment were recorded. Of the 652 identified patients, we were able to determine outcomes of methadone initiation in 564 (86.5%). Among these, 422 (74.8%) were deemed successful initiations, as determined by whether or not the patient remained on methadone at follow-up with subjective improvement in pain control, on a stable dose of methadone. Of the unsuccessful trials, 97/142 were primarily due to adverse events, 16 of which were considered serious enough to require hospitalization, including two due to sudden cessation of opioid therapy leading to withdrawal. Some of the included adverse events were not necessarily causal from the initiation of methadone, for example, development of bowel obstruction or delirium. Only one death occurred from a deliberate overdose of multiple medications, including methadone. Initiation of methadone for analgesia in ambulatory cancer patients can be done safely in an outpatient setting using a start-low go-slow method, and can be expected to be helpful in ∼75% of patients. Discontinuation is more likely to be for side effects than for inadequate analgesia. Access to methadone therapy can safely be widened by slow initiation, avoiding more dangerous rapid switching protocols and reducing the need for hospitalization.

Encouraging pharmacist intervention and standardization of labeling and dispensing of oral liquid medications

ObjectivesTo initiate a call to action for community pharmacists and key-pharmacy stakeholders in the standardization of oral-liquid dosage forms. Data sourcesNot applicable. SummaryUnintentional overdose of medication due to administration error results in thousands of pediatric hospitalizations yearly. A lack of prescription and dosage device standardization pertaining to oral-liquid medications continue to be a public health hazard. Multiple professional organizations have publicly endorsed the standardization of oral liquid dosage forms. Universal adoption will not be achieved until key-pharmacy stakeholders encourage their pharmacists to use best practices when verifying and preparing prescription medication. Specifically, these practices should include immediate conversion of prescriptions containing non-metric volumes into metric volumes, providing appropriate sized oral dosing syringes for all oral liquid prescriptions, writing dosing directions in the safest format, and counseling patients and caretakers of proper medication administration. ConclusionCommunity pharmacists are uniquely positioned to lead the universal adoption of these best practices to ensure proper oral-liquid dosing administration for all patients.

Physician suicide

IntroductionPhysician Suicide is a potential health risks resulting from strains and burden associated with medical education and profession. Suicide is an occupational hazard. Each year in the United States, 300 to 400 physicians take their own lives.ObjectiveTo provide a summary about physician suicide and its risk factors and mental health issues associated.MethodsThe search was conducted using PubMed with terms: “suicide in physicians”, “physician suicide”, “suicide in doctors”, “physician depression”, by using a review of literature with documents in English.DiscussionSuicide is a major health problem. Suicide death is a self-inflicted with evidence that the person aims die. Mental disorders represent a large burden of disease worldwide and can also damage to physical health. The most common psychiatric diagnoses among physicians who complete suicide are affective disorders, alcoholism, and substance use disorders. In physicians, the female suicide rates are higher than that in males. The most common means of suicide by physicians are lethal medication overdoses and firearms. There are common risk factors, such as work-related stress, depression, negative life events, alcohol and isolation. In addition, there is a physicians’ tendency not to recognize depression in themselves and not to seek help.ConclusionsPrioritize to physician mental health, change professional attitudes and institutional policies, learn to recognize depression and suicidality, educate medical students, residents, routinely screen all primary care patients for depression that can help physicians recognize depression in themselves and to seek treatment for depression and suicidality because there is “no health without mental health”.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

An Examination of Claims-based Predictors of Overdose from a Large Medicaid Program.

Health systems may play an important role in identification of patients at-risk of opioid medication overdose. However, standard measures for identifying overdose risk in administrative data do not exist. Examine the association between opioid medication overdose and 2 validated measures of nonmedical use of prescription opioids within claims data. A longitudinal retrospective cohort study that estimated associations between overdose and nonmedical use. Adult Pennsylvania Medicaid program 2007-2012 patients initiating opioid treatment who were: nondual eligible, without cancer diagnosis, and not in long-term care facilities or receiving hospice. Overdose (International Classification of Disease, ninth edition, prescription opioid poisonings codes), opioid abuse (opioid use disorder diagnosis while possessing an opioid prescription), opioid misuse (a composite indicator of number of opioid prescribers, number of pharmacies, and days supplied), and dose exposure during opioid treatment episodes. A total of 372,347 Medicaid enrollees with 583,013 new opioid treatment episodes were included in the cohort. Opioid overdose was higher among those with abuse (1.5%) compared with those without (0.2%, P<0.001). Overdose was higher among those with probable (1.8%) and possible (0.9%) misuse compared with those without (0.2%, P<0.001). Abuse [adjusted rate ratio (ARR), 1.52; 95% confidence interval (CI), 1.10-2.10), probable misuse (ARR, 1.98; 95% CI, 1.46-2.67), and possible misuse (ARR, 1.76; 95% CI, 1.48-2.09) were associated with significantly more events of opioid medication overdose compared with those without. Claims-based measures can be used by health systems to identify individuals at-risk of overdose who can be targeted for restrictions on opioid prescribing, dispensing, or referral to treatment.

Hypoglycemia in a resource-poor Nigerian environment: A cross-sectional study of knowledge of symptoms, causes, and self-management practices among ambulatory type 2 diabetic patients in South-East Nigeria

Background: Hypoglycemic emergencies are potentially life-threatening complication of diabetes management that predisposes the patients to higher risk of disability and premature death. As the impetus for the prevention of diabetes-related hypoglycemic endpoints grows, emphasis should also be focused on patients' knowledge of symptoms, causes, and self-management practices for hypoglycemia. Aim: The study was aimed at describing the knowledge of symptoms, causes, and self-management practices for hypoglycemia among ambulatory type 2 diabetic patients in Eastern Nigeria. Materials and Methods: A cross-sectional descriptive study was carried out on 145 type 2 diabetic Nigerians at a primary care clinic in Eastern Nigeria. Data on knowledge of symptoms, causes, and self-management practices for hypoglycemia were collected using pretested, structured, and researcher-administered questionnaire. Results: The age of the type 2 diabetic patients ranged from 32 to 78 years with mean age of 44 ± 10.2 years. There were 59 (40.7%) male and 86 (59.3%) female. Thirty-six (24.8%), 22.8%, and 29.0% had adequate knowledge of symptoms, causes, and self-management practices for hypoglycemia with the most common symptom, cause, and self-management practice being dizziness (69.7%), overdose of antidiabetic medications (91.0%), and taking drink containing glucose (67.6%), respectively. Educational level was significantly associated with adequate knowledge of symptoms (P = 0.039), causes (P = 0.02), and self-management practices (P = 0.016) for hypoglycemia. Conclusion: Knowledge of causes, symptoms, and self-management practices for hypoglycemia was inadequate. The most common symptom, cause, and self-management practice for hypoglycemia were dizziness, overdose of medications, and taking of drink containing glucose, respectively. Adequate knowledge of causes, symptoms, and self-management practices for hypoglycemia was associated with educational level. There is a need for hypoglycemic-oriented diabetes education, especially in resource-poor environment.

Implementation of a Schedule II patient agreement for opioids and stimulants in an adult primary care practice

Background:The consumption of controlled substances in North Carolina and the nation has created a health crisis with epidemic levels of medication diversion, abuse, overdose and death. Primary care providers are the principal prescribers of controlled substances and at greatest risk of encountering patients that abuse medications. Guidelines recommend patient agreements with monitoring requirements when prescribing opioids and stimulants. Studies have focused on opioids and excluded stimulants. Adherence to recommended monitoring requirements has not been fully evaluated.Methodology:This was a quality improvement project using the Plan-Do-Check-Act procedure. The following outcome measures were evaluated: signed agreement on file, prescription monitoring program (pmp) checks, urine screens, and prescriptions written without a mandatory visit.Implementation:Who: patients aged 19 and over prescribed a long-term Schedule II medication for the chronic conditions of pain and/or attention deficit hyperactivity disorder. What: implemented a patient agreement and measured fidelity to components of the agreement. When: seven months pre- to seven months post-implementation. Where: in an adult primary care practice with approximately 2,500 patients. How: an agreement was implemented with monthly feedback provided.Results:Post-implementation, 94% of patients meeting criteria had a signed agreement in their medical record. Adherence to urine screening improved from 5.3% to 71.1%. Guideline adherence to pmp checks improved from 11.3% to 99.0%. Guideline deviation for prescriptions written without a visit improved from 20.6% to 0%. All improvements were statistically significant (P < .001).Conclusion:A Schedule II controlled substance patient agreement was successfully implemented in a primary care practice reducing risk for both the patient and provider.

Management of hypoglycemia

Hypoglycemia is a condition characterized by an abnormally low level of blood glucose and has significant clinical consequences if left untreated. It is a potential adverse event in the treatment of diabetes mellitus. Causes of hypoglycemia are varied, but in diabetic patients, it is most often iatrogenic. Medication changes or overdoses, infection, dietary changes, and changes in activity levels are some of the important reasons for a person to develop hypoglycemia. Prompt diagnosis and treatment of hypoglycemia is an essential component of the management of diabetes. Evaluation of the cause is important, especially if there are recurrent episodes of hypoglycemia.

Adolescent Suicidal Ingestion: National Trends Over a Decade

PurposeSuicide attempts by adolescents most commonly involve the overdose of medications. To date, there has been little information on the over-the-counter or prescription medicines that adolescents ingest for self-harm. Identification of medications chosen in suicide attempts may help guide anticipatory guidance to parents by primary care providers and Poison Centers in prevention programs. MethodsThis was a retrospective observational study using the American Association of Poison Control Center's National Poison Data System. Data were collected on patients aged 13–19 years old at the time of their substance ingestion, between the years 2004 and 2013 and that were coded as reason for ingestion of “intentional-suspected suicide.” ResultsDuring the 10-year study period, there were 390,560 poison center calls for intentional-suspected suicide in the United States between 2004 and 2013, accounting for 80.3% of all “intentional” ingestion calls in the adolescent population. Over the entire age range, the most common substance ingested included acetaminophen (10.9%), ibuprofen (9%), selective serotonin reuptake inhibitors (7.7%), atypical antipsychotic (6%), and antihistamines (5%). The most common medications coded as resulting in major clinical effects or death were antidepressants and atypical antipsychotics. ConclusionsAdolescent ingestion choices for suicide attempts have remained relatively consistent over the past 10 years. However, there was a recent decrease in selective serotonin reuptake inhibitor ingestions. The most common medications used in an overdose attempt were ibuprofen and acetaminophen. Further preventative efforts are needed in this at-risk population from multiple providers at various levels.

Trend of Suicide in Iran During 2009 to 2012: Epidemiological Evidences from National Suicide Registration

Background: Suicide behaviors cause a large portion of Disability adjusted life years worldwide. Objectives: The aim of this research was to study the trend, correlations and discrepancy of registered suicide incidents in Iran from 2009 to 2012 using data from the Iranian suicide registry. Materials and Methods: Suicide registry entries throughout the country between 2009 and 2012, including suicidal attempts and suicides, were collected. Data on age, gender, occupational, marital and residential status along with suicide method, history of previous attempt and history of medical or mental disorders were registered by health service provision staff at the service centers. Geographic mapping and statistical analysis were performed. Results: Amongst the 252911 attempted suicides during the period, we found suicide attempt and suicide rate of 30.5 - 44.8 and 1.76 - 2.23 per 100000 individuals, respectively, denoting overall suicide fatality rate of 2.63. The rate of suicide attempt in different provinces ranged between 0.7 and 271.1 and the rate of suicide between 0.17 and 17.7 per 100000 individuals. Attempted suicides showed more fatality in males, elderly, widow/widowers, divorced and unemployed subjects as well as in residents of rural areas. The most common attempt methods were medication overdose (84), and the mostcommonsuicide methods were hanging (30.3), medications overdose (28.1) and self-burning (17.9); these methods are found at different rates in various parts of the world. Conclusions: While the registry could provide us the most valid data on suicide, the wide range of suicide and suicide attempt rates in different provinces not only could question this statement but also could highlight the importance of studying the ethnic/geographic variations in suicide epidemiology with improved suicide registry and surveillance systems. A¯Â?½ 2016, Mazandaran University of Medical Sciences.

Package Design Affects Accuracy Recognition for Medications.

Objective:Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors.Background:An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors.Method:In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated.Results:The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications.Conclusion:Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications.Application:A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose.

Community Pharmacists' Perspectives on Dispensing Medications With the Potential for Misuse, Diversion, and Intentional Overdose: Results of a Province-Wide Survey of Community Pharmacists in Canada

ABSTRACTBackground: Community pharmacists frequently encounter patients at risk of medication misuse, diversion, and intentional overdose. However, few studies have examined the perspective of the pharmacist on the identification and management of these patients. Objective: To understand the perspective of community pharmacists on the dispensing of select medications commonly associated with misuse, diversion, and overdose. Methods: An online survey was disseminated by electronic mail to community pharmacists listed in the College of Pharmacists of Manitoba directory. The survey was open from July to September 2014. Descriptive statistics were used to describe demographic information of the pharmacist and practice setting, and pharmacists' perceptions on the dispensing of select medications. Results: A total of 82 community pharmacists completed the survey. Most pharmacists considered a one-month supply appropriate for a psychotropic agent; but a 7–10 day-supply was considered appropriate for an opioid for acute pain. Factors that aid pharmacist decisions on providing select medications to patients include familiarity with the patient, ease of access to medical history information, and ease of access to the prescribing physician. Only 10.3%, 16.2%, and 32.4% felt they have received adequate training on the management of patients at risk for suicide, drug diversion, and medication misuse, respectively. Conclusion: Findings from this study demonstrated a need for improved systems for managing patients at risk for medication misuse, diversion, and overdose. Strategies that warrant further attention for limiting the means of medication misuse include increased access to electronic medical records and providing additional continuing education support for community pharmacists.

Prescription opioid abuse: pharmacists' perspective and response.

Opioid medication abuse and overdose are major concerns for public health, and a number of responses to address these issues have taken place across the US. Pharmacists and the pharmacy profession have made important contributions as a part of the response to this national crisis. This article provides a brief review of the antecedents, driving forces, and health status of patients involved in the opioid medication and overdose epidemic. This review further discusses pharmacy-based actions that have been undertaken to address this issue, including prescription drug monitoring, take-back, and naloxone training/distribution programs. This review likewise examines current efforts underway in the field to educate practitioners and needed future steps that must be taken by pharmacists in order to continue the profession’s pivotal role in working toward resolving this national public health problem. In particular, evidence and arguments are presented for proactively identifying and intervening with patients who abuse and/or are at risk for overdose. Continued and active engagement by pharmacists in these efforts has the potential to result in important reductions in opioid medication abuse and overdose and improvements for patient’s health.

The Influence of Polyethylene Glycol Solution on the Dissolution Rate of Sustained Release Morphine.

Whole bowel irrigation (WBI) is a management option for overdose of medications poorly adsorbed to activated charcoal, with modified release properties, or for body packers. Polyethylene glycol (PEG) is a mixture of ethylene oxide polymers of varying molecular weight. PEG with an average molecular weight of 3350g/mol is used for WBI. PEG electrolyte lavage solution has been shown in vitro to hasten the dissolution of acetaminophen. The impact of PEG on the pharmacokinetics of extended release pharmaceuticals is unknown. Lower average molecular weight PEG mixtures are used as solvents and excipients. We sought to investigate the impact of PEG on the release of morphine from several extended release morphine formulations. An in vitro gastric model was developed. To test the validity of our model, we first investigated the previously described interaction of ethanol and Avinza®. Once demonstrated, we then investigated the effect of PEG with several extended release morphine formulations. In the validation portion of our study, we confirmed an ethanol Avinza® interaction. Subsequently, we did not observe accelerated release of morphine from Avinza® or generic extended release morphine in the presence of PEG. The use of PEG for gastric decontamination following ingestion of these extended release morphine formulations is unlikely to accelerate morphine release and aggravate intoxication.