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➤ C o n t i n u i n g E d u c a t i o n ➤ tech talk ce the national continuing education program for pharmacy technicians Answer online for instant results www.pharmacygateway.ca CE just for technicians Tech Talk CE is the only national continuing education program for Canadian pharmacy technicians. It is independently accredited by the CE division at Rogers Publishing Ltd., publisher of Pharmacy Practice, which has been producing CE lessons for pharmacists for more than 10 years. As the role of the technician expands, use Tech Talk CE as a regular part of your learning portfolio. Note that a passing grade of 70% is required to earn the CE credit. Technicians certified by the Pharmacy Technician Certification Board of Alberta can submit CE units earned through Tech Talk CE to their certification board. Tech Talk CE is generously sponsored by Novopharm Limited. Download back issues at www.pharmacygateway.ca or www.novopharm.com. Answering Options 1. Answer the lesson online and get your results instantly at www.pharmacygateway.ca. 2. Use the reply card inserted with this CE lesson. Circle the answers on the card and mail in the pre-paid, self-addressed card or fax to Mayra Ramos, 416-764-3937. To pass this lesson, a grade of 70% (7 out of 10) is required. If you pass, you will receive 1 CEU. You will be advised of your results in a letter from Tech Talk. Please allow 8 to 12 weeks. Please note: Tech Talk CE is not accredited by the Canadian Council for Continuing Education in Pharmacy (CCCEP). CE Faculty CE Coordinator: Margaret Woodruff, R.Ph, B.Sc. Phm., MBA Humber College Clinical Editor: Lu-Ann Murdoch, B.Sc.Phm. Author: Susan Halasi, M.Sr.Phm, RPh MPH Reviewer: Stephanie Bradley, CPhT 1 CEU free april/may 2007 Misuse of OTC products By Susan Halasi, M.Sc.Phm. Statement of objectives Upon completion of this lesson, the pharmacy technician should be able to: 1. Identify patients who are prone to abusing over-thecounter products. 2. Understand the consequences of abusing specific Win a Sony P prize p SP ackage (Value ! $ 430) Find ou t on pag how e 3. over-the-counter products. 3. Recognize why people may misuse over-the-counter products and properly direct them to the appropriate healthcare professional. Introduction The abuse of over-the-counter (OTC) products is a growing concern for legislators and professionals alike. The pharmacist or pharmacy technician often detects prescription drug abuse when a medication is dispensed. OTC products, however, have an element of self-selection, so abuse is more difficult to recognize. The Canadian Parliamentary Research Branch, Political and Social Affairs Division, has investigated the costs associated with substance abuse and published a policy paper about it. Beyond the obvious costs associated with OTC misuse, the paper cites several indirect costs resulting from the long-term health problems in users, the breakdown of family relationships, an increase in violent or abusive behaviour in the user, and the absence or inability to be productive in the workplace, which must also be considered when calculating the real costs associated with substance abuse.1 The federal government of Canada created the Precursor Control Regulations in 2002 in an attempt to curb the misuse of OTC products. The regulations are designed to limit, or control, specific OTC products that are readily available in a pharmacy, including pseudoephedrine and other chemicals such as iodine crystals, isopropyl and rubbing alcohol, lye, lithium batteries and rock salt, which are commonly used to manufacture the street drug crystal methamphetamine.2 The MethWatch initiative strives to educate and help front-line staff recognize and deal with dubious purchases of certain self-selected products. The program instructs employees on how to deal with unusually large purchases of targeted products without confronting the customer and endangering themselves. The pharmacy technician could comply with this legislation simply by placing an anonymous call to the RCMP toll-free hotline that is listed on the MethWatch website.3 This lesson is intended to help pharmacy technicians identify those individuals who may be abusing OTCs, so they do not become unwitting accomplices. As well, it will acquaint them with consequences of such abuse, assist them in understanding what drives people to overuse products, and provide guidance on when technicians should direct patients to the pharmacist for help. Population-specific indicators Adolescents (under 20 years of age) A recent survey of high school students was conducted in an Ohio suburb to investigate misuse of OTC products by adolescents.4 A total of 39,345 students were asked how often they used OTC drugs to get “high.” The study didn’t differentiate or inquire as to which substances were misused. The survey also asked about their home situation (two parents, joint custody, or single-parent structure). OTC abuse by students from a traditional family unit was lower, but misuse did not vary significantly by family structure. Overall, 4.7% of students indicated they misused OTC An educational service for Canadian pharmacy technicians, brought to you by Novopharm www.novopharm.com tech talk ce Continuing Education drugs, with females abusing these products more often than males. Misuse of medications increased with grade level. Aboriginal youth reported the highest levels of OTC misuse, followed by Caucasian and Asian populations, while African American students indicated they rarely used OTC products to get “high.” Students abusing OTC products were more likely to use alcohol and illicit drugs to cope with depression brought on by “stress” in their lives.4 Addiction specialist Dr. Shannon Miller suggests this age group thinks OTC drugs are a “smart choice” because they’re relatively cheap (especially the generic/house brand products), readily accessible (the family medicine cupboard/by shoplifting), carry no stigma for abuse (compared to heroin or cocaine), and carry minimal risk for detection (home or job test kits).5,6 In this report, adolescents sought escape from boredom, by intoxicating themselves at parties, before, during, or after school.6 Female adolescents also revealed they may abuse laxatives in an attempt to achieve the “ideal” body image. Individuals with anorexia try to use techniques such as restrained eating, self-induced vomiting, and bowel purging with stimulant laxatives, to continually lower their weight.7 Bulimics will eat normally, then induce vomiting using their fingers, utensils or purgatives to achieve weight control.8 Adults (21 to 50 years of age) Adults abuse various OTC products for a number of reasons. Antihistamines and cough suppressants provide “cheap thrills” for this age group, if money is a factor. Furthermore, extracting opioids and decongestants from certain OTC drugs is part of manufacturing illicit street drugs, which are then sold to others for a huge profit.9,10 Females who feel pressure to maintain an “ideal” body image are more likely to abuse laxative products than males. Diarrhea resulting from laxative abuse may lead to an electrolyte imbalance, and the potential for kidney damage.8 The recent phenomenon of achieving a “sculpted” body has led millions of people to abuse OTC products sold as dietary supplements. Such products (many of which contain ephedrine-like derivatives) have the potential to cause anxiety, insomnia, psychosis and even fatal cardiovascular problems.11 Seniors (over 55 years of age) A study conducted in the south of Italy utilized a questionnaire to determine the extent of overuse of laxatives. The survey showed that over 40% of respondents took laxatives when they didn’t need them. The most common self-prescribers were elderly and female. The authors suggested that laxative abuse in those who suffer from anorexia or bulimia can lead to colon cancer or laxative poisoning. Such behaviour in the elderly may affect drugs with narrow therapeutic windows, such as warfarin or digoxin. Laxatives can cause severe water and electrolyte loss, and affect levels of vitamin K.12 OTC abuse categories The patterns of OTC drug abuse are not static. They continually evolve as professionals and legislators observe these trends in illegal use or diversion of products, and try to counter such activities.9 Technicians and pharmacists can work together to note these trends, report them and avoid being unwitting accomplices in drug abuse. Since the abused medications are constantly changing and no organization systematically researches and records information in this area, most of the information available is from case reports, making the information anecdotal and incomplete. The following examples provide insight into selected drug categories with reported abuse potential and some of the dangers or issues associated with this abuse/misuse. They do not imply that other OTCs are not abused and technicians need to stay vigilant about all OTC sales to see emerging patterns of inappropriate use. Documented abuse of OTCs Ant i h i s t am i n e s Dimenhydrinate is a common medication that is normally used for nausea and vomiting. Abusers have been characterized as adolescents, and individuals with a psychiatric history (schizophrenia, depression, substance abuse, personality disorders). These individuals are reported to become intoxicated (“high”) when they consume anywhere between 7501,250 mg (about 15-25 tablets).9 Chronic abusers have been reported to take doses as large as 5,000 mg, or 100 tablets, daily.13,14 If the individual becomes addicted, then withdrawal or abstinence symptoms will occur when they are unable to get a supply of the medication. Withdrawal symptoms include lethargy, agitation, hostility, clumsiness, nausea, vomiting, hallucinations, confusion and aggression. Technicians may attribute these symptoms to a psychiatric disorder, rather than realize it’s a drug-related problem.13,14 Diphenhydramine is normally used as an antihistamine for allergic reactions and as a sleeping aid for insomnia (due to its drowsiness adverse effect). The profile of a typical abuser includes patients with schizophrenia and individuals with chronic insomnia. Reported cases of chronic abuse include daily consumption of 1,250-2,500 mg (50-100 tablets).9 Withdrawal symptoms tech talk have also been reported and are associated with diarrhea, sweating, salivation, insomnia, anxiety and aggression. Cough and cold Dextromethorphan, a cough suppressant, is reported to have been abused by a 23-year-old man who used 26-48 ounces daily for five years (he purchased this item by the case).9 The effects of abusing this OTC have been likened to using LSD, producing euphoria, hallucinations and altered time perception. Adverse effects of high taking doses include nausea, vomiting, psychosis, mania, seizures and respiratory depression.9 Increased abuse of this product has led many physicians to recommend that dextromethorphan be rescheduled to prescription-only status.6 Pseudoephedrine, a decongestant, is misused for its stimulant and hallucinatory effects. As previously noted, the active ingredient in this OTC can be extracted for the manufacture of crystal meth and the Meth Watch program has been established to help front-line staff deal with issues surrounding its sale.4,9 Laxatives and Purgatives As previously explained, stimulant-type laxatives (bisacodyl, castor oil, senna) have been abused in an attempt to control weight in patients who are bulimic or anorexic. 7,8,12 Abuse of laxatives is associated with chronic diarrhea, electrolyte and acid-base disturbances, which can become life-threatening. 8,12 Chronic use may mask cancer or create absorption difficulties for drugs with a narrow therapeutic window, such as warfarin or digoxin.12 These patients may also abuse ipecac syrup, which is normally intended to induce vomiting in situations where a patient has ingested something poisonous. Heartbeat irregularity resulting from ipecac abuse can cause death.8 Pain Relievers Codeine is a narcotic and is available over-the-counter in combination products only. It is usually combined with ASA or acetaminophen and caffeine. Abusers who are seeking its euphoric effects may attempt to extract the codeine from these combination analgesics by dissolving tablets in water and passing them through coffee filters. 10,17 However, this pattern of codeine extraction has declined since pharmacies have made the product less available to consumers by placing it behind the counter. Nevertheless, codeine remains readily available from illicit sources.9,17 Patients with liver, kidney or heart disease or the elderly are at greatest risk for developing acute kidney failure due to abuse of non-steroidal anti-inflammatory drugs including ibuprofen.18 April/may 2007 The technician’s role The above examples provide some insight into the variety of over-the-counter medications that have the potential for misuse or abuse. However, since patterns of abuse constantly change, it can be challenging to distinguish appropriate and inappropriate use of OTC medications. Often education is all that is needed to address the problem within the pharmacy environment. For example, if a pharmacy technician notices an individual purchasing topical hydrocortisone, the technician should ensure the patient speaks to the pharmacist to receive proper instructions for using the product. However, in some situations there are no obvious reasons to suspect a problem. Therefore the pharmacy technician needs to watch out for some general indicators of misuse and abuse. To help technicians identify a situation of misuse or abuse, the following checklist details some of the behaviours that could indicate a problem: 1.Be aware of patients who purchase an unusually large quantity of one product. What defines a large quantity is sometimes difficult to measure, but purchasing several bottles when the norm is one could indicate a problem. 2.Another indicator to watch out for is if the patient buys the same quantity, but does so frequently (possibly every few days), when the medication would last for weeks under normal circumstances. 3.When a patient buys a product in a drug category that is known to be misused, this may also indicate a problem, although as previously stated this is a changing target. 4.The patient fits the profile discussed above of a potential abuser. Keep in mind, there are often very legitimate reasons for a patient to purchase large quantities or purchase frequently so it is important for the technician to never confront or accuse a patient. Simply be vigilant and try to refer them in a non-confrontational manner to the pharmacist. Common sense should also be used. As explained above, it is quite often the pharmacy team that first notices when a medication is starting to be abused so if the pharmacy technician suddenly notices a large increase in sales of a certain OTC product to a specific group of patients, a “red flag” should go up and the technician should report this to the pharmacist, who can then pass it on to the other healthcare professionals and/or the authorities as appropriate. Since many pharmacies keep track of OTC purchases in the patient’s computer medication profile, the pharmacy technician could assist the pharmacist by ensuring appropriate entries are entered into the system. Summary The challenge for pharmacy technicians and pharmacists alike is to control the problem of abuse, yet make over-the-counter products accessible to the majority of the population who use them appropriately. Through awareness, vigilant monitoring and education, pharmacy technicians and pharmacists can promote the safe and effective use of such products.9,20 Do you do Tech Talk CE? THEN LISTEN UP! Finish a Tech Talk CE lesson and refer a colleague to do it too for a chance to win 1 of 3 great prizes. If your colleague does the lesson, and refers someone to do it too, they also have a chance to win. Up for grabs: 2 Sony Playstation Portable prize packages (approx. retail value $430) 1 Apple iPod Nano (approx. retail value $170) Click on www.pharmacygateway.ca to access over 20 Tech Talk CE lessons written especially for pharmacy technicians like you. Go to www.pharmacygateway.ca/techcontest for full contest details or simply fax back this form at the number below. Act fast! The first 25 people to complete CEs and refer a friend automatically receive a cozy polar fleece blanket or sweatshirt! Go online or fill out this form and fax to 416-764-3931. Referral name ______________________________________ Referral address ____________________________________ Referral email or phone # _____________________________ Your name, email and phone # _________________________ Name of lesson completed _____________________________ Win 1 of 3 great prizes Contest Closes September 30, 2007. To enter, you must be employed as a pharmacy technician and be a Canadian resident over age of majority. Entry form and Full Rules at www.pharmacygateway.ca/techcontest. Odds of winning depend on number of eligible entries received. Mathematical skill-testing question to be correctly answered to win. No Purchase Necessary. TECH tech talk TELL TECH Tech Talk CE is proudly sponsored by: april/may 2007 tech talk ce Dietary Supplements Ephedrine/creatine is used by more than one million people to gain muscle and lose fat, according to an American survey, despite lack of proof that it is effective. Ephedrine may cause anxiety, insomnia, psychosis, mania and fatal cardiovascular complications so its use should be monitored even in usual doses.11 Topical products Hydrocortisone can be used topically for skin inflammation and rashes. Inappropriate application to the face for extended periods of time has led to the development of rosacea accompanied by burning, itching, red papules and nodules.19 tech talk ce References: 1.Chenier NM. Substance abuse and public policy. Parliamentary Research Branch, Political and Social Affairs Division. 2001 January. [accessed December 12, 2006]. Available from : www.parl.gc.ca/information/ library/prbpubs/942-e.html 2.Anon. Crystal meth advisory. Pharm Connection Sep/Oct 2005; 18-9. 3.Meth Watch Coalition. Meth Watch: A Toolkit for Head Offices, Store Managers and Employees of Participating Organizations. 2005 April. [accessed Continuing Education December 15, 2006]. Available from: www.methwatch.ca 4.Steinman KJ. High school students’ misuse of overthe-counter drugs: a population-based study in an urban county. J Adolesc Health 2006;38:445-7. 5.Miller SC. Coricidin® HBP Cough and Cold Addiction. J Am Acad Child Adolesc Psychiatry 2005;44(6):509-10. 6.Schwartz RH. Adolescent abuse of dextromethorphan. Clin Pediatr 2005;44:565-8. 7.Gwadry-Sridhar F. OTC Counsellor: Counselling Patients on Constipation and Laxatives. Pharmacy Pract, December 1997. 8.Pray WS, editor. Nonprescription Product Therapeutics.1st ed. Lippincott Williams & Wilkins, 1999. 9.Webb J. Over-the-counter or underground, don’t be an accomplice to OTC abuse. Pharm Pract 2003;19(2):33-6. 10.Hughes GR, McElnay JC, Hughes CM, et al. Abuse/Misuse of Non-Prescription Drugs. Pharm World Sci 1999;21(6):251-5. 11.Kanayama G, Gruber AJ, Pope Jr HG, et al. Over-the-Counter Drug Use in Gymnasiums: An Underrecognized Substance Abuse Problem? Psychother Psychosom 2001;70:137-40. 12.Motola G, Mazzeo R, Rinaldi B, et al. Self-prescribed laxative use: a drug-utilization review. Adv Therapy 2002;19(5):203-8. 13.Halpert AG, Olmstead MC, Beninger RJ. Mechanisms and Abuse Liability of the Antihistamine dimenhydrinate. Neurosci Biobehav Rev 2002;26:61-7. 14.Rowe C, Verjee Z, Koren G. Adolescent Dimenhydrinate Abuse: Resurgence of an Old Problem. J Adolesc Health 1997;21:47-9. 15.Marinetti L, Lehman L, Casto B, et al. Over-theCounter Cold Medications—Postmortem Findings in Infants and the Relationship to Cause of Death. J Anal Tox 2005;29:738-43. 16.Ujiye G. Precursors to Illicit Drugs. Pharm Connection Jul/Aug 2003;10-5. 17.Fleming GF, McElnay JC, Hughes CM. The separation of codeine from nonprescription combination analgesic products. Substance Use & Misuse 2003;38(9):1217-26. 18.Whelton A. Renal Effects of Over-the-Counter Analgesics. J Clin Pharmacol 1995;35:454-63. 19.Tackett BN, Smith MC, Nedorost ST, et al. ➤ Questions Please select the best answer for each question or answer online at www.pharmacygateway.ca for instant results. 1.Substance abuse has been associated with: a) Violent and abusive behaviour. b) Improved productivity at work. c)No real change in the abuser’s health. d) None of the above. 2. One of the following statements is TRUE about adolescent abusers: a)Adolescents in a single-parent family significantly abuse OTC products compared to individuals coming from a traditional family setting. b)Male adolescents are the most frequent abusers of laxative OTC drugs. c)Adolescents consider OTC drugs cheap, easily accessible, and often overlooked as a way to get “high.” d)It is the group in Grades 7 through 9 who are more likely to abuse OTC drugs than high school seniors. 3. Regarding OTC abuse by adults: a)Cough and cold products are not abused since they cause sleepiness. b)The abuse of laxatives by women is common, but presents no real danger. c)The abuse of dietary supplements, particularly those containing ephedrine may cause cardiovascular disorders. d)None of the above. 4. One of the following statements is TRUE about dimenhydrinate abuse. a)Chronic abusers of dimenhydrinate may take up to 10 tablets daily. b)Adolescents have not been known to abuse dimenhydrinate, usually it is someone with a psychiatric history (schizophrenia, personality disorder). c)No abstinence or withdrawal symptoms are associated with the discontinuation of large quantities of dimenhydrinate. d)Withdrawal symptoms would include lethargy, agitation, hostility, clumsiness, nausea, vomiting, hallucinations, confusion and aggression. 5. Abuse of dextromethorphan: a)Has led emergency physicians to recommend that it be changed to a prescription-status drug. b)Will cause euphoria, hallucinations and altered time perception. c)Was purchased by the case by an individual taking excessive quantities daily. d)A, B and C are correct. 6. Abusers purchasing large quantities of pseudoephedrine: a)Use it for its hallucinatory effects. b)May extract the chemical for the manufacture of an illicit product. c)Should not be stopped, but reported to RCMP Diversion Program. d)A, B and C are correct. 7. Stimulant laxative abuse: a)Can be seen in the adolescent, adult and senior population. b)Normalizes electrolytes, but does cause loss of water. c)Speeds up absorption, increasing the benefit of drugs with narrow therapeutic index. d)Is not seen in the bulimic patient. 8.Abuse of OTC analgesics: a)Is common because codeine is very difficult to obtain on the street. b)Is infrequent because it is impossible to extract codeine from tablets. c)Such as non-steroidal anti-inflammatory drugs can result in acute kidney failure. d)Abuse of OTC analgesics has not been reported. 9. When it comes to OTC abuse, healthcare professionals: a)Should not get involved with their customers OTC use; it is not their business. b)Should not be unwitting accomplices to OTC abuse. c)Should monitor OTC use in order to provide optimal patient care and ensure patient safety. d)B and C are correct. 10. Increased awareness by healthcare professionals about the abuse of OTC products: a) Involves education and vigilant monitoring of certain product categories. b) Won’t really affect accessibility and location of OTC products of abuse. c) A and B are correct. d) None of the above. Morbidity of Over-the-Counter Topical Steroids. J Am Acad Dermatol 2006;55(1):182. 20.Wazaify M, Shields E, Hughes CM, et al. Societal Perspectives on Over-the-counter (OTC) Medicines. Fam Pract 2005;22:170-76. tech talk For information about CE marking, please contact Mayra Ramos at (416) 764-3879 or fax (416) 764-3937 or email [email protected]. All other inquiries about Tech Talk CE should be directed to Laurie Jennings at (416) 764-3917 or [email protected] april/may 2007