Controlled Medication Agreements

Controlled Medication Agreements for controlled substances are an important part of pain management. For the patient, they offer informed consent on the dangers of longterm opioid therapy and clearly explain the expectations and monitoring requirements of the practice. For the physician, they can offer significant legal protection. This document is offered for educational purposes only and is provided "as is". It is not intended to provide any legal advice or supplement legal counsel. Before initiating any agreement within your practice, I would run your your agreement by a pain medicine specialist and a lawyer. Click here to download a PDF version of this document. Best wishes!

Lice! Lice! Lice!

What do you do when the Nix (1% permethrin) does not get rid of the patient's lice? Well... Assuming that you are doing all the other stuff (using the lice comb, treating family members, etc.), consider using Elimite cream. "But Dave, the patient doesn't have scabies!" you say. Well Elimite cream is 5% permethrin which is 5 times more concentrated than the permethrin in Nix. And, for me, this tip usually does the trick.

Of course there are many other Lice tips and tricks and medications (and some are quite flammable!). This is just what works for me.

Vagisil Cream and Manliness?

Ok... I admit it. Vagisil cream is not the most manly thing a guy can pick up at the neighborhood Walgreens. Heck, I'd rather pick up a box of tampons! But, the stuff does relieve minor topical pain. The main ingredient is benzocaine, a local anesthetic. I've used it on patient's with shingles, minor first degree burns, etc. It's much cheaper than the Lidoderm Patches. And I don't have to fill out a prior auth form only to have the Lidoderm Patch denied because I'm using it off-label!

BUT I do recommend that the wives purchase the Vagisil for their man. Real men do NOT purchase Vagisil... NOT EVER!

Refills on Albuterol Inhalers

Each albuterol inhaler has 200 puffs. And since we advised patient to give themselves TWO puffs per treatments. There are about 100 "treatments" in one inhaler. Knowing this, I rarely give out more than 1 inhaler at a time (and I rarely give refills). The reason is that I can use the patient's refill history to give me a rough estimate of the patient's asthma control. If the patient is requesting a refill of their albuterol inhaler every three months, that means they are using their inhaler on the average 1 to 2 times a day (definitely not in control). And if they are requesting their refill only after one month, that means that they are using their inhaler at least three times a day! Yikes!

Simvastatin at 80 mg Dose No Longer Recommended

The FDA recently put out this recommendation regarding simvastatin at the 80 mg dose. I rarely ever go that high anyway (since going from 40 mg to 80 mg rarely helps to bring down the LDL very much). But it's still good to know.

The difference between glyburide and glipizide?

Both medications are common sulfonylureas use to treat type II diabetes. However, glipizide has a shorter half-life compared to glyburide (12 hours versus 22 hours). And glipizide has a lower incidence of hypoglycemia. Although the pharmaceutical companies want us to prescribe their newer oral agents (which are not part of the ADA guidelines), sulfonylureas like glipizide are considered "well validated" and "Tier I" medications for the treatment of type II diabetes (after metformin).

Commonly Prescribed Anticholinergic Medications

Yesterday we discussed the classic anticholinergic side effects. Today we are going to list some commonly prescribed medications in primary care with anticholinergic side effects:

• Muscle relaxers (flexeril, robaxin)
• Incontinence medications (Detrol, ditropan)
• Atrovent inhaler and Spireva
• Tricyclic antidepressants (amitryptyline)
• Benadryl
• Antispasmotic medications (Bentyl, Levsin, trihexphendyl)
• Atropine
• Cogentin
• Antidiarrhea medications (Lomotil)

Classic Anticholinergic Side Effects

• Blind as a bat (blurred vision, mydriasis)
• Mad as a hatter (hallucinations, psychosis, delirium, memory loss, coma)
• Red as a beet (flushing)
• Hot as heat (fever, hyperthermia)
• Dry as a bone (dry mouth, dry eyes)
• The bowel and bladder lose their tone (constipation, urinary retention, ilius) 
• And the heart runs alone (tachycardia, hypertension)

To remember this pneumonic, the first two rhyme with "bat", the next two rhyme with "beet", and the last three rhyme with "bone." Some of this pneumonic doesn't really make any sense since "bowel and bladder lose their tone" suggests diarrhea and urinary incontinence when, in fact, the opposite is the case.

Tips on Inpatient Geriatric Delerium

This is an awesome tip that I learned from Dr. Mina Zeini (who is also faculty here at Florida Hospital Family Medicine Residency). This tips was given as part of our "Learning Center" teaching series which our faculty personally do for our residents. Enjoy!

     1. Use the CAM (Confusion Assessment Method)

           1. Must have acute onset and fluctuating course  AND
           2. Must have Inattention

               PLUS

           3. Disorganized thinking

               OR

           4. Altered level of consciousness

     2. Find out the CAUSE!

     3. Do NOT RESTRAIN!!! (increases delirium)

     4. Haldol at low dose (0.25 to 0.5 mg IV) is the first line therapy (discontinue as you find out cause)

     5. TRY TO AVOID BENZOS (it worsens delirium)

Detecting Fentanyl on Urine Drug Screen?

This is an awesome tip that I learned from Dr. Carlos Dumois (who is also faculty here at Florida Hospital Family Medicine Residency)... 

Like oxycodone, fentanyl will not typically be detectable on a standard urine drug screen (i.e. opioids will likely be negative). According to the Mayo Clinic Proceedings: it is undetectable not because it has no metabolites (it does), but because the chemical structures of fentanyl and its metabolites differ radically from those of opiates (ie, morphine and codeine).

To screen for diversion, specific confirmatory testing needs to be orders. Confirmatory testing needs to be ordered for oxycodone also.

The "Rule of 20" for Pediatric Amoxicillin Dosing

The Rule of 6 for dosing amoxicillin, which we discussed in a previous post, is probably outdated since amoxicillin is typically dosed 80 to 90 mg/kg/day instead of 40 mg/kg/day for children (max 1000 mg per dose). So lets update this rule. For 90 mg/kg/day of amoxicillin, use the following calculation:

   Weight in Pounds  x  20   =   mg dose of amoxicillin per dose

The other change is that this calculation is assuming 2x/day dosing (instead of 3x/day dosing). Let's go through an example. Assuming that you have a 10 pound child in your office, the calculation would look like this: 10 x 20 = 200. So this child would need 200 mg of amoxicillin 2x/day. Since amoxicillin comes in 400 mg per teaspoon, the child would need ½ teaspoon by mouth 2x/day.

The important thing to remember is that this calculation is PER DOSE (and NOT per day). Also, remember that this calculation only works for dosing amoxicillin 2x/day. Double check this calculation with your normal method of calculating the amoxicillin dose. I think you will find that they are pretty close!

The Miracle of Insulin

Have you ever stopped to wonder what a miracle insulin is? Before 1922, the death rate from type I diabetes was 100%. It wasn't until 1922 when Frederick Banting discovered insulin that hope arrived. Can you imagine that? 1922! That was not that long ago!

As doctors, we take insulin for granted. Right now, I'm going through the book The Discovery of Insulin by Michael Bliss. It's a great read! Full of suspense and intrigue! It's amazing how far we have come since the early days of Frederick Banting's discovery.

Pediatric Bactrim Dosing

Bactrim suspension is dose at approximately 1 teaspoon for every 22 pounds. This is given twice a day. For example, a 45 pound kid would get about 2 tsp by mouth twice a day. Just be aware of the maximum dose. Pretty cool eh? And no calculators involved!

"For The Rest of Your Life!"

This conversation occurs frequently:

"Mr. Jones, your cholesterol has gone back up. Are you taking your simvastatin everyday?"

"No... Was I suppose to?"

This is usually followed by an awkward silence.

"Ummmmm... Yeah.."

"Well, my last cholesterol was good and so I thought that I could just stop the medication."

For medications that need to be taken chronically, I have made it a habit to say something like, "You will likely need to take this medication for the rest of your life. If you make some dramatic changes to your lifestyle or you lose a lot of weight, we can talk about stopping the medicaiton. But don't stop the medication unless we talk about it or you are having a side effect." 

Renal Insufficiency and Metformin

Because of concerns of lactic acidosis (and subsequent high risk of mortality), metformin should not be used in patients with renal failure or severe renal insufficiency. When I get lab results back showing an elevated creatine, I have made it a habit to check 1) what the last creatine was, and 2) if the patient is currently taking metformin.

Child dies from hypotonic fluid bolus!

When I was in residency, an ER doctor gave a child hypotonic fluid (½ NS) as a fluid bolus. The child developed cerebral edema, had status seizures, and died. It was such a sad case for everyone involved (including the doctor). But I definitely learned an unforgettable lesson from this: hypotonic fluids should never be given as a bolus in anyone (especially children).

Funky TSH Results

When treating hypothyroidism, sometimes I get unexpected TSH results. Before making another adjustment to a patient's levothyroxine dose, I always double check 1) compliance with taking the levothyroxine, and 2) if they are taking their levothyroxine with vitamins, antacids, iron, or calcium supplementations (which can all decrease levothyroxine absorption in the gut).

The Walmart $4 Generic List

Here is the link to the Walmart $4 Generic List. Here are some interesting things that I noticed:

1. Albuterol premixed nebulizer solution is on the list (25 vials for $4). That's pretty amazing considering that Proventil HFA costs around $55! Not that I'm advocating that doctors give all their asthma patients nebulizer machines, but the price of a basic nebulizer machine is around $55. This could be an interesting option for our self-pay patients who are really strapped for cash. Too bad there are no inhaled steroids on the list!
2. Terbinafine (Lamisil) is also a $4 med. I can remember a time when it was well over $150. 
3. Metformin ER is generic. Having an extended release metformin may help some of my patients who complain for GI issues from the regular metformin. 
4. Antipyrine/Benzocaine otic drops are on the $4 list. That's good to know for my kids with simple but painful otitis media. 
5. Sprintec and Tri-Sprintec are the only $4 birth control pills on the list. 
6. Fosamax 70 mg is on the list. I had no idea! 

There rest of the list is mostly common knowledge. I'm just waiting for simvastatin to go on the list. 

ACE Inhibitors and Birth Defects

As family doctors are diagnosing diabetes and hypertension earlier and earlier, the use of ACE Inhibitors in younger patients is becoming more common. However, it is good to be reminded that ACE Inhibitor may be associated with an increased risk of birth defects (and currently this is a black-boxed warning). For woman of childbearing age, options other than ACE Inhibitors should be considered. So when we get that fax from the insurance company urging us to start an ACE Inhibitor for our young, diabetic, female patient, we should feel free to tell them to bugger off.

Asprin use in Diabetic Patients

Hmmmmm... It looks like aspirin use in diabetic patients is not as "cut and dry" as we once thought. But still, most of my diabetic patients seem to meet the criteria since they are typically older patients with multiple risk factors for cardiovascular events:

The organizations state that only men older than 50 and women older than 60 who have one or more additional major risk factors should be treated with aspirin for primary prevention of cardiovascular events.