Use and Abuse of Prescription Painkillers – Dentists, Drugs and Dependence

Happy Canada Day. (Dr. Noorali Bharwani)
Happy Canada Day. (Dr. Noorali Bharwani)

NBC News called it “The Deadly Triangle: Dentists, Drugs and Dependence.”

In the U.S., about five million people each year have wisdom teeth removed. Many of them are prescribed Percocet, a commonly used painkiller for post-surgery discomfort. But most patients are never warned that Percocet has the potential to make patients dependent on the drug. It is very addictive.

Percocet is an opioid, a class of drugs that chemically follows the same nerve pathways as heroin, eliciting a sense of euphoria. Examples of weak opioids are – codeine and dihydrocodeine. Examples of strong opioids are – tramadol, buprenorphine, methadone, diamorphine, fentanyl, hydromorphone, morphine, oxycodone, and pethidine.

Recently, a Harvard research team reported in the Journal of the American Medical Association (JAMA) that dentists are among the leading prescribers of opioid analgesics, particularly for surgical tooth extractions. The most revealing aspect of the study was that the highest number of these opioid painkiller prescriptions were for teenagers, aged 14 to 17 years old, closely followed by young adults 18 to 24 years, says the NBC News.

Opioid abuse has sky rocketed.

Some patients and certain conditions do need strong painkillers. When used properly, prescription drugs can help. But, there are many dangerous and unpredictable side effects associated with abusing prescription drugs including addiction, overdose and death, say Government of Canada website on prescription drug abuse.

Besides opioids (used to treat pain) there are other prescription medications, which can be addictive. For example benzodiazepines (used to treat anxiety and sleep disorders), and stimulants (used to treat attention deficit disorder).

When an individual intentionally takes prescription drug for recreational purposes to get high or change mood then it is called drug abuse.

Prescription drug abuse is a growing public health and safety problem in Canada, particularly among youth. In the 2012 Canadian Alcohol and Drug Use Monitoring Survey, approximately 410,000 Canadians reported abusing prescription drugs like opioid pain relievers.

The abuse of prescription drugs has harmful effects on teens’ health. They are especially vulnerable because their bodies and minds are still developing. It can damage a teen for life.

Psychoactive drugs change brain function and results in alterations in perception, mood, or consciousness. These drugs are the third most commonly abused substances, after alcohol and marijuana, among Canadian youth. Last year, over 80,000 Canadian teenagers used prescription drugs to get high, even though it can be very dangerous.

In Alberta, since 1986, the College of Physicians and Surgeons (CPSA) started the Triplicate Prescription Program (TPP) – considered an important tool in reducing the misuse and abuse of prescription medications. TPP collects prescribing and dispensing data for listed drugs. When the data meet certain criteria, physicians and others involved in the care of the patient are alerted, provided with information and directed to resources to support them in providing safe care.

So the TPP program has been in force for 30 years. Has this put a dent in the use and abuse of narcotics and other drugs amongst vulnerable population of Alberta? I hope so but I don’t have the numbers.

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Grapefruit in Your Diet may Interfere with Certain Medications

The Statue of Liberty on Liberty Island in New York Harbor. (Dr. Noorali Bharwani)
The Statue of Liberty on Liberty Island in New York Harbor. (Dr. Noorali Bharwani)

“Our research group discovered the interaction between grapefruit and certain medications more than 20 years ago,” says an article in the Canadian Medical Association Journal (CMAJ March 5, 2013) written by Dr. David Bailey, Ph.D and his colleagues from Ottawa.

Certain other citrus fruits and products can interfere with several kinds of prescription pills. You are advised to check with your pharmacist and/or doctor before consuming any citrus products, including grapefruit, if you take prescription medications. Taking your medication and grapefruit product at different times does not stop the interaction.

Chemicals in the fruit can interfere with the enzymes that break down the medication in the digestive system. As a result, the medication may stay in your body for too short or too long a time. A medication that’s broken down too quickly won’t have time to work. On the other hand, a medication that stays in the body too long may build up to potentially dangerous levels.

There is a long list of medications that is affected by grapefruit and other citrus food. Here are some examples:

Antibiotics: erythromycin

Cholesterol reducing pills: atorvastatin (Lipitor), lovastatin (Altoprev), others

High blood pressure pills: felodipine, carvedilol (Coreg), others

Pills for heart problems: amiodarone (Coradarone, Pacerone)

Antidepressants: diazepam (Valium, Diastat), fluvoxamine, others

Pills to prevent organ rejection in transplant recipients: cyclosporine (Sandimmune and others)

Play it safe with prescription drugs. Always ask your doctor or pharmacist when you get a new prescription if it interacts with any foods or other medicines.

Many of the drugs that interact with grapefruit are highly prescribed and are essential for the treatment of important or common medical conditions. Currently, more than 85 drugs have the possibility of interacting with grapefruit; of these drugs, 43 have interactions that can result in serious adverse effects.

The chemicals in grapefruit involved in this interaction are the furanocoumarins.

One whole grapefruit or 200 mL of grapefruit juice is sufficient to cause clinically relevant increased systemic drug concentration and subsequent adverse effect. Seville oranges, often used in marmalades, limes and pomelo also produce this interaction.

In spite of the scientific evidence from reliable sources regarding adverse effects as discussed earlier, in routine clinical practice physicians do not see too many complications. One reason could be that multiple factors likely need to combine to achieve a marked increase in systemic drug concentration. It is reasonable to assume that just exposure to any interacting combination would not be sufficient to cause a clinically important change in drug response in all, if not most, cases.

Having said that, the fact remains you have to be vigilant. Pharmacists are the best source of information when it comes medications.

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Quinine Not a Safe Drug for Treating Nocturnal Leg Cramps

A young tourist in Los Angeles, 2007. (Dr. Noorali Bharwani)
A young tourist in Los Angeles, 2007. (Dr. Noorali Bharwani)

Nocturnal leg cramps, that are cramps occurring at night, also known as rest cramps, are a painful involuntary muscle contraction that typically occur in the legs or feet during prolonged periods of rest and often interrupt sleep, says an article in the Canadian Medical Association Journal (CMAJ March 3, 2015).

Leg cramps are seasonal and roughly double between the winter lows and summer highs. It is not clear why there is such a seasonal occurrence. There is a midsummer peak and a midwinter dip.

Quinine sulfate at a dose of 200-300 mg at night has been used for many years to treat nocturnal leg cramps, says the article. Quinine is modestly effective. Other drugs were found to be either possibly effective (vitamin B complex, naftidrofuryl, calcium-channel blockers) or likely not effective (gabapentin, magnesium).

There is a long list of possible side effects that can occur with the usual dose of quinine. Some of the side effects are tinnitus (ringing in the ears), high-tone hearing loss, photophobia (visual intolerance to light) and other visual disturbances, just to mention a few.

Rarely, it can cause serous blood disorders (immune thrombocytopenic purpura and drug-mediated thrombotic microangiopathy). Overdose of quinine sulphate can cause serious and even fatal arrhythmias (irregular heart rhythm).

As of September 30, 2010, Health Canada had received 71 reports of serious adverse reactions suspected of being associated with quinine use (41 were either life threatening or required hospital admission), says the article. In 2009, the US Food and Drug Administration (FDA) explicitly noted an unfavourable risk-benefit ratio for quinine when used for leg cramps.

Although quinine is modestly effective, concerns regarding potential adverse effects have tempered enthusiasm about its use for nocturnal leg cramps, says the article. In fact practice guidelines for American neurologists on the symptomatic management of muscle cramps concluded that, although likely effective, quinine should be avoided for routine use because of the potential for toxic effects.

The author of the article says that quinine does not have Health Canada approval for the treatment of nocturnal leg cramps, yet it is widely used for this indication.

What else can be done for nocturnal leg cramps? Nightly calf and leg muscle stretching showed significant decrease in both the frequency and severity of leg cramps. The author does not suggest that quinine should be completely banned. It can be tried for short period. During the trial, patients should be closely monitored and the quinine stopped after four weeks if there is no benefit, says the article.

Patients continuing to take quinine after four weeks should be followed and advised periodically to try stopping it, says the author of the article.

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Unused Prescription Drugs Should be Disposed of Carefully

A lonely tree. (Dr. Noorali Bharwani)
A lonely tree. (Dr. Noorali Bharwani)

It is a common dilemma in every household – what to do with expired and unused medications.

An article in the Canadian Medical Association Journal (CMAJ August 5, 2014) says unused prescription drugs should not be treated like leftovers and kept sitting in a closet for years to come.

On May 11, 2013, Public Safety Canada and the Canadian Association of Chiefs of Police coordinated the first National Prescription Drug Drop-Off Day, which resulted in the return of more than two tones of unused medications, says the CMAJ article. This initiative was repeated on May 10, 2014.

The whole idea of this exercise was to reduce the amount of unused prescription drugs in Canadian households and, ultimately, drug-related harm. Unused prescription drugs are common in most households.

Some individuals are reluctant to throwaway unused medications because they may be useful in the future. A good example is painkillers. A second example is antibiotics.

A review found that more than a third of patients did not complete their antibiotic course as prescribed, and unused antibiotics were taken by more than a quarter of the patients for new infections.

If you keep unused prescription drugs in the house then another member of the family may think that the same pills may be useful for his or her ailment.

Unused opioids, benzodiazepines and stimulants are major sources of misuse and diversion, says the article. Fifteen per cent of students in grades seven to 12 in Ontario reported using prescription medications (most often opioids and stimulants) for recreation in the preceding year. Most of these pills were prescribed to one of the parents or sibling.

Unused prescription drugs are sometimes brought to “pill parties” (also called “pharm” or “Skittles” parties), where adolescents experiment with pills they select from the pool of medications brought by partygoers, says the article. Some of the drugs can kill if mixed with other drugs or alcohol.

Self-medication with antibiotics, without proper professional diagnosis, is a common practice, most often for a sore throat and common cold.

What about our toddlers?

Between 2001 and 2008, more than 450 000 cases of poisoning in children less than six years of age were reported to US poison control centers. Of these, 95 per cent involved the ingestion of a prescription medication, which resulted in substantial morbidity and resource use (i.e., non-fatal injury, visit to the emergency department and admission to hospital), as well as 66 deaths, says the article.

To minimize these kinds of harm, there should be responsible disposal of unneeded or expired medications.

Health Canada recommends that unused medications be returned to local pharmacies or municipal waste disposal centers and should not be disposed off in the garbage or by flushing them down the toilet.

Flushing the pills down the toilet is not a bad idea although Health Canada does not like it. The US Food and Drug Administration recommends disposal in the garbage after the unused medications have been mixed with coffee grinds or cat litter to mask the drug or render it unpalatable. Not an easy disposable system.

The most important thing to remember is all medications should be stored in a secure place.

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