Congratulations to Dr. Baselt for the publication of his 10th edition and the expansion of his classic toxicology text to cover over 1,500 medications and chemicals. This enduring work provides a c...

Disposition of Toxic Drugs and Chemicals in Man

Background Despite increased cardiometabolic risk in individuals with mental illness taking antipsychotic medication, metabolic screening practices are often incomplete or inconsistent. Method We undertook a systematic search and a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) meta-analysis of studies examining routine metabolic screening practices in those taking antipsychotics both for patients in psychiatric care before and following implementation of monitoring guidelines. Results We identified 48 studies ( n =290 534) conducted between 2000 and 2011 in five countries; 25 studies examined predominantly schizophrenia-spectrum disorder populations; 39 studies ( n =218 940) examined routine monitoring prior to explicit guidelines; and nine studies ( n =71 594) reported post-guideline monitoring. Across 39 studies, routine baseline screening was generally low and above 50% only for blood pressure [69.8%, 95% confidence interval (CI) 50.9–85.8] and triglycerides (59.9%, 95% CI 36.6–81.1). Cholesterol was measured in 41.5% (95% CI 18.0–67.3), glucose in 44.3% (95% CI 36.3–52.4) and weight in 47.9% (95% CI 32.4–63.7). Lipids and glycosylated haemoglobin (HbA1c) were monitored in less than 25%. Rates were similar for schizophrenia patients, in US and UK studies, for in-patients and out-patients. Monitoring was non-significantly higher in case-record versus database studies and in fasting samples. Following local/national guideline implementation, monitoring improved for weight (75.9%, CI 37.3–98.7), blood pressure (75.2%, 95% CI 45.6–95.5), glucose (56.1%, 95% CI 43.4–68.3) and lipids (28.9%, 95% CI 20.3–38.4). Direct head-to-head pre–post-guideline comparison showed a modest but significant (15.4%) increase in glucose testing ( p =0.0045). Conclusions In routine clinical practice, metabolic monitoring is concerningly low in people prescribed antipsychotic medication. Although guidelines can increase monitoring, most patients still do not receive adequate testing.

Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices

The authors review the historical use of medicinal cannabis and discuss the agent's pharmacology and pharmacokinetics, select evidence on medicinal uses, and the implications of evolving regulations on the acute care hospital setting.

Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting.

Timing of New Black Box Warnings and Withdrawals for Prescription Medications

The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system-depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.

Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use

Drug testing, commonly used in health care, workplace, and criminal settings, has become widespread during the past decade. Urine drug screens have been the most common method for analysis because of ease of sampling. The simplicity of use and access to rapid results have increased demand for and use of immunoassays; however, these assays are not perfect. Falsepositive results of immunoassays can lead to serious medical or social consequences if results are not confirmed by secondary analysis, such as gas chromatography‐mass spectrometry. The Department of Health and Human Services’ guidelines for the workplace require testing for the following 5 substances: amphetamines, cannabinoids, cocaine, opiates, and phencyclidine. This article discusses potential false-positive results and false-negative results that occur with immunoassays of these substances and with alcohol, benzodiazepines, and tricyclic antidepressants. Other pitfalls, such as adulteration, substitution, and dilution of urine samples, are discussed. Pragmatic concepts summarized in this article should minimize the potential risks of misinterpreting urine drug screens.

/pdf/urine-drug-screening-practical-guide-for-clinicians-27r24g8mrn.pdf

Urine drug screening: practical guide for clinicians.

Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens

Objective. To determine pharmacy students’ knowledge of and attitudes toward medical marijuana and to determine if pharmacy students need additional education on the topic.Methods. Pharmacy students were asked to complete a survey on medical marijuana that assessed their knowledge of, medical uses of, adverse effects with, and attitudes toward medical marijuana through 23 Likert-scale questions.Results. Three hundred eleven students completed the survey. Fifty-eight percent of the students felt that medical marijuana should be legalized in all states. However, the majority of students did not feel comfortable answering consumers’ questions regarding efficacy, safety, or drug interactions related to the substance. Accurate responses for diseases or conditions for permitted medical marijuana use was low, with only cancer (91%) and glaucoma (57%) identified by more than half the students.Conclusion. With an increasing number of states adopting medical marijuana use, pharmacy schools need to evaluate the adeq...

Pharmacy Students' Knowledge and Attitudes Regarding Medical Marijuana.

OBJECTIVE:To report a case of severe prolonged thrombocytopenia possibly associated with isotretinoin.CASE SUMMARY:A 27-year-old white woman developed severe thrombocytopenia and elevated transaminases after 3½ months of treatment with isotretinoin. Prior to the onset of thrombocytopenia, the patient had also received a 10-day course of cephalexin. Rectal bleeding was reported by the patient, who was otherwise asymptomatic. Liver enzyme values returned to normal approximately 1 week after discontinuation of isotretinoin; however, platelet counts required approximately 2 months to normalize. Based on the Naranjo probability scale, possible causality exists between isotretinoin and thrombocytopenia.DISCUSSION:The exact mechanism by which isotretinoin caused thrombocytopenia in this patient is not clearly understood. To our knowledge, only 3 previous cases of isotretinoin-associated thrombocytopenia have been reported. The long recovery process that occurred in our patient is possibly a direct result of the ...

Karen E. Moeller

Papers

Urine drug screening: practical guide for clinicians.

Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens

Pharmacy Students' Knowledge and Attitudes Regarding Medical Marijuana.

Prolonged Thrombocytopenia Associated with Isotretinoin

Quality of monitoring for metabolic effects associated with second generation antipsychotics in patients with schizophrenia on public insurance