- Avoid the use of meperidine for pain control,
especially in elderly and renal-compromised
patients
- Eliminate tincture of opium from community
pharmacy inventory if possible. If it must be
stocked, segregate and/or secure tincture of
opium in a separate area to avoid confusion
with paregoric.
- When appropriate, consider nonopiate medications
and nonpharmacologic therapies for
pain
- For electronic prescribing systems, list
only the most frequently used medications,
strengths, and doses
- Eliminate error-prone abbreviations from preprinted
prescriptions and electronic prescribing
systems
- Separate morphine and hydromorphone, concentrated
and conventional oral liquid opiates,
and extended- and immediate-release formulations
of oxycodone in storage, dispensing,
and administration areas
Improve Access to Information
- Use "paregoric," the official name of camphorated
opium tincture in the United States,
on prescriptions, inventory lists (including
computer systems), and labels
- Ensure that oxycodone prescriptions clearly
specify the dosage form (eg, extended or
immediate release)
- Provide equianalgesic charts for different
opiate products for prescribers, nurses, and
pharmacists
- In long-term care facilities, require documentation
of patch application (including location)
and removal on nursing medication administration
records (MARs). Consider including an
order to check the placement and location of
the patch each day or each shift.
- Establish dose ranges by weight, and build
dose alerts into electronic prescribing systems
and pharmacy systems
Simplify and Standardize
- Prescribers should establish protocols for
pain management, depending on the severity
of pain
- In long-term care facilities and hospice
programs, establish protocols for pain management,
including a standard pain scale for
assessment and reassessment, guidelines
for the use of specific analgesics, conditions
requiring a dose reduction, and requirements
for monitoring
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- Reduce the variety of opiates and other analgesics
in electronic prescribing systems to
those used most frequently
- Prescribe and dispense liquid medications
with the dose specified in milligrams, never
in volume
- Never use error-prone abbreviations and
symbols, such as DTO, MS, trailing zeros, or
naked decimals
Differentiate
- Use tall-man lettering for HYDROmorphone
on labels, preprinted prescriptions, MARs,
patient profiles, and drug listings on computer
screens
- Apply auxiliary warning labels to areas
where opiates are stored and directly to
products that look similar to help differentiate
them, when appropriate
Use Reminders
- Apply warning labels to concentrated forms
of morphine and opium tincture and build in
computer screen alerts to remind staff about
their concentrations
Employ Redundancies
- Incorporate prompts in electronic prescribing
and pharmacy computer systems to verify
past opiate use for patients prescribed a
fentanyl transdermal patch greater than 25
mcg/hr, concentrated morphine solutions, or
long-acting opiate products
- Routinely compare narcotic prescriptions
with narcotic sign-out records to ensure
errors are not being made
Educate Patients
Provide direct patient counseling to all
patients and/or their caregivers receiving
opiate products
Provide guidelines to patients and caregivers
for appropriate monitoring of patients who
are receiving opiates. Include information
about contacting their prescriber regarding
uncontrolled pain prior to taking more of the
same or different pain control medications
(eg, adding OTC medications).
Instruct patients who use fentanyl patches
to apply them properly, avoid heat exposure,
and store and dispose of the patches in a
secure manner to avoid unintended access
by children, pets, or drug-seeking individuals.
Include directions on how to set up a dosing
calendar that includes where a patch is
applied and when it should be removed.
Advise patients to swallow oral extendedrelease
formulations whole. Apply warning
labels to not crush or chew extended-release
formulations to prescription vials.
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