Case 1: Suboxone is a tablet with a combination of 2 active ingredients—buprenorphine and naloxone—in a 4:1 ratio. Buprenorphine is a partial mu-receptor agonist, and thus reduces opioid cravings and withdrawal symptoms. Naloxone is an opioid antagonist that is commonly used intravenously to counteract the effects of opioid overdose. Suboxone is administered sublingually to avoid first-pass metabolism of buprenorphine, allowing therapeutic concentrations to be achieved. Naloxone is poorly absorbed from both the sublingual and oral route, however; therefore, notable concentrations will not be achieved when used as prescribed for opioid dependence. The pharmacist should notify the intern that the purpose of naloxone in the Suboxone tablet is to discourage diversion and misuse of the tablets. Should a person who has recently taken opioids or who is dependent on full opioid agonists crush and inject Suboxone tablets, the antagonistic properties of naloxone will predominate and will cause withdrawal symptoms. The pharmacist should counsel RT regarding the proper administration technique to ensure optimal absorption of buprenorphine from the sublingual route. RT should make sure his mouth is moist and, if needed, drink water prior to placing the Suboxone tablets under his tongue. RT should place both tablets under his tongue, one on the left side and one on the right side and leave them in place until fully dissolved, generally 5 to 10 minutes. RT should also refrain from talking, as this may interfere with absorption, as will chewing or swallowing the tablet.
Case 2: Prickly pear cactus (PPC) (also known as opales, nopal cactus, and opuntia) is a complementary alternative medicine used in the Mexican, Mexican- American, and Hispanic cultures as a treatment for type 2 diabetes mellitus. Although data suggest 100 to 500 g of broiled PPC may lower blood glucose in patients diagnosed with type 2 diabetes mellitus, little is known about its long-term efficacy and safety. Proposed mechanisms of action of PPC include slowing carbohydrate absorption from the gastrointestinal tract due to high fibrous polysaccharide content and improving glucose utilization by enhancing insulin sensitivity. PPC has been reported to interact with prescription antidiabetic drugs, including sulfonylureas and metformin, causing significant hypoglycemia. The pharmacist should encourage TW to discuss his diabetes treatment with his physician given his suboptimal control and lack of data supporting long-term use of PPC. TW should also be made aware that consuming PPC may lead to additive glucose lowering and may put him at risk for hypoglycemia, given the potential interaction with both of his current medications. As TW may possibly start taking PPC, the pharmacist should review the common signs and symptoms of hypoglycemia and the process of managing hypoglycemia with TW. TW should monitor his blood glucose closely and report any hypoglycemic events to his physician immediately.