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Should ASC’s Consider Valium A Safe “Take-At-Home” Pre-Operative Drug?

July 27, 2012 Leave a comment

I recently received an inquiry from one of our Clients regarding a practice the physicians wanted to initiate at their ASC.  The physicians believed that patients would be best served if given 0.5mg of Valium taken post-operatively at home the morning of surgery.  This would enable them to be nice and relaxed when they got to the pre-op area.

Consideradtion #1 Patient Age and Side Effects 

There are several issues going on here.  When considering what drugs to use with any patient, one has to consider the age of the patient and all possible side effects inherent to the age.  Obviously, the elderly and the very young have special considerations regarding their age whenever choosing a drug, but what is in consideration here is adult and geriatric patients.

Valium is a benzodiazeprine and is used widely to reduce tension and anxiety and, in surgery or certain medical treatments, to induce amnesia.  It is also used for seizures, restless leg syndrome, as a muscle relaxant, and for its sedative effects.

Adverse effects include anterograde amnesia.  Cognitive deficits can persist for up to 6 months or longer. Produces sedfation.  Paradoxicaol effects include excitement, rage, worsening of seizures in epileptic patients.  In patients suffering from, or prone to depression these symptoms can worsen.

The sedative effect of Valium may last longer in older patients.  There is also an increased incident of falls and accidents following the administration of Valium in the older patients.  It can lead to catastrophic side effects if mixed with alcohol. (Remember Karen Ann Quinlan?).  Valium is very addictive.  One physician discourages it use under any condition due to its degree of impairment in some patients.

Valium is detectable in the blood for up to 3 days.

If patients are given a sedative at home, doesn’t this increase their chances of falling at home?

Consideration #2 Falls Prevention Strategies at Home 

Falls in the elderly are a serious concern.  Within our ASCs, we initiate a “Falls Prevention Program.”  We inservice our staff in this area and measure their competency.  We track and trend falls and make changes in our Centers to decrease the possibility of falls.  We paint parking guards in the  parking lots and curbs.  We escort patients to their car.  We don’t leave patients alone to dress following surgery, but insist on staying with them to assist.  We identify patients at a high risk to fall with colored socks or wristbands.  We hold their arm when ambulating.  We recognize that the patient has received sedation, and are, thus, at a higher risk to fall.

BUT if these same patients are given a sedative at home doesn’t this increase their chances of falling at home?  I think of some of our elderly patients especially with their walkers, canes, and underlying health conditions that pre-dispose them to falling.  I know, too, how many times patients with underlying conditions get their feet “tangled up” and fall, and know that this risk has to increase when sedated.

Consideration #3 Alcohol Use by Patients

Valium can be lethal if taken with alcohol.  While alcohol use in the elderly is far below that of the 20 something age group, it is not uncommon.  Alcohol use in the elderly may, in fact, be under-reported.  Many retirees believe they can now sit back and do whatever they want.  Many believe they have earned the right to drink whenever and whatever they choose.  Many life-long habitual users may have increased their alcohol intake with all the golf games, card games, bingo matches, etc. to the extent that a “little nip” at breakfast is not uncommon.  This under reporting includes admitting to their physicians the extent of their use.  Valium and Alcohol do NOT mix…even that little nip can be dangerous.  It should be a concern that our patients fully understand this, discuss their use honestly with their physicians, and comply with instructions.

Consideration #4 Patient Depression and Dependence

Depression is increasingly common among our older population.  Their lives have changed, and are continuing to change, on an ongoing basis, in almost every aspect.  They retire from careers of 20-30 years that have demanded a large part of their lives and have helped to define them as individuals.  They become “stay at home” residents of the community.  This is where they might discover they have no hobbies, or they find that the hobbies they had before aren’t available to them now due to heath problems.  Their physical condition has changed.  They don’t have the stamina they once had.  They may be experiencing some underlying health conditions such as high blood pressure, cardio-vascular disease, coronary disease, diabetes.  Their mortality may be smacking them square in the face.   Husbands and wives are thrust together all day long, another adjustment.  Valium can increase this depression…but, the sedative properties may also provide an escape from all their problems and lead to dependence.

Consideration #5 Choosing Alternative Drugs 

The advantages of Valium under a controlled situation cannot be argued.  However, I would argue that there are other equally advantageous drugs that may be used to provide sedation and insomnia.  Cost may be a factor, as some of the alternative drugs are certainly more costly than Valium.

Consideration #6 Patient/Care Person’s Education 

Patients being given Valium should be reminded to not drive, make important decisions, or sign legal documents for up to 24 hours after taking the drug.

At the very least, the patient’s care person needs to be thoroughly educated about the drug during the pre-operative phone call, so as to be able to take the necessary precautions.

Consider #7 Risk Management and an Alternative Strategies

I am not pointing fingers at this drug and saying, “No! No! No!”  Valium is a staple in any health clinic’s inventory as recommended by WHO.  I am merely pointing out that it is not to be considered lightly, and we, as ambulatory surgery healthcare specialists, need to look at it seriously when prescribing it as a “take at home” med prior to surgery.

I recommend, as a licensed risk manager, that we not give the patients this drug at home prior to their admission to the center, but that we expedite the admission process such that their dosage could be given as soon as possible once they are admitted to the pre-op area.

We should always take great consideration in selecting any drug we prescribe to the patient to be taken at home with no medical supervision.

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Disposing of Drugs

October 19, 2011 1 comment

More and more surgery centers (and other healthcare institutions) are faced with the challenge of disposing of their unwanted or expired drugs.  The Controlled Substance Act and DEA regulations dictate the handling of controlled substances to include the disposal of unused drugs.  Pharmacies are mandated NOT to take back unused or expired drugs.  In the past, organizations were advised to return these to reverse drug distribution centers or to the DEA, but now, neither of these will accept unused or expired drugs.  We were, also in the past, advised to flush them down the drain.  This included not only unused drugs or expired drugs, but medication left in syringes and IV solutions and/or other medications in solution.  While expired pharmaceuticals do not represent a serious threat to public health or to the environment, improper disposal may be hazardous if it leads to contamination of water supplies or local sources used by nearby communities or to wildlife.  States such as California and Washington prohibit disposal of virtually any drugs down the sewage system.

In general, wastes that are acceptable for flushing down the sewage system include IV solutions such as saline or glucose, lactated ringers, or solutions containing nutrients or electrolyte salts.  Not acceptable would be IV solutions containing antibiotics, actineoplastic/chemotherapeutic agents, controlled substances or narcotic pain medication.

Drugs Suitable for Flushing per the FDA include:

  • Fentanyl citrate
  • Daytrana Transdermal Patch
  • Duragesic Transdermal System (fentanyl)
  • OxyContin Tablets
  • Avinza Capsules (morphine sulfate)
  • Baraclude Tablets (entecavir)
  • Reyataz Capsules (atazanavir sulfate)
  • Tequin Tablets (gativloxacin)
  • Zerit for Oral Solution (stavudine)
  • Meperidine HCL Tablets
  • Percocet (oxycodone and acetaminophen)
  • Xyrem (sodium Oxybate)
  • Fentora (fentanyl buccal tablet)
  • Meperedine tablets (demoral)

Understand that this author and other environmental experts disagree with the FDA and these disposal recommendations. Instead it is recommend to crush all solid medication or dissolve medications (solid or liquid) in water and mixing that solution with kitty litter (already in the center as part of the spill kit for hazardous substances) or other unpalatable substance such as coffee grounds for disposal.

The White House Office of National Drug Control Policy (ONDCP) and the EPA, as well as the American Pharmacists Association (APhA) have all published similar recommendations.

Institutions producing large amounts of unused pharmaceuticals such as hospitals or pharmaceutical distribution centers may utilize encapsulation to destroy unused or expired drugs.  Encapsulation involves immobilizing the pharmaceutical in a solid block with a plastic or steel drum.  The container is then filled with cement, a cement-like mixture, plastic foam or sand.  Such disposal methods are not practical for a surgery center; rather, surgery centers should use either the above “crushing and dissolution” method or inertization/immobilization.

Inertization is a variant of encapsulation and involves removing the packaging materials, paper, cardboard and plastic, from the pharmaceuticals.  Pills are removed from the blister packs, ground, mixed with water and some mixture—could be litter or coffee grounds—placed in a bottle such as an empty saline bottle, top taped and then hidden in the trash to go to landfill.

Ampoules can be crushed using protective hand and eye wear and placed in mixtures such as above or diluted with water and disposed of as above.  Sweep up the crushed glass and dispose of in sharps containers practicing safety precautions.

The disposal of controlled substances must always be in the presence of two licensed persons, one of whom should be your pharmacy consultant.  Substances have to be rendered unusable as discussed above, and then can be dispersed among the landfill (or follow the above FDA list for sewage disposal).

Aerosol containers to include inhalers should go to the landfill.

Non-controlled substances may be disposed of by:

  • Keep the medication in the original container, but mark out any identifying information.
  • If pills, add water to dissolve.  For liquids, add litter or coffee grounds or even dirt/sand.
  • Close the lid and secure with duct or packing tape.
  • Place the bottles inside an opaque container such as a saline or water/irrigating solution bottle, detergent bottle, etc.
  • Capeand tape the container closed.
  • Hide the container in the trash.  DO NOT place in your recycling bin

SmarXt Disposal poster

There is HUGE emphasis being placed on controlling the unlawful distribution of drugs today.  We, in the ambulatory surgery industry, can do much to curtail this activity by properly controlling how WE dispose of the unused or expired drugs in our centers.

Please follow our blog for more information to come as this remains a hot topic especially in the realm of controlled substances.

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