Timothy Ives - Academia.edu (original) (raw)

Papers by Timothy Ives

Research paper thumbnail of Intended and unintended consequences: Changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012–2018 – Controlled and single-series interrupted time series analyses

Drug and Alcohol Dependence

Research paper thumbnail of Association Between Statewide Opioid Prescribing Interventions and Opioid Prescribing Patterns in North Carolina, 2006–2018

Pain Medicine, 2021

Objective To examine the impact of three sequential statewide policy and legislative intervention... more Objective To examine the impact of three sequential statewide policy and legislative interventions on opioid prescribing practices among privately insured individuals in North Carolina. Methods An interrupted time series approach was used to examine level and trajectory changes of new and prevalent opioid prescription rates, days’ supply, and daily morphine milligram equivalents before and after implementation of a 1) prescription drug monitoring program, 2) state medical board initiative, and 3) legislative action. Analyses were conducted using individual-level claims data from a large private health insurance provider serving North Carolina residents, ages 18–64 years, from January 2006 to August 2018. Results Rates of new and prevalent prescription opioid patients were relatively unaffected by the prescription monitoring program but sharply declined in the months immediately following both medical board (−3.7 new and −19.3 prevalent patients per 10,000 person months) and legislat...

Research paper thumbnail of Affective disorders, opioid misuse, and fibromyalgia in a primary care patients

Research paper thumbnail of RESEARCH ARTICLES Assessing Implementation of Cultural Competency Content in the Curricula of Colleges of Pharmacy in the United States and Canada

Objectives. To assess the presence of curricular and organizational content related to cultural c... more Objectives. To assess the presence of curricular and organizational content related to cultural competency within colleges of pharmacy in the United States and Canada. Methods. Curriculum committee chairs (n 5 87) and student leaders (n 5 54) in colleges of pharmacy in the United States and Canada were surveyed via an e-mailed assessment tool. Results. Forty-nine (56.3%) curriculum committee chairs and 27 (50%) student leaders returned usable responses. Respondents reported that cultural competency was mentioned in 61.2% of their mission statements, and half had made curricular changes with respect to diversity within the past 5 years. Almost 94% felt the necessity to add cultural competency topics to required courses in the curriculum, and 42.9% wanted to add a course specific to cultural competency into the curriculum. Conclusion. Curriculum committee chairs recognize the need to add curricular content related to cultural competency, but not all of the respondents have implemented...

Research paper thumbnail of Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program

Pain Medicine, 2020

Background Types and correlates of pain medication agreement (PMA) violations in the primary care... more Background Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. Methods A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. Results Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patien...

Research paper thumbnail of Pharmacist-Managed Diabetes Education Service

American Journal of Health-System Pharmacy, 1983

A pharmacist-managed education service for diabetes patients is described. Clinical pharmacists i... more A pharmacist-managed education service for diabetes patients is described. Clinical pharmacists in three ambulatory-care centers provide diabetes-patient education based on guidelines developed and approved by the pharmacy, therapeutics, and standing orders committee. Patients are referred by their primary health-care provider; they receive individualized information concerning the pathophysiology and therapy of diabetes mellitus and instruction in self-care methods. A questionnaire completed by the patient before the initial visit aids the pharmacist in assessing the patient's educational needs, developing an individualized teaching program, and establishing long- and short-range treatment goals. The pharmacist spends one hour with the patient for the initial visit and 15 minutes for subsequent visits; patient charges are 15fortheinitialvisitand15 for the initial visit and 15fortheinitialvisitand7.50 for further teaching sessions. Records maintained by the pharmacist enable primary-care providers to follow the patient's progress and anticipate problems. Patients return for periodic assessment of their progress. Patient teaching by pharmacists has been provided and reimbursed in this ambulatory-care setting for 10 years. The pharmacist-educators' responsibilities include assessment, planning, instruction, and follow-up.

Research paper thumbnail of Doxepin-induced acute glossitis

American Journal of Health-System Pharmacy, 1980

A case of doxepin-induced acute glossitis is reported. Painful, tender, papular lesions on the to... more A case of doxepin-induced acute glossitis is reported. Painful, tender, papular lesions on the tongue were observed in a 48-year-old woman seven days after initiation of doxepin and ampicillin therapy. Doxepin daily dosage (administered in four divided doses) subsequently was reduced from 175 to 150 to 125 mg, then both drugs were discontinued. The glossitis, treated with viscous lidocaine, resolved over a three-week period. Four weeks after doxepin therapy was firt initiated, the drug was reinstituted; glossitis recurred eight days later. After discontinuation of doxepin, the glossitis slowly regressed. Drug-induced glossitis, its mechanism of action, and treatment are reviewed. When unexpected oral inflammation and pain occur, the potential for drug-induced oral lesions should be considered. Treatment is primarily empirical, with unresponsive cases being candidates for therapy of corticosteroids applied topically to the oral lesions.

Research paper thumbnail of Illicit Use of Diphenoxylate Hydrochloride to Prevent Narcotic Withdrawal Symptoms

Drug Intelligence & Clinical Pharmacy, 1980

Three of his patients received only 10 mg po; one received 25 mg po; and one, 50 mg po. The other... more Three of his patients received only 10 mg po; one received 25 mg po; and one, 50 mg po. The other two patients received injections — one of 25 mg im, and one of both 50 mg im and 50 mg iv. Since chlordiazepoxide is slowly and poorly absorbed intramuscularly,' all but one case could be considered within the usual dosage range. Our patient received triazolam 0.25 mg po, which is within the normal range for geriatric patients.

Research paper thumbnail of Short-Acting Opioids Are Associated with Comparable Analgesia to Long-Acting Opioids in Patients with Chronic Osteoarthritis with a Reduced Opioid Equivalence Dosing

Pain Medicine, 2017

Setting. There are no studies that exist within the primary care setting that address optimal opi... more Setting. There are no studies that exist within the primary care setting that address optimal opioid therapy in osteoarthritis patients. In light of the recently released US Centers for Disease Control and Prevention guidelines on opioid use in chronic noncancer pain, there is a pressing need to better characterize the effectiveness of long-and short-acting opioids. Objective. To examine the effectiveness of shortacting opioids (SAO) vs long-acting opioids (LAO) and combination therapies (SAO and LAO) for treating chronic osteoarthritis pain in a retrospective trial. Perspective. This article investigates the effectiveness of short-acting vs long-acting opioids for the treatment of chronic noncancer pain, specifically osteoarthritis. This information could potentially aid practitioners in primary care environments to design equally efficacious and less costly opioid regimens, while simultaneously enhancing patient safety.

Research paper thumbnail of Pharmacists can develop special skills to provide pharmaceutical care to patients with chemical dependencies. A one-year residency program in North Carolina shows how

American Pharmacy, 1994

Pharmacists can develop special skills to provide pharmaceutical care to patients with chemical d... more Pharmacists can develop special skills to provide pharmaceutical care to patients with chemical dependencies. A one-year residency program in North Carolina shows how.

Research paper thumbnail of Mexiletine use in pregnancy and lactation

American Journal of Obstetrics and Gynecology, 1987

Treatment of arrhythmias during pregnancy is complicated by insufficient information on the effec... more Treatment of arrhythmias during pregnancy is complicated by insufficient information on the effects of the drug on the fetus or possible alterations of the drug's pharmacodynamics in the mother. The use of mexiletine, a newly introduced antiarrhythmic agent, during the entire course of pregnancy and subsequent lactation is presented.

Research paper thumbnail of Fluconazole for Postpartum Candidal Mastitis and Infant Thrush

Journal of Human Lactation, 2002

This case report illustrates the difficulties inherent in treating candidal mastitis in lactating... more This case report illustrates the difficulties inherent in treating candidal mastitis in lactating women and concurrent thrush in the breastfeeding baby. This mother's candidiasis vacillated from topical to ductal, depending on which medications were being used over the course of several months. Her baby's oral thrush was unique in that there were never any white plaques visible on his oral mucosa. Ultimately, both mother and child were treated simultaneously with oral fluconazole, with a relief of symptoms in both individuals.

Research paper thumbnail of Physician perceptions of integrating advanced practice pharmacists into practice

Journal of the American Pharmacists Association, 2018

Objectives: Barriers have prevented full integration of advanced practice pharmacists (APPs) into... more Objectives: Barriers have prevented full integration of advanced practice pharmacists (APPs) into collaborative practice in some areas despite evidence describing their value. APPs in North Carolina can be recognized as Clinical Pharmacist Practitioners (CPPs) under a collaborative practice agreement and provide comprehensive medication management under physician supervision. This study describes the perceptions of physicians regarding the barriers and benefits of integrating CPPs into interprofessional teams and compares physician and CPP perceptions. Methods: This prospective descriptive study surveyed CPP supervising physicians in North Carolina. The questionnaire consisted of 17 multiple-choice and free-response questions. Questions included demographics, perceived benefits and challenges of incorporating CPPs into health care teams, and services provided by CPPs. Findings were compared with previously published data that assessed CPP perceptions about the same topics to gain insight into common perspectives of team members. Results: Fifty-six physicians (23.1%) responded, identifying enhanced clinical outcomes (87.5%), access to drug knowledge (58.9%), and creation of a multidisciplinary model for learners (57.1%) as the top benefits of working with CPPs. Primary barriers included limited reimbursement (60.7%) and billing difficulties (51.8%). More CPPs acknowledged provider acceptance as a barrier (25.9% vs. 3.6%; P ¼ 0.001). Twelve physicians (21.4%) and no CPPs identified space as a barrier. Conclusion: Physicians identified enhanced clinical outcomes, access to drug knowledge, and creation of a multidisciplinary model for learners as the top benefits of incorporating CPPs into teams, and billing difficulties and limited reimbursement were the primary barriers. These findings were similar to the perceptions of CPPs, with exceptions being that physicians were more concerned about space limitations and CPPs noted that provider acceptance may be difficult. These findings may provide guidance to providers desiring to establish collaborative practice.

Research paper thumbnail of Association of Opioid Dose Reduction With Opioid Overdose and Opioid Use Disorder Among Patients Receiving High-Dose, Long-term Opioid Therapy in North Carolina

JAMA Network Open

IMPORTANCE Rapid reduction or discontinuation of long-term opioid therapy may increase risk of op... more IMPORTANCE Rapid reduction or discontinuation of long-term opioid therapy may increase risk of opioid overdose or opioid use disorder (OUD). Current guidelines for chronic pain management caution against rapid dose reduction but are based on limited evidence. OBJECTIVE To characterize the association between rapid reduction or abrupt discontinuation of opioid therapy (vs maintained or gradual reduction) and incidence of opioid overdose and OUD among patients prescribed high-dose, long-term opioid therapy (HDLTOT). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted among patients aged 18 to 64 years who were prescribed HDLTOT (Ն90 daily morphine milligram equivalents for Ն90% of 90 days) from January 2006 to September 2018, with follow-up up to 4 years after cohort entry. Claims data were drawn from a large private health insurer in North Carolina and analyzed from March 1, 2006, to September 30, 2018. EXPOSURES Time-varying exposure of rapid dose reduction or discontinuation (>10% dose reduction/week) vs maintenance, increase, or gradual reduction or discontinuation. MAIN OUTCOMES AND MEASURES The main outcome was incident opioid overdose (fatal or nonfatal) or diagnosed OUD. Inverse probability-weighted cumulative incidence of outcomes were estimated using the cumulative incidence function and hazard ratios (HRs) using marginal structural Fine-Gray models as a function of rapid dose tapering or discontinuation (vs gradual reduction or discontinuation or maintained or increased), accounting for competing risks. RESULTS A total of 19 443 patients (median [IQR] age, 49 [41-55] years; 10 073 [51.8%] men) who received HDLTOT were identified. Rapid reduction or discontinuation was associated with higher risk of fatal and nonfatal overdoses compared with gradual reduction after the first year (year 1: HR, 1.43; 95% CI, 0.94-2.18; years 2-4: HR, 1.95; 95% CI, 1.31-2.90). There was no association between rapid reduction or discontinuation and diagnosed OUD through 2 years of follow-up; however, the hazard of incident OUD among patients exposed to rapid tapering or discontinuation was greater 25 to 48 months after the start of follow-up (HR, 1.28; 95% CI, 1.01-1.63). CONCLUSIONS AND RELEVANCE In this cohort study, rapid dose reduction or discontinuation was associated with increased risk of opioid overdose and OUD during long-term follow-up. These findings reinforce prior concerns about safety of rapid dose reductions for patients receiving HDLTOT and highlight the need for caution when reducing opioid doses.

Research paper thumbnail of Constant Morphine Infusion for Severe Sickle Cell Crisis Pain

Drug Intelligence & Clinical Pharmacy, 1987

The use of a constant infusion of intravenous morphine sulfate in a patient with severe sickle ce... more The use of a constant infusion of intravenous morphine sulfate in a patient with severe sickle cell crisis is described. After several days of poor control with intramuscular and intravenous narcotic injections, adequate analgesia was obtained with the infusion of morphine within two hours of initiation of therapy. No adverse effects were noted. With the advantages provided by an intravenous narcotic infusion, this protocol should be considered as a suitable alternative to conventional methods for providing pain control in patients in sickle cell crisis.

Research paper thumbnail of Amitriptyline-Induced Tonic-Clonic Seizures in the Mentally Retarded

Drug Intelligence & Clinical Pharmacy, 1980

as a contraceptive. In the U.S.A., the use of chlormadinone acetate or medroxyprogesterone acetat... more as a contraceptive. In the U.S.A., the use of chlormadinone acetate or medroxyprogesterone acetate is not considered advisable for other reasons, but in Europe these drugs are used. If a woman carrying a male fetus continues to take the contraceptives that contain some antiandrogenic progestogens, feminization of the fetus could occur; and a certain type of intersexuality, known as testicuhr feminization syndrome, may even be produced. Certain types of progestogens may, therefore, produce virilization of a female fetus, while other types may produce feminization of a male fetus. I think that this explanation is interesting since monophasic contraceptives are being combined with CPA and ethinyl-estradiol, and the possibility of failure of hormonal contraception is becoming more frequent due either to pharmacological interactions (with rifampicin, phenobarbitone, phenytoin, etc.), or to enzymatic induction produced by alcohol or tobacco. The result of these combinations and interactions may be feminization of the male fetus, of which very little is known.

Research paper thumbnail of Benzoyl Peroxide

Research paper thumbnail of Improving the well-being of nursing home residents

Journal of The American Board of Family Practice, May 1, 1995

Research paper thumbnail of Implementation and reliability of a depression protocol in an outpatient internal medicine diabetes population

Objectives: The prevalence of mood disorders increases with chronic illness. The presence of diab... more Objectives: The prevalence of mood disorders increases with chronic illness. The presence of diabetes doubles the odds of co-morbid depression. Additionally, the connection between depression and medical non-compliance has been well established and alleviating the burden of one disease may reduce morbidity from the other. Our objective is to describe a systematic approach to depression screening and follow-up of patients with diabetes and the post-implementation assessment of staff adherence to the screening and treatment algorithm. Methods: In January 2007 we began using a validated tool for depression, the Patient Health Questionnaire (PHQ-2 and PHQ-9) to improve detection and control of undiagnosed illness. A once a year prompt to trigger PHQ screening was added to the patients clinic check-in documents. Monthly run charts were developed to follow rates of screening and evidence-based treatment algorithms were developed and adopted. Assessment of adherence to these algorithms was...

Research paper thumbnail of Pharmacotherapeutic treatment of anxiety disorders: Investigating the correlation between GAD-7, PHQ-9, and brief pain inventory scores

Pharmacotherapeutic treatment of anxiety disorders: Investigating the correlation between GAD-7, ... more Pharmacotherapeutic treatment of anxiety disorders: Investigating the correlation between GAD-7, PHQ-9, and brief pain inventory scores. Andrea L. Leone, Timothy J. Ives, and Susan J. Blalock; Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC.Objectives: Published studies show evidence of co-morbidities between anxiety, somatization, and chronic pain in population studies. Studies also show a significant link between the treatment of psychopathology, commonly depression, and improvement in chronic pain. The primary objective of this study is to determine if concurrent pharmacotherapeutic management of anxiety, as measured by the GAD-7, will improve chronic pain patients' Brief Pain Inventory (BPI) scores. The secondary objective is to determine if the pharmacotherapeutic management of co-morbid depression, as measured by the PHQ-9, will also impact BPI scores. Methods: Current, IRB-approved studies contain preliminary patient data, which w...

Research paper thumbnail of Intended and unintended consequences: Changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012–2018 – Controlled and single-series interrupted time series analyses

Drug and Alcohol Dependence

Research paper thumbnail of Association Between Statewide Opioid Prescribing Interventions and Opioid Prescribing Patterns in North Carolina, 2006–2018

Pain Medicine, 2021

Objective To examine the impact of three sequential statewide policy and legislative intervention... more Objective To examine the impact of three sequential statewide policy and legislative interventions on opioid prescribing practices among privately insured individuals in North Carolina. Methods An interrupted time series approach was used to examine level and trajectory changes of new and prevalent opioid prescription rates, days’ supply, and daily morphine milligram equivalents before and after implementation of a 1) prescription drug monitoring program, 2) state medical board initiative, and 3) legislative action. Analyses were conducted using individual-level claims data from a large private health insurance provider serving North Carolina residents, ages 18–64 years, from January 2006 to August 2018. Results Rates of new and prevalent prescription opioid patients were relatively unaffected by the prescription monitoring program but sharply declined in the months immediately following both medical board (−3.7 new and −19.3 prevalent patients per 10,000 person months) and legislat...

Research paper thumbnail of Affective disorders, opioid misuse, and fibromyalgia in a primary care patients

Research paper thumbnail of RESEARCH ARTICLES Assessing Implementation of Cultural Competency Content in the Curricula of Colleges of Pharmacy in the United States and Canada

Objectives. To assess the presence of curricular and organizational content related to cultural c... more Objectives. To assess the presence of curricular and organizational content related to cultural competency within colleges of pharmacy in the United States and Canada. Methods. Curriculum committee chairs (n 5 87) and student leaders (n 5 54) in colleges of pharmacy in the United States and Canada were surveyed via an e-mailed assessment tool. Results. Forty-nine (56.3%) curriculum committee chairs and 27 (50%) student leaders returned usable responses. Respondents reported that cultural competency was mentioned in 61.2% of their mission statements, and half had made curricular changes with respect to diversity within the past 5 years. Almost 94% felt the necessity to add cultural competency topics to required courses in the curriculum, and 42.9% wanted to add a course specific to cultural competency into the curriculum. Conclusion. Curriculum committee chairs recognize the need to add curricular content related to cultural competency, but not all of the respondents have implemented...

Research paper thumbnail of Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program

Pain Medicine, 2020

Background Types and correlates of pain medication agreement (PMA) violations in the primary care... more Background Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. Methods A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. Results Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patien...

Research paper thumbnail of Pharmacist-Managed Diabetes Education Service

American Journal of Health-System Pharmacy, 1983

A pharmacist-managed education service for diabetes patients is described. Clinical pharmacists i... more A pharmacist-managed education service for diabetes patients is described. Clinical pharmacists in three ambulatory-care centers provide diabetes-patient education based on guidelines developed and approved by the pharmacy, therapeutics, and standing orders committee. Patients are referred by their primary health-care provider; they receive individualized information concerning the pathophysiology and therapy of diabetes mellitus and instruction in self-care methods. A questionnaire completed by the patient before the initial visit aids the pharmacist in assessing the patient's educational needs, developing an individualized teaching program, and establishing long- and short-range treatment goals. The pharmacist spends one hour with the patient for the initial visit and 15 minutes for subsequent visits; patient charges are 15fortheinitialvisitand15 for the initial visit and 15fortheinitialvisitand7.50 for further teaching sessions. Records maintained by the pharmacist enable primary-care providers to follow the patient's progress and anticipate problems. Patients return for periodic assessment of their progress. Patient teaching by pharmacists has been provided and reimbursed in this ambulatory-care setting for 10 years. The pharmacist-educators' responsibilities include assessment, planning, instruction, and follow-up.

Research paper thumbnail of Doxepin-induced acute glossitis

American Journal of Health-System Pharmacy, 1980

A case of doxepin-induced acute glossitis is reported. Painful, tender, papular lesions on the to... more A case of doxepin-induced acute glossitis is reported. Painful, tender, papular lesions on the tongue were observed in a 48-year-old woman seven days after initiation of doxepin and ampicillin therapy. Doxepin daily dosage (administered in four divided doses) subsequently was reduced from 175 to 150 to 125 mg, then both drugs were discontinued. The glossitis, treated with viscous lidocaine, resolved over a three-week period. Four weeks after doxepin therapy was firt initiated, the drug was reinstituted; glossitis recurred eight days later. After discontinuation of doxepin, the glossitis slowly regressed. Drug-induced glossitis, its mechanism of action, and treatment are reviewed. When unexpected oral inflammation and pain occur, the potential for drug-induced oral lesions should be considered. Treatment is primarily empirical, with unresponsive cases being candidates for therapy of corticosteroids applied topically to the oral lesions.

Research paper thumbnail of Illicit Use of Diphenoxylate Hydrochloride to Prevent Narcotic Withdrawal Symptoms

Drug Intelligence & Clinical Pharmacy, 1980

Three of his patients received only 10 mg po; one received 25 mg po; and one, 50 mg po. The other... more Three of his patients received only 10 mg po; one received 25 mg po; and one, 50 mg po. The other two patients received injections — one of 25 mg im, and one of both 50 mg im and 50 mg iv. Since chlordiazepoxide is slowly and poorly absorbed intramuscularly,' all but one case could be considered within the usual dosage range. Our patient received triazolam 0.25 mg po, which is within the normal range for geriatric patients.

Research paper thumbnail of Short-Acting Opioids Are Associated with Comparable Analgesia to Long-Acting Opioids in Patients with Chronic Osteoarthritis with a Reduced Opioid Equivalence Dosing

Pain Medicine, 2017

Setting. There are no studies that exist within the primary care setting that address optimal opi... more Setting. There are no studies that exist within the primary care setting that address optimal opioid therapy in osteoarthritis patients. In light of the recently released US Centers for Disease Control and Prevention guidelines on opioid use in chronic noncancer pain, there is a pressing need to better characterize the effectiveness of long-and short-acting opioids. Objective. To examine the effectiveness of shortacting opioids (SAO) vs long-acting opioids (LAO) and combination therapies (SAO and LAO) for treating chronic osteoarthritis pain in a retrospective trial. Perspective. This article investigates the effectiveness of short-acting vs long-acting opioids for the treatment of chronic noncancer pain, specifically osteoarthritis. This information could potentially aid practitioners in primary care environments to design equally efficacious and less costly opioid regimens, while simultaneously enhancing patient safety.

Research paper thumbnail of Pharmacists can develop special skills to provide pharmaceutical care to patients with chemical dependencies. A one-year residency program in North Carolina shows how

American Pharmacy, 1994

Pharmacists can develop special skills to provide pharmaceutical care to patients with chemical d... more Pharmacists can develop special skills to provide pharmaceutical care to patients with chemical dependencies. A one-year residency program in North Carolina shows how.

Research paper thumbnail of Mexiletine use in pregnancy and lactation

American Journal of Obstetrics and Gynecology, 1987

Treatment of arrhythmias during pregnancy is complicated by insufficient information on the effec... more Treatment of arrhythmias during pregnancy is complicated by insufficient information on the effects of the drug on the fetus or possible alterations of the drug's pharmacodynamics in the mother. The use of mexiletine, a newly introduced antiarrhythmic agent, during the entire course of pregnancy and subsequent lactation is presented.

Research paper thumbnail of Fluconazole for Postpartum Candidal Mastitis and Infant Thrush

Journal of Human Lactation, 2002

This case report illustrates the difficulties inherent in treating candidal mastitis in lactating... more This case report illustrates the difficulties inherent in treating candidal mastitis in lactating women and concurrent thrush in the breastfeeding baby. This mother's candidiasis vacillated from topical to ductal, depending on which medications were being used over the course of several months. Her baby's oral thrush was unique in that there were never any white plaques visible on his oral mucosa. Ultimately, both mother and child were treated simultaneously with oral fluconazole, with a relief of symptoms in both individuals.

Research paper thumbnail of Physician perceptions of integrating advanced practice pharmacists into practice

Journal of the American Pharmacists Association, 2018

Objectives: Barriers have prevented full integration of advanced practice pharmacists (APPs) into... more Objectives: Barriers have prevented full integration of advanced practice pharmacists (APPs) into collaborative practice in some areas despite evidence describing their value. APPs in North Carolina can be recognized as Clinical Pharmacist Practitioners (CPPs) under a collaborative practice agreement and provide comprehensive medication management under physician supervision. This study describes the perceptions of physicians regarding the barriers and benefits of integrating CPPs into interprofessional teams and compares physician and CPP perceptions. Methods: This prospective descriptive study surveyed CPP supervising physicians in North Carolina. The questionnaire consisted of 17 multiple-choice and free-response questions. Questions included demographics, perceived benefits and challenges of incorporating CPPs into health care teams, and services provided by CPPs. Findings were compared with previously published data that assessed CPP perceptions about the same topics to gain insight into common perspectives of team members. Results: Fifty-six physicians (23.1%) responded, identifying enhanced clinical outcomes (87.5%), access to drug knowledge (58.9%), and creation of a multidisciplinary model for learners (57.1%) as the top benefits of working with CPPs. Primary barriers included limited reimbursement (60.7%) and billing difficulties (51.8%). More CPPs acknowledged provider acceptance as a barrier (25.9% vs. 3.6%; P ¼ 0.001). Twelve physicians (21.4%) and no CPPs identified space as a barrier. Conclusion: Physicians identified enhanced clinical outcomes, access to drug knowledge, and creation of a multidisciplinary model for learners as the top benefits of incorporating CPPs into teams, and billing difficulties and limited reimbursement were the primary barriers. These findings were similar to the perceptions of CPPs, with exceptions being that physicians were more concerned about space limitations and CPPs noted that provider acceptance may be difficult. These findings may provide guidance to providers desiring to establish collaborative practice.

Research paper thumbnail of Association of Opioid Dose Reduction With Opioid Overdose and Opioid Use Disorder Among Patients Receiving High-Dose, Long-term Opioid Therapy in North Carolina

JAMA Network Open

IMPORTANCE Rapid reduction or discontinuation of long-term opioid therapy may increase risk of op... more IMPORTANCE Rapid reduction or discontinuation of long-term opioid therapy may increase risk of opioid overdose or opioid use disorder (OUD). Current guidelines for chronic pain management caution against rapid dose reduction but are based on limited evidence. OBJECTIVE To characterize the association between rapid reduction or abrupt discontinuation of opioid therapy (vs maintained or gradual reduction) and incidence of opioid overdose and OUD among patients prescribed high-dose, long-term opioid therapy (HDLTOT). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted among patients aged 18 to 64 years who were prescribed HDLTOT (Ն90 daily morphine milligram equivalents for Ն90% of 90 days) from January 2006 to September 2018, with follow-up up to 4 years after cohort entry. Claims data were drawn from a large private health insurer in North Carolina and analyzed from March 1, 2006, to September 30, 2018. EXPOSURES Time-varying exposure of rapid dose reduction or discontinuation (>10% dose reduction/week) vs maintenance, increase, or gradual reduction or discontinuation. MAIN OUTCOMES AND MEASURES The main outcome was incident opioid overdose (fatal or nonfatal) or diagnosed OUD. Inverse probability-weighted cumulative incidence of outcomes were estimated using the cumulative incidence function and hazard ratios (HRs) using marginal structural Fine-Gray models as a function of rapid dose tapering or discontinuation (vs gradual reduction or discontinuation or maintained or increased), accounting for competing risks. RESULTS A total of 19 443 patients (median [IQR] age, 49 [41-55] years; 10 073 [51.8%] men) who received HDLTOT were identified. Rapid reduction or discontinuation was associated with higher risk of fatal and nonfatal overdoses compared with gradual reduction after the first year (year 1: HR, 1.43; 95% CI, 0.94-2.18; years 2-4: HR, 1.95; 95% CI, 1.31-2.90). There was no association between rapid reduction or discontinuation and diagnosed OUD through 2 years of follow-up; however, the hazard of incident OUD among patients exposed to rapid tapering or discontinuation was greater 25 to 48 months after the start of follow-up (HR, 1.28; 95% CI, 1.01-1.63). CONCLUSIONS AND RELEVANCE In this cohort study, rapid dose reduction or discontinuation was associated with increased risk of opioid overdose and OUD during long-term follow-up. These findings reinforce prior concerns about safety of rapid dose reductions for patients receiving HDLTOT and highlight the need for caution when reducing opioid doses.

Research paper thumbnail of Constant Morphine Infusion for Severe Sickle Cell Crisis Pain

Drug Intelligence & Clinical Pharmacy, 1987

The use of a constant infusion of intravenous morphine sulfate in a patient with severe sickle ce... more The use of a constant infusion of intravenous morphine sulfate in a patient with severe sickle cell crisis is described. After several days of poor control with intramuscular and intravenous narcotic injections, adequate analgesia was obtained with the infusion of morphine within two hours of initiation of therapy. No adverse effects were noted. With the advantages provided by an intravenous narcotic infusion, this protocol should be considered as a suitable alternative to conventional methods for providing pain control in patients in sickle cell crisis.

Research paper thumbnail of Amitriptyline-Induced Tonic-Clonic Seizures in the Mentally Retarded

Drug Intelligence & Clinical Pharmacy, 1980

as a contraceptive. In the U.S.A., the use of chlormadinone acetate or medroxyprogesterone acetat... more as a contraceptive. In the U.S.A., the use of chlormadinone acetate or medroxyprogesterone acetate is not considered advisable for other reasons, but in Europe these drugs are used. If a woman carrying a male fetus continues to take the contraceptives that contain some antiandrogenic progestogens, feminization of the fetus could occur; and a certain type of intersexuality, known as testicuhr feminization syndrome, may even be produced. Certain types of progestogens may, therefore, produce virilization of a female fetus, while other types may produce feminization of a male fetus. I think that this explanation is interesting since monophasic contraceptives are being combined with CPA and ethinyl-estradiol, and the possibility of failure of hormonal contraception is becoming more frequent due either to pharmacological interactions (with rifampicin, phenobarbitone, phenytoin, etc.), or to enzymatic induction produced by alcohol or tobacco. The result of these combinations and interactions may be feminization of the male fetus, of which very little is known.

Research paper thumbnail of Benzoyl Peroxide

Research paper thumbnail of Improving the well-being of nursing home residents

Journal of The American Board of Family Practice, May 1, 1995

Research paper thumbnail of Implementation and reliability of a depression protocol in an outpatient internal medicine diabetes population

Objectives: The prevalence of mood disorders increases with chronic illness. The presence of diab... more Objectives: The prevalence of mood disorders increases with chronic illness. The presence of diabetes doubles the odds of co-morbid depression. Additionally, the connection between depression and medical non-compliance has been well established and alleviating the burden of one disease may reduce morbidity from the other. Our objective is to describe a systematic approach to depression screening and follow-up of patients with diabetes and the post-implementation assessment of staff adherence to the screening and treatment algorithm. Methods: In January 2007 we began using a validated tool for depression, the Patient Health Questionnaire (PHQ-2 and PHQ-9) to improve detection and control of undiagnosed illness. A once a year prompt to trigger PHQ screening was added to the patients clinic check-in documents. Monthly run charts were developed to follow rates of screening and evidence-based treatment algorithms were developed and adopted. Assessment of adherence to these algorithms was...

Research paper thumbnail of Pharmacotherapeutic treatment of anxiety disorders: Investigating the correlation between GAD-7, PHQ-9, and brief pain inventory scores

Pharmacotherapeutic treatment of anxiety disorders: Investigating the correlation between GAD-7, ... more Pharmacotherapeutic treatment of anxiety disorders: Investigating the correlation between GAD-7, PHQ-9, and brief pain inventory scores. Andrea L. Leone, Timothy J. Ives, and Susan J. Blalock; Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC.Objectives: Published studies show evidence of co-morbidities between anxiety, somatization, and chronic pain in population studies. Studies also show a significant link between the treatment of psychopathology, commonly depression, and improvement in chronic pain. The primary objective of this study is to determine if concurrent pharmacotherapeutic management of anxiety, as measured by the GAD-7, will improve chronic pain patients' Brief Pain Inventory (BPI) scores. The secondary objective is to determine if the pharmacotherapeutic management of co-morbid depression, as measured by the PHQ-9, will also impact BPI scores. Methods: Current, IRB-approved studies contain preliminary patient data, which w...