Managing Acute Pain and Opioid Risks Following Wisdom Teeth Extraction: An Illustrative Case.

Introduction: The opioid epidemic has awakened educators to the insufficiency of training in the areas of pain management and substance use disorders within the curricula of health sciences schools. The University of Pittsburgh Center of Excellence in Pain Education created an online educational module focusing on factors contributing to the opioid epidemic and the role of robust interprofessional communication in avoiding common practitioner errors. Methods: The 1-hour module created by an interprofessional team comprised a pretest, video presentation featuring case vignettes, posttest, and learner satisfaction survey. The content of the module focused on four core concepts: (1) managing acute perioperative pain, (2) maximizing opioid safety, and (3) identifying and (4) managing suspected opioid abuse and diversion. Results: Data were obtained from 250 dental, pharmacy, and nursing students from the University of Pittsburgh who completed the module as part of their respective profession-specific curricula. Results collapsed across the three school-specific implementations indicated an average increase in knowledge test scores from pre- to posttest (Z = -8.82, p < .001). In addition, the learner satisfaction data revealed an overall positive response to the module, with students commenting that they enjoyed the module and felt it provided them with a valuable learning experience. Discussion: Learner outcomes and feedback suggest that our interprofessional team was successful in creating an effective learning module applicable to several health care professions, namely, pharmacy, dentistry, and nursing. Future studies might address the application of the knowledge gained to actual patient care.

Evaluation of medical marijuana topics in the PharmD curriculum: A national survey of schools and colleges of pharmacy.

INTRODUCTION: To summarize the status of medical marijuana instruction in the PharmD curriculum and capture future plans for the incorporation of medical marijuana content. METHODS: One hundred and forty United States schools and colleges of pharmacy were contacted to complete an anonymous survey regarding inclusion of medical marijuana topics in their curriculum, future plans for inclusion, and evaluation of perceived importance of specific topics. RESULTS: Forty nine percent (68/140) of schools and colleges completed the survey and 62% (44/68) include medical marijuana content in their curriculum. Of the schools and colleges that do not include it, 23% (6/26) plan to incorporate medical marijuana topics within the next 12 months. In regards to perceived importance of specific topics related to medical marijuana, all topics received a median score of three on a scale of one to five, with one being of high importance. CONCLUSION: With more states legalizing medical marijuana, schools and colleges of pharmacy need to evaluate inclusion of medical marijuana topics in their curriculum to prepare student pharmacists to effectively care for patients using this product.

Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization.

BACKGROUND AND AIMS: Uncertainty about optimal treatment duration for buprenorphine opioid agonist therapy may lead to substantial variation in provider and payer decision-making regarding treatment course. We aimed to identify distinct trajectories of buprenorphine use and examine outcomes associated with these trajectories to guide health system interventions regarding treatment length. DESIGN: Retrospective cohort study. SETTING: US Pennsylvania Medicaid. PATIENTS: A total of 10 945 enrollees aged 18-64 years initiating buprenorphine treatment between 2007 and 2012. MEASUREMENTS: Group-based trajectory models were used to identify trajectories based on monthly proportion of days covered with buprenorphine in the 12 months post-treatment initiation. We used separate multivariable Cox proportional hazard models to examine associations between trajectories and time to first all-cause hospitalization and emergency department (ED) visit within 12 months after the first-year treatment. FINDINGS: Six trajectories [Bayesian information criterion (BIC) = -86 246.70] were identified: 24.9% discontinued buprenorphine < 3 months, 18.7% discontinued between 3 and 5 months, 12.4% discontinued between 5 and 8 months, 13.3% discontinued > 8 months, 9.5% refilled intermittently and 21.2% refilled persistently for 12 months. Persistent refill trajectories were associated with an 18% lower risk of all-cause hospitalizations [hazard ratio (HR) = 0.82, 95% confidence interval (CI) = 0.70-0.95] and 14% lower risk of ED visits (HR = 0.86, 95% CI = 0.78-0.95) in the subsequent year, compared with those discontinuing between 3 and 5 months. CONCLUSIONS: Six distinct buprenorphine treatment trajectories were identified in this population-based low-income Medicaid cohort in Pennsylvania, USA. There appears to be an association between persistent use of buprenorphine for 12 months and lower risk of all-cause hospitalizations/emergency department visits.

A model for supporting and training clinical pharmaceutical scientist PhD students.

OBJECTIVES: To enhance the clinical training and financial support of graduate students in a Clinical Pharmaceutical Scientist PhD Program at the University of Pittsburgh School of Pharmacy. DESIGN: The School of Pharmacy and University of Pittsburgh Medical Center entered into a collaborative agreement to develop the Clinical Scientist Associate (CSA) program, as well as financially support students enrolled in a Pharmaceutical Sciences PhD program. These clinical training experiences are in addition to the didactic and laboratory experiences in the pharmaceutical sciences graduate program. ASSESSMENT: Since 2002, three students have participated as CSAs, simultaneously working on their graduate research and meeting the requirements of the CSA program. CONCLUSIONS: The CSA program is a novel model for clinical training and support of post-PharmD graduate students enrolled in a PhD clinical pharmaceutical scientist program.

The effect of isoniazid on CYP2E1- and CYP4A-mediated hydroxylation of arachidonic acid in the rat liver and kidney.

Cytochrome P450 (P450) bioactivation of arachidonic acid to hydroxyeicosatetraenoic acids (HETEs) has been reported to be isoform- and tissue-specific. To determine whether altered P450 expression affects the production of these metabolites, the formation of HETEs after isoniazid-mediated CYP2E1 induction was evaluated in the rat liver and kidney. Male Sprague-Dawley rats received isoniazid (200 mg/kg) or saline intraperitoneally once daily for 5 days. Chlorzoxazone, lauric acid, and arachidonic acid hydroxylation was measured in liver and kidney microsomes with and without preincubation with the specific CYP2E1 inhibitor, trans-1,2-dichloroethylene (DCE). P450 isoform content and tissue HETE metabolite concentrations were also determined. Isoniazid increased CYP2E1 protein, and the 6-hydroxychlorzoxazone formation rate was increased by 2.7 +/- 0.3- and 2.2 +/- 0.5-fold in liver and kidney, respectively. Formation of 19-HETE and 11-hydroxylauric acid was induced 2.3 +/- 0.6-fold and 2.2 +/- 0.4-fold in the liver, respectively, with no difference in the kidney. All of the induced activities were attenuated by DCE. An unanticipated decrease in liver CYP4A expression and in vitro 20-HETE formation rate was observed after isoniazid administration. Isoniazid decreased liver and kidney 20-HETE content to 34 +/- 10% and 15.6 +/- 5.3% of control, respectively, without significantly altering tissue 19-HETE concentration. Based on these findings, we conclude that under induced conditions, CYP2E1 is a primary enzyme involved in liver, but not kidney, formation of 19-HETE. In addition, formation of both CYP4A and 20-HETE is reduced in the liver by isoniazid. It was also demonstrated that tissue concentrations parallel in vitro inhibited formation rates for 20-HETE, but not the induced 19-HETE formation in the liver.

Determination of 20-hydroxyeicosatetraenoic acid in microsomal incubates using high-performance liquid chromatography-mass spectrometry (HPLC-MS).

20-HETE is a potent, vasoconstrictive arachidonic acid metabolite with a limited number of published methods for quantitative assessment of microsomal formation rate. The purpose of this study was to evaluate the utility of HPLC-MS (negative ESI) for quantitation of rat microsomal 20-HETE enzyme kinetics. Calibration curves were linear over 0.75-16 ng on-column (r(2)>0.996). The intra- and inter-assay precision and accuracy were <15%. Microsomal 20-HETE revealed saturable (100 microM) kinetics (brain K(m) and V(max): 39.9+/-6.0 microM and 8.7+/-0.6 pM/min per mg; liver K(m) and V(max): 23.5+/-3.2 microM and 775.5+/-39.8 pmol/min per mg; kidney K(m) and V(max): 47.6+/-8.5 microM and 1933+/-151 pM/min per mg). This paper demonstrates HPLC-MS as an efficient method for quantitating 20-HETE enzyme kinetics in microsomes from rat tissues.

Alkaloids of Thalictrum angustifolium.

Fractionation and chromatography of the ethanolic extract of the roots of Thalictrum angustifolium L. (Ranunculaceae) afforded five alkaloids: noroxyhydrastinine (1), O-methylthalicberine (2), berberine iodide (3), jatrorrhizine iodide (4), magnoflorine iodide (5). In addition, one simple aromatic compound, methyl-4-hydroxybenzoate (6), was also isolated. These compounds were identified via comparison of their spectral data with authentic compounds or spectra available within our laboratory. This is the first reported isolation of these compounds from this species.