Storage of Narcotics.
Storage of narcotics:
The following are the responsibilities in regard to storage of narcotics.
Storage in pharmacy.
- The drugs should be kept in a separate cupboard and the key handled by the pharmacist
- A register book should be keep up to date indicating total quality of each drug, the date and where to sign.
- During issuing of drugs, FEFO METHOD IS USED (First Expiry, First Out).
- The register book should be kept for 2 years from the last entry.
Storage on the ward:
- All narcotics must be stored in a double locked compartment or automated dispensing cabinet except refrigerated narcotic infusion bag
- The keys for locked compartment/cupboard must be carried by the nursing unit personnel especially ward I/C or stored in an approved lock box at all times and spare key with a pharmacist.
- Areas with more than one narcotic key, must account for all keys at end of each shift and document this in NCD(Narcotic Drug) administration record books
- Ampoules must be well labeled and separated
- Keys lost or removed from the hospital premises require a lock key replacement by physical plant personnel.
- There should be a register book for stock in and stock out
- Empty ampoules must be kept for replacement.
- Use the FEFO and keep the records for two years
- All narcotics received and issued out on nursing units must be documented in the NCD administration record book or in an automated dispensing system record. Issues must include the patients name physician name and dose.
- All wastage of NCD’S must be singled by a witness after observing the wastage into the sharps container on the units.
- Counts must be performed once per shift by two nurses. An incident report must be completed for discrepancies not resolved prior to shift change
- A count variance of less than 5% for oral narcotic solutions can be corrected without completion of an incident report. The patients services manager is responsible for ensuring discrepancies are resolved and all required signature are obtained in the NCD administration book which must be returned to pharmacy within 2 weeks of completion.
Key Considerations in Narcotic Storage
The responsibility for the storage of narcotics typically falls on the Pharmacy staff, while on wards, storage falls on the nursing staff, who must ensure that the drugs are stored in a secure and controlled environment, and that their access is restricted only to authorized personnel. Nurses must be aware of the regulations and guidelines that govern the storage and handling of narcotics, and must follow strict protocols to ensure the safety and effectiveness of these drugs. By following these best practices, nurses can help prevent diversion, abuse, and misuse of narcotics, and ensure that they are used only for their intended therapeutic purposes.
Secure storage: Narcotics must be stored in a secure and locked cabinet or safe, which is only accessible to authorized personnel. The storage area should be located in a secure and well-lit area, away from public access and preferably near the nursing station for easy monitoring, for ward storage.
Proper labeling: All narcotics must be labeled with their generic name, strength, quantity, lot number, and expiration date. The labels must be legible and firmly affixed to the container, and any outdated or damaged labels should be replaced immediately.
Accurate inventory: An accurate inventory of all narcotics must be maintained at all times, with regular checks and reconciliations between the actual stock and the recorded inventory. The nursing staff must also document any discrepancies, losses, or incidents related to the use or storage of narcotics.
Temperature control: Some narcotics, such as fentanyl and hydromorphone, are particularly sensitive to temperature and humidity, and must be stored in a cool and dry environment to prevent degradation or loss of potency. The storage area must be monitored regularly for temperature and humidity levels, and any deviations from the recommended range must be promptly reported and addressed.
Access control: Access to the narcotics storage area must be strictly controlled and limited to authorized personnel, who have been trained and approved to handle and administer narcotics. The nursing staff must follow strict protocols for accessing and dispensing narcotics, including checking the patient’s identity, verifying the prescription and dosage, and documenting the administration.
Disposal: Narcotics that are expired, damaged, or no longer needed must be disposed of properly, in accordance with government regulations. The nursing staff must follow the prescribed procedures for disposing of narcotics.
Expired, rejected or returned Class A drugs
- Unused drugs must be returned to the prescriber or dispenser.
- If expired or rejected for any reason return to pharmacy in charge who will contact the drug inspector.
- Expired drugs should be destroyed by the pharmacy in charge WITNESSED BY THE Drug inspector.
- Destruction follows the WHO guidelines.
- Details of quantity destroyed and reason must be written in the Class A register.
Importation of Class A drugs
- Manufacture and wholesale of Class A drugs requires an annual import lincence.
- Currently NDA allows only National Medical store (Government) and Joint Medical Stores (NGO) to import narcotics.
- Private retail pharmacies and hospitals access through the above agencies.
Prescription practices of narcotics:
This is a process of sending a written document from prescriber to the dispenser ordering for narcotics.
Ordering in the pharmacy to the wards:
- In the pharmacy, the person responsible obtains the drugs from the registered body as far as ordering is concerned, the pharmacist keeps the records of all entries of drugs.
- Narcotics must be dispensed by a registered pharmacist or medical practitioners
Ordering on the ward:
- Being a group of drugs that can easily be abused, the prescription of narcotics has been limited to registered medical practitioners (doctors) who should prescribe it after evaluating that other NSAIDS cannot relieve pain especially after surgery, cancer treatment e.t.c .
- The doctor makes 2 copies, one is retained in stores/ pharmacy and the other in the patients file. It has to be written clearly with full names of the prescriber and signature, drug, the patients name, route, duration e.t.c.
- The drug given must be indicated by empty ampoules
- If the in charge orders the drug, she or he must sign the orders properly
- On collection, drugs must be checked
- After checking, the nurse who receives the drugs signs them to confirm that he/she has received the drug.
Only the following are allowed to prescribe Class A drugs;
- Registered medical doctor
- Registered dentist
- Registered veterinary Surgeon
- Specialized palliative care nurse or Clinical officer
Prescription forms must have all the details because it is a legal document.
Prescription is valid for 14 days. Supply must not exceed 1 month. It must be in duplicate.
The following must be included:
- Name, age, sex, address
- Total dose of drugs prescribed in words and figures
- Stipulated form of drug e.g. tablets, oral solution, injection.
- Specify strength where possible e.g. 5mg/5mls or 50mg/5mls oral morphine.
Any person in the possession of classified drugs unlawfully is liable to:-
- A fine not exceeding Ug shs.2 million
- Imprisonment for a term not exceeding 2 years
- Both may be applied
- NDA statute is under review
- Pharmacists’ council is established
- Guidelines for handling Class A drugs were established in 2001.
Legal Implications of Narcotics as stipulated in the Narcotic Drugs and Psychotropic Substances(control) Act.
The Narcotic Drugs and Psychotropic Substances (Control) Act, No. 3 of 2016 in Uganda has several legal implications for narcotics.
- Firstly, it criminalizes the possession, sale, manufacture, and trafficking of narcotics, including cocaine, heroin, and marijuana. Those found guilty of these offenses can face severe penalties, including imprisonment and fines.
- Secondly, the Act establishes the National Drug Authority, which is responsible for regulating the importation, exportation, and distribution of controlled substances in Uganda. The Authority has the power to issue licenses and permits for the manufacture, distribution, and sale of narcotics, and to conduct inspections to ensure compliance with the Act’s provisions.
- Thirdly, the Act creates a legal framework for the treatment and rehabilitation of individuals with substance abuse problems. It establishes a National Drug Policy and a National Drug Abuse Prevention and Control Program, which are designed to prevent drug abuse and promote public awareness of the dangers of narcotics.
- Those found guilty of these offenses can face severe penalties, including imprisonment and fines. For example, possession of narcotic drugs can result in up to 10 years’ imprisonment or a fine of up to 10 million Ugandan shillings (about 2,700 USD), or both. Trafficking, on the other hand, can result in life imprisonment or a fine of up to 20 billion Ugandan shillings (about 5.5 million USD), or both.
Overall, the Narcotic Drugs and Psychotropic Substances (Control) Act, No. 3 of 2016 in Uganda aims to combat drug abuse and trafficking while also providing for the treatment and rehabilitation of individuals struggling with addiction. It is important for individuals in Uganda to understand the legal implications of narcotics and to comply with the provisions of this Act to avoid facing serious legal consequences.
Administration of narcotics on the ward:
- The drug to be administered should be prescribed by the doctor.
- The drug must be administered by a qualified staff or a 3rd year student under a supervision of a qualified staff.
- Both people must sign in the register after administration
- The drug must be administered according to the 5R’S i.e. right patient, right drug, right dose, right route, right time.
- Empty ampoules must be handed over to the in charge
- In case of any remainder, it should be taken back to the pharmacy
- The drug wasted must be recorded and signed for.
Precautions on narcotics:
- Dispensed by registered pharmacist or medical practitioner.
- Medical practitioners should not get the drug for personal use
- Keep the drug with an anti dote
- Order must be from a doctor/ medical practitioner with a prescribed form
- Transport should be legal (should be transported by legal means).
- Comply with the rules from NDA.
- Health inspector should be allowed to check on records and obtain sample
- Not allowed to export or import. Trade by licensed pharmacist, drug shop.
NARCOTIC DRUG ABUSE
Narcotics are very good drugs used to mange pain however besides managing pain, it also causes euphoria, narcosis, tolerance and dependence which leads to abuse
Drug abuse is the use of drugs to person gains with out physician prescription/ non-medical purpose.
Narcotic abuse is therefore its use to seek feeling of well being other than pain killing.
Drug dependence is a state resulting from the interactions of a person and a drug in which the person has a compulsion to continue taking the drug experience pleasurable psychological effects and some times to avoid discomfort due to withdraw.
Drug tolerance is where by more of drug is needed to produce the same response. This usually happens with drug causing dependence.
REASONS FOR NARCOTIC DRUG ABUSE AND DEPENDENCE:
- Intermittent use of drugs for social or emotional reasons rather than medical reasons e.g. drinking alcohol to relieve stress or to forget problems (escapism)
- Continuous use of a drug for along time.
- Curiosity and wanting to belong e.g. some one may be eager to know the taste of the drug and also wanting to be accepted in the groups of drunkards
- Genetics some are drunkards from generation to generation of grand parents.
- Availability of drugs, Easy access to drugs perhaps can lead many into the vice.
- Work pressure.
- Weak laws
- Irrational drug use
- Recreational purpose
- ADHD in children.
- Pear pressure
Effects of narcotics
Addiction and dependence- is a complex set of behaviors typically associated with misuse of certain drugs, developing over time and with higher drug dosages. It is divide into physical and psychological.
- Physical dependence: is when a person stops using narcotics and develops withdrawal symptoms.
- Psychological dependence: using the drug for personal satisfaction even if the risks are known to the user.
- Tolerance– decreased response to the drug where increased dosage leads to achieving the desired effect.
The effects of narcotic abuse are;
- Cognitive impairment.
- Opioid hyperalgesia
- Infection at the injection site.
- Transmission of infections like HIV, HEPB
- Nausea and vomiting.
SIGNS OF NARCOTIC DEPENDENCE
- Ingestion of large amount /tolerance.
- Presence withdrawal symptoms
- Shallow breath constipation
- Nausea and vomiting.
- Reduced recreation activities
- Small pupils
- Slurred speech.
SIGNS OF WITHDRAWAL
- Abdomen cramp.
- Yawning running nose.
- Muscle ache.
- Wide pupils.
- Lack of appetite
- Mental status effects include euphoria, sedation, decreased anxiety, a sense of tranquility, and indifference to pain produced by mild-to-moderate intoxication. Severe intoxication can lead to delirium and coma.
- Physiological effects:
- Respiratory depression (may occur while the patient maintains consciousness)
- Alterations in temperature regulations
- Hypovolemia (true as well as relative), leading to hypotension
- Needle marks or soft tissue infection
- Increase sphincter tone (can lead to urinary retention)
TREATMENT OF NARCOTIC OVER DOSE:
- The patient with narcotic over dose may be brought to emergency unit unconscious with other signs like constricted pupil
- Collateral history and urine test may guide in making decision
- Give naloxone 1.V which reverses the effects of narcotics in 1-5 minutes substituting the irrational drug with methadone.
TREATMENT OF WITHDRAWAL SYMPTOMS:
- Clonidine relieves symptoms of withdrawal such as salvation, running nose, sweating, muscle ache.
- Clonidine can be used together with naloxone which is along acting narcotic antagonist that produces rapid detoxification
- Narcotic abuse group and counseling.
- Health education of patients about narcotics.
- Maintain lock and key for the drugs.
- Allow the patient to express their feelings about the drug and advice accordingly.
- Avoid long term therapy of narcotics.
- Strict suppression of patients on narcotics.
Nursing responsibility during administration of narcotics
Narcotics are regulated by the federal law, the nurse must record the date, time, clients name, type and amount of the drug used and sign the entry in a narcotic inventory sheet, if the drug must be wasted after it is signed out, the sct must be witnessed and the narcotic sheet signed by the nurse and the witness. Computerized narcotic documentation method are also available.
- Keep narcotic antagonists such as naloxone, readily available to treat respiratory depression
- Assess allergies or adverse effects from narcotics previously experienced by the client.
- Asses for any respiratory disease such as asthma that might increase the risk of respiratory depression
- Asses the characteristics of pain and the effectiveness of drugs that have been previously used to treat pain
- Take and record baseline vital parameters before administering the drug.
- Administer the drug following established guidelines.
- Monitor vital signs and the L.O.C, pupilary response, nausea, bowel function, urinary function and effectiveness of pain management
- Teach non-invasive methods of pain management for use in conjunction with narcotic analgesics, this is to avoid narcotic overuse
Client and family teaching
- The use of narcotic to treat severe pain is unlikely to cause addiction.
- Do not drink alcohol.
- Do not take over the counter medications unless approved by the health care provider.
- Increase intake of fluids and fiber in the diet to prevent constipation.
- The drugs often cause dizziness, drowsiness and impaired thinking. Use with caution when driving or making decisions.
- Report decreasing effectiveness or the appearance of the side effects to the physician.
Treatment is multistage process
- Assess the patient through the WHO criteria of CAGE (
- a). Cut down
- (b). Annoyed
- (c). Guilty
- (d). Eye opener
- Detoxification: patient should be motivated and helped to appreciate the disadvantage of alcohol use.
- (a). Drugs include: Chlordiazepoxide 25mg three times a day or diazepam or haloperidol in large doses.
- (b). Carbamazepine to guide against seizures or convulsions. 200-400mg b.d
- (c). Vitamin B complex or multivitamins
- Motivational counseling
- (a). Show the patient that he has a problem
- (b). With the help of the person identify the cause of the problem and try to eliminate it if possible.
- (c). Help the person to solve the problem.
- Prevent relapses
- (a). Observe any change in behaviour
- (b). Any sign of craving for the substance
- (c). Ensure the client does not get access to the substance
- (a). Treat any complications
- (b). Provide proper nutrition especially protein foods for building damaged tissues
- Social reintegration:
- (a). Encourage community or social support from the friends, families or communities as much as possible
- (b). Encourage the client to join alcohol anonymous groups or any supportive groups.
- Group therapy and Counseling :
- (a). Help client to manage difficult feelings and situations related to the use of substance.
- (b). Encourage the client to be assertive.
- (c). Identify relaxation techniques and use of leisure time
- (d). Present materials associated with substance abuse and their effects in the body.
- Vocational rehabilitation:
- Train the client in simple activities to keep busy and earn his or her
- Health education
- (a). Create awareness about the dangers of alcohol use
- (b). Encourage effective coping mechanism not through the use of alcohol
- (c). Taking drugs as prescribed
- (d). Share feelings and problems with people.