Discussion w3 652

Q-1

Opioid dependence must be identified when patients come in for medication reviews or by a drug search. It is reasonable to assume a patient who has been on the maximum or exceeded the maximum recommended dose of an opioid analgesic continuously should be assessed further. A patient assessment can be carried out by any of the practice clinical staff: GPs, advanced nurse practitioners, mental health practitioners, clinical pharmacists, and practice nurses with relatively little additional training. However many providers do not feel confident, trained, or experienced in managing drug dependence. Opioid dependence is suggested by the factors such as overt drug-seeking behavior, lost or misplaced prescriptions, frequent requests for additional medication, use of additional over-the-counter medication, requests for medication for out-of-hours medical services, walk-in centers, or other surgeries and a previous history of drug or alcohol dependence (Becker & Liebschutz, 2018). Thus my response would be to ask how often is he taking his OxyContin, review the prescribed dosage, emphasis how long the prescription should last him, and ask how history of previous addiction. I would then offer non-narcotic alternatives, assist to find alternative ways to cope with chronic pain and stress which may be contributing to his pain and refer to pain clinic if needed.

Becker, W. C., & Liebschutz, J. M. (2018). Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study. Journal of general internal medicine, 33(2), 166–176. https://doi.org/10.1007/s11606-017-4211-y

Q-2

In this scenario, the patient’s appropriate treatment involved a multitude of therapies to appropriately treat the underlying cause (Azadfard, Heucker & Learming, 2020); (Wolfe, 2021); (Shah & Heucker, 2021). With this patient presentation I believe he is currently withdrawing from his recent abuse of opioids, and would need to have that addressed appropriately prior to entering a post-acute facility rehabilitation center (Azadfard, Heucker & Learming, 2020); (Wolfe, 2021); (Shah & Heucker, 2021). With this being said I would like to admit him to the hospital for investigation of his abdominal pain and withdrawl symptoms (Azadfard, Heucker & Learming, 2020); (Wolfe, 2021); (Shah & Heucker, 2021). I would also order Zofran 4mg IV Q6 PRN nausea, but also an EKG to check his QT prolongation due to his other home medications as well as combining it with methadone (Shah & Heucker, 2021). I would also want to order a non-contrast CT Scan of his abdomen due to his intractable abdominal pain as it may be an ileus due to the recent abuse of opiates (Beach & De Jesus, 2021).

I would like to consult Neurosurgery to see if there is anything they can provide from a surgical standpoint or treatment management. I would also like to consult psychiatry for the patient’s admittance of opioid addiction and abuse and an appropriate treatment plan (Azadfard, Heucker & Learming, 2020).

The patient’s signs and symptoms of nausea, vomiting, abdominal pain, intermittent piloerection and diaphoresis are some cardinal signs of opiate withdrawal (Shah & Heucker, 2021). The recommended treatment for this is to begin a weaning course with methadone beginning at 10mg dose every 4-6 hours and weaning it as tolerated (Shah & Heucker, 2021). In Florida, ACAGNP are able to prescribe Schedule II-IV as defined in Florida Statues, including methadone, however the drawback is that they can only be prescribed by an NP in the acute-care facility (Important Legislative Update regarding HB 423, 2016).

Since the patient has admitted to an addiction issue, as well as wanting help we still have to go through the normal process of reporting healthcare provider prescription abuse (Impaired Practitioner Programs, 2021). On the other hand, he admits to abusing his own prescriptions, but does not state when he uses and abuses such as being at work and unable to function. Ethically we should report him regardless as he is responsible for the safety of others as an ACNP. In Florida, there are impaired practitioners programs that help all ranges of providers get through this exact issue and should be provided to the patient (Impaired Practitioner Programs, 2021).

 

 

 

References:

Azadfard, M., Huecker, M.R., Leaming, J.M.(2020). Opioid Addiction. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK448203/

Beach, E.C., De Jesus, O. (2021). Ileus. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK558937/

Impaired Practitioner Programs. (2021). Florida Board of Health, Medical Quality Assurance. Retrieved from: https://flhealthsource.gov/board-members-impairment-programs

Important Legislative Update regarding HB 423. (2016). Florida Board of Nursing. Retrieved from: https://floridasnursing.gov/new-legislation-impacting-your-profession/

Wolfe, D. (2021). "Biotechnologies and the future of opioid addiction treatments". The International journal of drug policy (0955-3959), 88 , 103041.

Shah, M., Huecker, M.R. (2021) Opioid Withdrawal. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK526012/

Q-3

Ethically and professionally, what are your concerns for this patient and his own ACNP practice? What resources are available to you as a prescriber to track this patient's opioid use/abuse? What resources are available to a provider of medical care who suffers from addiction?

Substance abuse by medical professionals raises many concerns, including significant legal consequences and threats to patient care. This patient is at high risk for making procedural errors, wrong diagnoses, and prescribing improper medications. The chance of going through withdrawal also makes him a threat to his patient’s safety. Bartlett et al. (2017) explain that healthcare professionals who use opioids are at a significantly higher risk of relapse than the general population, requiring more intensive post-treatment monitoring and continuing care recovery plans.

Like most states, New Mexico requires reporting health practitioners suspected of impairment. I would have an ethical, moral, and legal duty to identify and report a fellow healthcare worker who is impaired and risking patient safety. Luckily there are many helpful resources such as state-run professional associations that assist professionals who have substance abuse problems. The New Mexico Health Professional Wellness Program for instance provides a number of services including substance use issues as well as medical, psychiatric, emotional, or situational stresses. Other resources include the International Doctors in Alcoholics Anonymous, New Mexico Medical Board, and NM Medical Society (New Mexico state board of nursing, 2019).

 

Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2017). Harm reduction: compassionate care of persons with addictions. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses, 22(6), 349–358.

D'Souza, R. S., Lang, M., & Eldrige, J. S. (2020). Prescription Drug Monitoring Program. In StatPearls. StatPearls Publishing.

Marie, B. S., Sahker, E., & Arndt, S. (2015). Referrals and Treatment Completion for Prescription Opioid Admissions: Five Years of National Data. Journal of substance abuse treatment, 59, 109–114. https://doi.org/10.1016/j.jsat.2015.07.010

New Mexico state board of nursing. (2019). Retrieved March 25, 2021, from https://www.nmsbon.gov/discipline-and-complaints/alternative-to-discipline