De-Prescribing

Patient 1

The Patient’s Concerns about the Opioid Medication and Clonazepam

The main concern about his nonstop use of both clonazepam and opioids is the possibility of respiratory depression, oversedation, and cognitive dysfunction because both belong to CNS depressants and have an increased probability of an overdose. The adverse effects of chronic benzodiazepine intake include dependence, memory loss, and impairment of psychomotor functions, which in turn contribute to falls and fractures (Edinoff et al., 2021). Another point of concern as a result of opioid use is opioid-induced hyperalgesia, where the use of opioids worsens pain sensitivity: De-Prescribing.

Patient Education

To teach a patient, I would explain to him that one cannot take both opioids and benzodiazepines since they lead to overdose and affect thinking in the process. In emphasizing why the medication is used only in the short term, I would explain that clonazepam is known to have signs and symptoms of withdrawal and that he can become dependent on it (Basit & Kahwaji, 2023). The permissible withdrawal syndromes are rather critical, and any attempts to quit taking the substance suddenly might cause seizures, paranoid attacks, and autonomic dysregulation. Besides, I would educate the patient on other available treatments, which include CBT, mindfulness, and non-benzodiazepine drugs, which are safer and effective in treating anxiety in the long run.

Instructing to Taper Off Clonazepam

He should stop taking clonazepam gradually to prevent very severe withdrawal symptoms. The first-rate reduction method is 10-25 % every 2-4 weeks as he tolerates it. If he receives 1 mg BID, I would taper it down to 0.75 mg after two weeks, lower it to 0.5 mg BID, and then decrease it until no prescription is given (Reid Finlayson et al., 2022). If the symptoms of withdrawal become unbearable, I will reduce the dose further and gradually. I would also find it helpful to apply CBT to support the patient in overcoming anxiety during this process.

Alternative Medication for Panic Attacks

Since he will be on opioids for the management of pain, it is appropriate to prescribe an alternative treatment for panic attacks, which is not a benzodiazepine. Selective serotonin reuptake inhibitors (SSRIs), such as sertraline or escitalopram, would be my first choice because they are effective in the long term and are not addictive (Chu & Wadhwa, 2023). Buspirone would also be a consideration for a patient who is apprehensive about SSRI-related side effects.

Starting the New Recommended Psychotropic Medication

When introducing sertraline, I would initiate a low daily dosage of 25 mg and titrate over weeks to the desired level (50-100 mg). I would titrate the drug slowly and gradually to maintain initial side effects such as headaches, nausea, and transient anxiety worsening at a low level (Singh & Saadabadi, 2023). I would observe the patient closely to confirm tolerance and desired therapeutic effect. If there is a persistent side effect and a sub-optimal response, I would switch to a second SSRI or adjust the dosage accordingly.

One Legal, Ethical, or Social Consideration with the Treatment Plan

Ethically, I am obligated under non-maleficence to see that the patient is not harmed in treatment. While tapering is necessary with the benzodiazepine, I would do so in a way that prevents withdrawal and panic disorder relapse. Legally, I would need to prescribe by controlled substance practice in order not to cause misuse and diversion (Olejarczyk & Young, 2024). Socially, I would appreciate it if the patient would care about how adjustment in medications would impact his anxiety and daily functioning.

Patient 2

Alprazolam’s Common Withdrawal Symptoms

Alprazolam withdrawal is complicated because the drug has a brief half-life. Rebound anxiety, agitation, insomnia, irritability, muscle tension, headaches, dizziness, nausea, palpitations, and excessive sweating are the typical symptoms. Severe symptoms are panic attacks, tremors, hallucinations, extreme agitation, confusion, and, in extreme conditions, even seizures (George & Tripp, 2023). Due to the severity of the withdrawal, I would have a planned schedule to stop safely.

Patient Education

I would inform her about the entire array of symptoms of withdrawal, mild and severe. I would tell her that mild symptoms such as irritability, insomnia, nausea, and anxiety are inevitable and are mostly transient with adjustment in the body. Severe symptoms such as confusion, hallucinations, and seizures are medical conditions and need medical attention (Newman et al., 2024). I would reassure the patient that a slow and graded reduction would substantially decrease the severity of withdrawal and that other treatments, such as CBT, would address anxiety symptoms in the process.

Conversion Strategy

Since she has had severe withdrawal symptoms from alprazolam while in a taper, the patient is changed to a long-acting benzodiazepine like diazepam. Diazepam has a longer half-life and is characterized by a smoother and milder withdrawal. The conversion rate is approximately alprazolam 1 mg and 10 mg of diazepam (Dhaliwal & Saadabadi, 2023). If she is taking 1 mg BID alprazolam (total daily 2 mg), I would cross her over to diazepam 10 mg BID. Depending on her tolerance and symptoms, it would be done in 2-5 mg steps, with a 1-2-week interval.

Patient 3

Potential Risks, Benefits, and Side Effects of Continuing Lorazepam

Lorazepam is known to cross the placenta freely and is known to cause disabilities of congenital, symptoms of neonatal withdrawal, and developmental issues. Postdelivery, it is secreted in the mother’s milk and results in sedation, feeding problems, and respiratory depression in infants. Although anxiety is successfully treated with lorazepam, the risks usually outweigh the benefits in pregnancy and lactation (Ghiasi et al., 2024).

SSRIs and psychotherapy are better choices in the treatment of anxiety in the long term. If she is on a continued course of lorazepam, fetal monitoring and observation in the neonatal period are required.

Alternative Medications in Pregnancy in Generalised Anxiety Disorder

The two most recommended alternative medicines are fluoxetine and sertraline, as they are safe and efficient to be used in the treatment of anxiety. The SSRI of choice for a woman who is breastfeeding is sertraline because little is secreted in the breast milk (Singh & Saadabadi, 2023). Buspirone, a non-benzodiazepine anti-anxiolytic, is a second option but is not helpful in panic attacks. Cognitive-behavioral therapy (CBT) is a highly recommended treatment because it is equally effective in lowering anxiety without exposing the patient to medications.

Recommendation on Discontinuing Lorazepam

To prevent symptoms of withdrawal, I would employ a slow reduction method, lowering lorazepam in a stepwise reduction of 10-25% every 1 to 2 weeks. If she takes 1 mg three times a day (TID), I would initially lower the dosage to 0.75 mg TID and later to 0.5 mg TID, with repeated reductions (Ghiasi et al., 2024). I would monitor symptoms of withdrawal, such as headaches, nausea, and agitation, which are usually transient and disappear over a matter of weeks. I also recommend psychological counseling and relaxation exercises to accompany the patient safely through reduction.

Education on the Risks of Untreated Anxiety

I would explain how, if left unchecked, anxiety is not only a risk to fetal and maternal health. Elevated chemicals such as cortisol are linked with early delivery, poor birth weight, and developmental problems. Substandard prenatal care, malnutrition, and post-delivery depression in mother and baby are also a cause of anxiety.

In addition, excessive anxiety in the mother is a cause of impaired bonding and emotional dysregulation in the baby (Akinsulore et al., 2021). I would reassure her that there are treatments available that are efficacious and not a risk to the mother and baby.

Patient 4

The Risks of Continuing the Benzodiazepine

Benzodiazepines such as clonazepam are especially hazardous in older patients, with risks involving cognitive decline, risk of falling, sedation, and benzodiazepine-related dementia. Because the patient is having memory loss and falling, ongoing treatment is quite likely causing these symptoms. Extended usage of benzodiazepines is also a cause of increased risk of fractures because there is impaired coordination (Gress et al., 2020). Extended sedation is a cause of social withdrawal, reduced mobility, and a general decline in functioning.

Evaluating the Patient

To evaluate clonazepam’s effects, I would conduct a comprehensive evaluation, such as a cognitive screen with the “Mini-Mental State Examination (MMSE)” or “the Montreal Cognitive Assessment (MoCA)” and a “Timed Up and Go (TUG)” test to assess balance and risk of fall. I would also examine the patient’s entire medication list because polypharmacy is common in the elderly and could be causing harm (Varghese & Koya, 2024). I would also interview the patient’s daughter because family members are attuned to subtle cognitive and behavioral changes.

Recommending Tapering Off This Medication

A slow taper is needed in order not to provoke withdrawal symptoms and a smooth transition. I would taper the dosage every two to four weeks by 10-25%. If he is on 1 mg TID, I would lower the dosage to 0.75 mg TID for a few weeks and then drop it again (Reid Finlayson et al., 2022).

If there are significant withdrawal symptoms, I would slow down the process. If the patient still requires anxiety treatment, I would switch over to a safer drug, e.g., SSRI, such as escitalopram.

Review of the Common Side Effects

I would explain to him and his daughter the possible symptoms of tapering medication. These are generally mild and include transient anxiety, agitation, mild confusion, dizziness, and insomnia, and these typically resolve with adaptation on lower doses. I would monitor closely, however, for severe symptoms such as severe agitation, hallucinations, severe confusion, and seizure and teach them how and where to seek medical care in case these symptoms occur (Reid Finlayson et al., 2022). Since he is at risk for falls, I would also teach home fall prevention, such as removing home hazards, installing hand bars, and enhancing home lighting.

References

Akinsulore, A., Temidayo, A. M., Oloniniyi, I. O., Olalekan, B. O., & Yetunde, O. B. (2021). Pregnancy-related anxiety symptoms and associated factors amongst pregnant women attending a tertiary hospital in south-west Nigeria. The South African Journal of Psychiatry: SAJP: The Journal of the Society of Psychiatrists of South Africa, 27. https://doi.org/10.4102/sajpsychiatry.v27i0.1616

Basit, H., & Kahwaji, C. I. (2023). Clonazepam. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556010/

Chu, A., & Wadhwa, R. (2023). Selective serotonin reuptake inhibitors. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554406/

Dhaliwal, J. S., & Saadabadi, A. (2023, August 28). Diazepam. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537022/

Edinoff, A. N., Nix, C. A., Hollier, J., Sagrera, C. E., Delacroix, B. M., Abubakar, T., Cornett, E. M., Kaye, A. M., & Kaye, A. D. (2021). Benzodiazepines: Uses, dangers, and clinical considerations. Neurology International, 13(4), 594–607. https://doi.org/10.3390/neurolint13040059

George, T., & Tripp, J. (2023). Alprazolam. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538165/

Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2024). Lorazepam. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532890/

Gress, T., Miller, M., Meadows, C., & Neitch, S. M. (2020). Benzodiazepine overuse in elders: Defining the problem and potential solutions. Cureus, 12(10). https://doi.org/10.7759/cureus.11042

Newman, R. K., Stobart, M. A., & Gomez, A. E. (2024, February 14). Alcohol withdrawal syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441882/

Olejarczyk, J., & Young, M. (2024, May 6). Patient rights and ethics. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538279/

Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D. E., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: an Internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823. https://doi.org/10.1177/20451253221082386

Singh, H. K., & Saadabadi, A. (2023). Sertraline. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547689/

Varghese, D., & Koya, H. H. (2024, February 12). Polypharmacy. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532953/

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What is the importance of de-prescribing? How might you assist a patient to taper from a medication safely or transition to a new medication?

In this Assignment, you will use the following patient examples to write a 5- to 6-page paper on considerations you have for how you might de-prescribe. Support your answers with five (5) evidence-based, peer-reviewed scholarly literature resources outside of Required Learning Resources in this course.

Note: APA style format guidelines will apply.

Patient Examples:

• Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.
• Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.
• Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety as lorazepam has been effective.
• Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”

TO PREPARE FOR THIS ASSIGNMENT:

• Review the assigned Learning Resources for this week. (Attached)
• Review the definitions presented in your text and resources for de-prescribing and tapering.
• Consider the importance of de-prescribing.
• Based on the example(s) provided, consider how you might de-prescribe a patient.

THE ASSIGNMENT
Answer the following questions using the patient examples described above.

Patient 1

• What are the concerns of the patient remaining on the opioid medication and clonazepam?
• How might you educate the patient about these risks and concerns?

The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:

• How would you instruct the patient to taper off clonazepam?
• What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
• How would you start the new recommended psychotropic medication for the patient?
• Discuss one legal, ethical, or social consideration with the treatment plan.
  

  De-Prescribing

Patient 2

• The patient reports withdrawal symptoms when previously tapering off the alprazolam. What symptoms are common withdrawal symptoms from this medication?
• Provide the patient education of withdrawal symptoms that range from common and less serious to withdrawal symptoms that are a cause for concern and that should prompt patient should seek medical attention.
• Given the patient’s history of having withdrawal effects from attempting to taper off alprazolam, what longer-acting benzodiazepine would you choose to convert the patient to?
• What is the dose you would prescribe and how would you taper off the medication?

Patient 3

• Review the potential risks, benefits, and side effects of continuing lorazepam throughout the pregnancy and postpartum for both the patient and fetus.
• Review other alternative medications to treat generalized anxiety disorder. Include risks, benefits, and potential side effects to both the patient and the developing fetus. Keep in mind, the patient is looking to breast feed for 6 months postpartum.
• The patient agrees that it would be safest for her pregnancy and fetus to discontinue the lorazepam. How would you recommend she discontinue lorazepam? Provide education on potential side effects from tapering off the medication, including common side effects to more serious side effects and when to seek medical attention.
• The patient would like to forgo medications at this time, given she is early in her pregnancy and is concerned about “damage” to the fetus if she were to continue medications. Provide education to the patient about the risks of untreated anxiety symptoms during pregnancy for both the patient and the fetus.

Patient 4

• Review potential side effects for elderly on benzodiazepines providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?
• How would you evaluate the patient for these side effects?
• The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?
• Review with the patient and daughter potential side effects of tapering off the medication. Review with them common side effects to more serious side effects and when to seek medical attention.