Response to Prof Davis and Cherie’s Posts

Response to Prof Davis and Cherie’s Posts

Hello Prof Davis

Tapering drugs is a systematic process involving a gradual decrease of medication content administered to a patient until the complete withdrawal of medication is administered to help the patient’s body adjust to the discontinuation of drugs. Such drugs are dangerous if discontinued abruptly (Basińska-Szafrańska, 2021). They pose severe side effects to a patient if the medication is not gradually reduced until the body adapts to the loss of the medicine. The process systematically helps the body adapt to withdrawal symptoms associated with such drugs.

Examples of drugs that require tapering to avoid associated dangerous symptoms include Clonidine, Venlafaxine, Topiramate, Gabapentin, and Prednisone. Gabapentin is tapered within one week at the rate of about 300mg after four days. Topiramate is phased out by tapering to 25 mg/day and increasing the tapering every week until total discontinuation. Venlafaxine is phased out by reducing the dosage to 25 mg/day for five to seven days, then further tapering from 25 to 50 mg/day until total discontinuation. Clonidine is phased out by reducing by 50% of the dosage within two to four days, then further tapering by 0.1 to 0.2 mg/day until total discontinuation. Finally, Prednisone is phased out by decreasing 5mg/day of the 40mg dosage until the dosage reaches 20mg/day, followed by increments of 2.5mg/day until the 10mg/day dosage. At 10mg/day dosage, tapering is done in increments of 1mg/day until total discontinuation.

Hello Cherie

Thank you for your intriguing discussion on the ML case patient; it’s very informative. A premise to the perception of the patient’s current regimen for chronic pain management is that the use of gabapentin coupled with opioids like Norco 5/325 mg presents a severe health risk and raises a red flag (Dydyk et al. 2021). I agree with the possible alternatives provided, and in addition, I would recommend regular physical exercise.

Moreover, I agree with the alternative screening technology because it facilitates early intervention for the patient’s risk of contracting drug abuse disorders apart from managing chronic pain. It, however, presents a dilemma over the appropriate communication strategies to address the patient’s drug addiction concerns, given that she is elderly. To help her, cultural sensitivity and diversity skills are needed to help create an excellent environment to address the problem. The example of a pain contract is good, and how you explain it is informative. Through the case of a patient, I enhanced my knowledge about safe prescriptions. You have appropriately demonstrated the concept of recording prescriptions in the state registry regarding schedule II and III medications, including the protocol expected within restricted states.

References

Basińska-Szafrańska, A. (2021). Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring. European Journal of Clinical Pharmacology, 77(6), 795-808.

Dydyk, A. M., Sizemore, D. C., Trachsel, L. A., Conermann, T., & Porter, B. R. (2021). West Virginia Opioid Prescribing For Chronic Pain While Avoiding Drug Diversion. StatPearls [Internet].

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1. PROF DAVIS
There are certain drugs that must be tapered when used long-term. If these medications are stopped abruptly, they can cause serious side effects. For example, if benzo is used long-term and stopped abruptly, it may cause seizures. Please provide 5 examples of medications that must be tapered (not including benzos) and describe the mechanism of action of these medications.

Response to Prof Davis and Cherie’s Posts

2. CHERIE
Question #1

When reviewing ML’s medical history, there are a few red flags with her current pain management plan. Considering ML’s injury happened ten years ago, her pain is classified as chronic. The interaction of gabapentin with opioids and benzodiazepines is one of my concerns. Although this combination can be used to manage chronic pain, studies have shown that the enhanced effects of gabapentin on CNS depressants increase the risk of respiratory depression, emergency room visits, overdose, and death (CDC, 2016). In terms of alternative treatments, because ML’s physical exam was unremarkable with the exception of right shoulder pain with full range of motion, physical therapy could be a viable option to prescribe pain medication. Another option is to utilize non-opioid drugs to treat pain caused by inflammation, as well as a referral to orthopedics for possible steroid injections (Cook et al, 2018).

SBIRT is an excellent screening technique for clinicians to use. SBIRT is a public health method to provide early intervention and treatment services for those who have or are at risk of acquiring drug use disorders, as well as those who are at risk of developing these disorders (SAMHSA, 2020).

In terms of ethical and legal concerns for ML, the goal is to successfully manage her pain while avoiding fostering substance usage or addiction. Despite the fact that she only drinks alcohol on occasion, her drugs may cause respiratory depression. All risks, benefits, potential side effects, and interactions should be explained to ML. The need for education to ensure that the drug is used safely cannot be overstated.

Question #2

https://www.fda.gov/media/114694/download (FDA, n.d).

Question #3

Safe prescribing requires the use of a pain contract, drug education, and the avoidance of polypharmacy. The use of the EMR (electronic medical record) also helps providers safely prescribe to help identify drug interactions with polypharmacy and reduce the occurrence of fraudulent prescriptions (Scott et al., 2018). As a future provider in the state of California, I would utilize the California database for scheduled medications to ensure the patient is not being prescribed controlled medications by multiple providers (CURES, 2022).

Question #4

Losartan, Gabapentin, and Atorvastatin can be continued as needed, but Diazepam and Norco are not available to be refilled. Schedule II medicines cannot be refilled; each period, ML must obtain a new prescription (CURES, 2022).

Question #5

Class II and III drugs cannot be prescribed unless the patient has been examined and determined to be in a life-threatening situation. The prescriber has the option of ordering no more than a 120-day supply if the patient is assessed to have an acute medical condition at the time of the assessment (Kenny & Preuss, 2021). Refilling a prescription for a Class II or Class III drug is not possible. Each time, a new prescription is necessary.

Question #6

Assembly Bill (AB) 2789 mandates that all prescriptions written by a licensed prescriber be written electronically starting January 1, 2022, in the state of California (State of California, 2021). The date of issue, the patient’s first, last, and current names and addresses, date of birth, clinician’s name, address, and DEA number must all be included on prescriptions for controlled substances. Finally, the prescription should include the drug’s name, strength, dose form, pill count, usage instructions, number of refills, and the prescriber’s signature (Kenny & Preuss, 2021).

Question #7

An NP can order controlled substances in California, but there are certain educational qualifications that must be met. The NP can then obtain and use a provisioning number, which will allow medications and medical supplies to be ordered (Board of Registered Nursing [BRN], 2004).

https://www.rn.ca.gov/pdfs/applicants/npfinstruct.pdf