Opiate Prescribing Guidelines

Assessment Description

The purpose of this assignment is to apply opiate prescribing guidelines in individual nursing practice. You are required to interview a pharmacist to complete Part Three of this paper. Write a 1,500-2,000-word paper that addresses the following:

Part One

Using the “2018 Arizona Opioid Prescribing Guidelines” in the topic Resources, describe how you would incorporate the prescription guidelines into your practice when caring for patients, communities, and populations. In your description provide a patient scenario for the following:

• Summary Guidelines for the treatment of acute pain versus chronic pain 
• Elaborated Guidelines for the treatment of acute pain and chronic pain 

Part Two

Review the “How to Implement These Guidelines Into Clinical Flow” section of the “2018 Arizona Opioid Prescribing Guidelines” in the topic Resources. Describe how you would implement the guidelines into your clinical practice, and provide a patient scenario that addresses the following:

• Implement these guidelines into clinical flow.
• Manage an “inherited patient” on opioid therapy.
• Evaluate patients for opioid disorder.
• Connect patients with medication-assisted treatment.
• Approach an opioid exit strategy.
• Manage pain and opioids in special populations.
• Connect with local and national resources.
• Correct clinical misperceptions about opioids.

Part Three

Interview an outpatient pharmacist. If possible, shadow the pharmacist. Discuss the following in your interview:

• What key elements must be included in a prescription for scheduled medications?
• Do you treat Scheduled II in the manner as Scheduled III-V? What is the difference between Scheduled II-V drugs?
• What are the main issues you see with problematic opioid prescriptions that could have been prevented by the prescriber? What issues do you find yourself calling the provider for?
• What are the barriers or issues that would prevent a patient from receiving their opioid prescription?
• In your opinion, how would we improve the opioid prescription process between the provider, pharmacy, and patient?
• How does a pharmacist incorporate a prescription monitoring program (PMP) in their daily practice?
• Describe the components of the PMP including milligram morphine equivalent (MME).

You are required to cite three to five sources related to interprofessional collaboration to complete this assignment. Sources must be published within the past 5 years and appropriate for the assignment criteria and nursing content.

Prepare this paper according to the guidelines found in the APA Style Guide, located in the Student Success Center. 

This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

                                                                Please view the explanation and answer below.         

 

 

Opiate Prescribing Guidelines.

 

 

Your name

Instructor’s name

Course Name and Code.

Date of submission

PART ONE.

Summary Guidelines for Acute Pain vs. Chronic Pain

            In Arizona, the guidelines for both acute and chronic pain essentially represent two divergent approaches. Acute pain from either injury or surgery, by definition, is short-lived. Therefore, the dosage and duration of the opioid should be limited. Most acute pains can be treated appropriately with a non-opioid medication like NSAIDs or acetaminophen. If opioids are prescribed, they are indicated only when non-opioid alternatives are inadequate and, even then, should be prescribed for the shortest duration, usually no more than five days. Whereas chronic pain extends beyond the normal healing time, 90 days needs a more holistic and multidisciplinary approach. Guidelines recommend the use of opioids in the management of chronic pain only when non-pharmacologic and non-opioid pharmacologic treatments have been tried and judged to be inadequate. Even in cases where opioids are being prescribed for chronic pain, it is desirable that patients should be kept under close monitoring, and opioids must not be used as the first-line treatment.

Acute Pain

            A 30-year-old woman comes into the emergency department with a second-degree burn to her hand from cooking. In treating her acute pain, the first-line intervention that the nurse practitioner would have is the initial use of non-opioid analgesics such as ibuprofen or acetaminophen and topical treatments based on considerations that will alleviate discomfort. If these measures were not sufficient for pain control, a short course of an opioid, for example, oxycodone, would be prescribed for no longer than three days. The patient would be educated on opioid risks, appropriate use, and the need to taper as soon as tolerable. In this scenario, opioids are the last choice, not the first line of treatment.

Chronic Pain

            Suppose non-opioid treatments such as gabapentin, lifestyle adjustments, and physical therapy are not sufficiently helpful for a 50-year-old man with diabetic neuropathy who has been experiencing painful legs for over a year. In that case, the nurse practitioner may try an opioid, perhaps beginning with a low dose of tramadol, but only after extensive patient education about the risks of long-term opioid use. Regular follow-up would be done at a point in time when an assessment for the efficacy and safety of opioid therapy is conducted. This would include consideration of the eventual transition to non-opioid pain management strategies as part of a comprehensive, multidisciplinary approach.

Explicated Guidelines for Acute and Chronic Pain

            Building on these general summary principles, the elaborated guidelines go on to address issues on the precision of prescribing opioids. For example, regarding the treatment of acute pain, prescribers are cautioned not to use long-acting opioids due to their potential for high dependency. Additionally, it is prudent that clinicians avoid prescribing opioids if the patients have a history of substance use disorder. In terms of chronic pain, providers are to regularly reassess the patient’s pain levels and overall functionality for whether continued opioid therapy is necessary and to explore opioid exit strategies when appropriate.

PART TWO

Implementing Guidelines into Clinical Flow

            Clinicians should create systems that provide checks and balances to ensure compliance with recommended prescribing practices and to make opioid prescribing guidelines widely integrated into day-to-day clinical practice. One of the best ways this can be achieved is through embedding decision-support tools into the system EHR. For example, upon a clinician’s prescribing of an opioid, an automated alert might remind the provider of the state’s opioid prescribing guidelines, such as the maximum recommended dosage, or to check the patient’s PMP record. Further, clinics may use pain management protocols that employ a multimodal approach, relegating to non-opioid therapies when possible. Education and training of staff on opioid risks, misuse, and overdose prevention should also be common. By incorporating guidelines into the clinical workflow, providers can minimize risks associated with opioid prescribing and ensure safety for the patient while improving outcomes.

Managing an Inherited Patient on Opioid Therapy

            A 62-year-old woman with chronic back pain from spinal stenosis presents to the new clinic, already taking 120 mg of morphine equivalent daily. The provider follows the guidelines, checking the PMP to review her opioid use history; she then conducts a thorough assessment of her pain levels, functionality, and risks for opioid misuse. With this plan, the provider recommends that she be weaned off the opioids gradually. Non-opioid modalities like physical therapy and CBT will be started for pain management. Throughout the course of the taper, a keen eye will be paidto withdrawal symptoms or an exacerbation of pain for which a downward readjustment in the tapering schedule can be made accordingly.

Opioid Disorder Screening

            The Arizona guidelines emphasize regular monitoring of patients who are undergoing opioid therapy to detect early warnings of OUD. Screening tools, including the ORT or the SOAPP-R, may be carried out to assess the risk of misuse of opioids prior to and during opioid therapy at regular intervals. Any patient showing any signs of abuse, such as requesting refills early or showing addictive behavior, should be further evaluated and considered for alternative treatments.

Connecting Patients to Medication-Assisted Treatment (MAT)

            Such patients who are identified to suffer from OUD must be referred for MAT programs. The “whole-patient” approach is necessary for this, which includes FDA-approved medicines like methadone, buprenorphine, or naltrexone, in addition to counseling and behavioral therapies. It is now important for providers to become well aware of the MAT programs in their locality. Similarly, addiction specialists also need to be worked with in order to ensure that proper care is provided to the patients.

Approaching an Opioid Exit Strategy

            Opioid tapers are important in the course of patients where opioids are no longer indicated for pain syndrome or are highly suspicious of OUD. This includes a slow and safe opioid taper while introducing other techniques for managing pain, including NSAIDs, physical therapy, and CBT. The goals of opioid tapering are to avoid withdrawal symptoms and maintain pain control(Baumbauer et al., 2019). A clinician may generate a written tapering schedule in which opioid dose is decreased by 10% weekly and nonopioid treatment for pain is gradually added.

Pain and Opioid Management in Special Populations

            Special populations include, but are not limited to, the elderly, pregnant women, and individuals with co-occurring psychiatric disorders; these patients deserve caution in the process of opioid prescription(Baumbauer et al., 2019). For example, among renal-impaired elderly patients, the metabolism of opioids may be impaired, leading to overdose or other adverse side effects. In these patients, providers should use the lowest possible effective dose, avoid long-acting opioids when appropriate, and closely monitor any signs and symptoms of opioid toxicity.

Connection with Local and National Resources

            Linking the patients to various local and national resources like pain management clinics, addiction recovery programs, and overdose prevention services provides additional support to patients with chronic pain problems or opioid misuse. The national resources include the CDC and SAMHSA, which also provide guidelines and toolkits that health providers can use in improving opioid prescribing practices.

Correcting Clinical Misperceptions About Opioids

            This may be one of the main reasons: the belief that opioids constitute the best choice for pain treatment is thus consolidated and leads to overtreatment. Research says the opposite; other classes of medications, such as NSAIDs and acetaminophen, can sometimes be equally effective but less dangerous. The education of patients and clinicians about the effectiveness of non-opioid treatments will help health professionals adopt a new model of care in which opioids are de-emphasized as the default treatment for pain.

PART THREE.

Elements of a Prescription for Scheduled Medication.

            The interviewee was made aware that, with regard to prescribed scheduled medication, there are elements a prescription should contain to make it valid. These include the full legal name of the patient, their date of birth, the prescriber’s full name and address and telephone number with the DEA number, the drug name, dosage, and quantity, and instructions for use(Preuss et al., 2023). Schedule II drugs, such as oxycodone or fentanyl, are required to be written on tamper-resistant prescription pads, and the prescription must be signed by the prescriber. Verbal and faxed prescriptions are not allowed for Schedule II medication, though it is allowed for Schedule III-V under very specific conditions. He further emphasized the written duration for use and the total quantity, in numeric and written form, to avoid alternation or misunderstandings.

Differences between Schedule II and Schedule III-V drugs

            While highlighting the difference between Schedule II and Schedule III- V drugs, the pharmacist underlined that Schedule II drugs have high abuse and dependency rates, hence, under stringent laws that regulate prescription. For example, Schedule II drugs are not refillable, and a new written prescription must be presented each time. This class of drugs is highly controlled due to their addictive capabilities, and the pharmacist should be very careful when it concerns dispensing such medications. In contrast, Schedule III-V drugs, such as tramadol or products containing codeine, have less potential for abuse and can be refilled up to five times within a six-month period from the date the prescription was initially written. She emphasized, however, that even though Schedule III-V drugs are less dangerous, they must nevertheless be closely monitored for the possibility of abuse.

Abuse of Problematic Opioid Prescriptions

            The pharmacist identified several of the common issues that occur with opioid prescriptions, most of which could have been prevented by the prescriber. One of the main problems is incomplete or vague information, such as missing patient identifiers, inappropriate dosing, or unclear instructions as to the frequency of administration. These findings usually require a follow-up call to the provider for clarification. Another problem that has come into sight is prescribers not querying the PMP prior to writing the prescription, with patients sometimes receiving opioids from more than one provider at a time, a situation that heightens the risk of an overdose. “In too many instances,” he said, “opioids are prescribed in quantities greater than the ailment would warrant, increasing the potential for abuse or diversion. To resolve these problems, the pharmacist is frequently tasked with communicating with the prescriber to request adjustments to the dose or clarification of directions for administration to the patient.

Barriers to Patients Receiving an Opioid Prescription

            The pharmacist discussed some of the issues that might prevent patients from receiving an opioid prescription. One of the main issues is insurance approval, which may be necessary for long-term opioid use. This process can lead to a waiting period for the patient before he or she can get his or her medication. Other complications include state regulations, such as limits on the quantity of opioids that can be prescribed, which may lead to pharmacies declining to fill prescriptions that exceed those limits without documentation supporting the higher dose(Preuss et al., 2023). Sometimes, patients have difficulty accessing their prescriptions; at times, smaller pharmacies do not stock a particular opioid, and at other times, pharmacies simply do not want to fill prescriptions for high-dose opioids out of fear of regulatory scrutiny. For example, patients labeled as high-risk by the PMP may experience delays or denials in filling opioid prescriptions.

Improving the Opioid Prescription Process

            The opioid prescription process can be improved for both the provider and the pharmacy as well as for the patient if communication and collaboration between the parties involved are better. One recommendation includes increasing the rate of e-prescribing for controlled substances to reduce errors in handwritten prescriptions and allow for the provision of all the required information. The pharmacist also recommended that the prescriber make more consistent use of the PMP, which would allow them to identify potential issues sooner, such as having multiple prescriptions from different providers. This could also help improve patient education on the risks of opioids and proper use of the medications, in itself having the potential to decrease misuse. Other recommendations include developing a standard opioid prescription form that would prompt the prescriber to determine if opioid therapy is needed, discuss risk with the patient, and document other pain management alternatives tried.

Incorporating Prescription Monitoring Programs (PMPs) into Daily Practice

            He explained that the PMP constitutes part of their practice daily in the dispensing of controlled substances. For every opioid prescription, the pharmacist is supposed to review the patient’s record from PMP to look for any red flags that may indicate misuse of opioids, including the issuance of numerous prescriptions by doctors and multiple or concurrent prescriptions of controlled substances(Kenny &Preuss, 2024). The PMP also allows the pharmacist to check the patient’s history of prescription for suspicious patterns, such as questionably high opioid use or too frequent early refill requests. In that case, where opioid misuse is suspected, the pharmacist might prefer calling the prescriber or could refuse to fill the prescription if it were risky to the patient. This PMP system protects against opioid diversion and overprescribing; thus, this system supports the safer use of opioids.

Components of the PMP and Milligram Morphine Equivalent (MME)

            The components of the PMP were further elaborated on by the pharmacist as one statewide electronic database that monitors every controlled substance prescription in opioids. Another critical feature is MME determination by the PMP system because this is the standard method whereby the potency of opioids may be compared. Thus, the conversion of prescribed doses of opioids into MME would allow the PMP system to provide a summary of the total opioid burden on the patient to the pharmacist or prescriber. This is where the pharmacist pinpointed that guidelines recommend exercising caution when the total daily MME exceeds 50 and significant overdose risk when it exceeds 90. Having this information at hand allows the pharmacist to also counsel the patient on risks associated with high opioid dosage, thus supporting alternatives or tapering when appropriate.

References.

Arizona Department of Health Services. (2018). ARIZONA OPIOID PRESCRIBING GUIDELINES 2018. https://www.azdhs.gov/documents/audiences/clinicians/clinical-guidelines-recommendations/prescribing-guidelines/az-opioid-prescribing-guidelines.pdf

Baumbauer, K. M., Young, E. E., Starkweather, A. R., Guite, J. W., Russell, B. S., &Manworren, R. C. B. (2019). Managing Chronic Pain in Special Populations with Emphasis on Pediatric, Geriatric, and Drug Abuser Populations. Medical Clinics of North America, 100(1), 183–197. https://doi.org/10.1016/j.mcna.2015.08.013

Kenny, B. J., &Preuss, C. V. (2024, January 9). Pharmacy Prescription Requirements. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538424/

Preuss, C. V., Kalava, A., & King, K. C. (2023, April 29). Prescription of Controlled Substances: Benefits and Risks. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537318/