My concerns with MLs current regimen are the use of controlled substances, for a prolonged period. These drugs are intended

Number 1 post: NB

My concerns with ML’s current regimen are the use of controlled substances, for a prolonged period. These drugs are intended for short-term use because they can cause dependency (Visovsky, Zambroski, Hosler, 2019). Since this patient has been taking benzodiazepines (BZN) for what appears to be several years, she will need to be reevaluated and gradually tapered off the medication. Stopping the medication abruptly can lead to physical withdrawal symptoms. The plan would be to taper her off the controlled drugs and prescribe NSAIDs such as Motrin and Tylenol instead. I would also try other non-pharmacological treatments such as physical therapy.  

ML has a history of cigarette smoking and alcohol use. Since she will continue taking gabapentin for her nerve pain, she will need to be monitored closely as alcohol interacts with gabapentin and can decrease its effectiveness. Both alcohol and cigarette smoking, can lead to an increased risk of benzodiazepine dependence and put the patient at an increased risk of heart attack and stroke.  Another concern I have is her communication with managing medications, this may be difficult, especially with transitioning care. Ineffective communication due to the language barrier can result in medication discrepancies (Science Direct, 2021)

Regarding ethical concerns, I believe that beneficence exemplifies the concept of the moral obligation to act in the best interests of others. As healthcare providers, we must practice beneficence in our clinical settings daily by making selections and decisions about how to best care for our patients without causing harm or breaking the law.

The attached sample pain contract provided by Pinnacle Interventions Pain and Spine Consultants (Ko, Murray, 2020) is appropriate, and will be signed by the provider and Ms. ML and will be kept in her records. 

              Pinnacle Interventions Pain and Spine Consultants (Ko, Murray, 2020)

To ensure safe prescribing, it is important to check the state-run prescription monitoring programs to avoid having multiple prescriptions being filled. Specific information must be included on a legal prescription such as the patient’s name, date, name of the medication, route, dose, quantity to be dispensed, frequency, duration, and signature of the prescriber as well as the DEA number. The pharmacy is also required to provide information about the drug and how it is to be given (Visovsky, Zambroski, Hosler, 2019). Since ML is Latino, having this information in her native language would be valuable.

If the current list of medication was to be continued, a handwritten prescription for the controlled substances must be presented to the pharmacy.  Emergency prescriptions may be called into the pharmacy if followed by a valid written prescription within 7 days, stating that a previously placed prescription was called in (Trevor, 2015). In some states such as TN, gabapentin is considered a controlled substance and cannot be called into the pharmacy. Losartan and Atorvastatin can be called into the pharmacy.

To prevent multiple prescriptions from being filled I would immediately document the prescription information into the state-run prescription monitoring programs such as California’s prescription drug monitoring program (PDMP) and The Ohio Automated RX Reporting System (OARRS) databases that are used to monitor controlled prescription drugs dispensed to patients. According to Jenni (2020), reporting must happen within five minutes of prescription.

 Refill for C-III, C-IV, and C-V can be done within 6 months after initial prescriptions.  Both California and Ohio allow nurse practitioners prescriptive authority for drugs falling into schedule II, III, IV, or V (Med Source Consultants, 2018).

Number 2 post: BW

In this week's discussion, a Hispanic female patient presents with chronic ailments requesting a six-month supply of her current medication list. The first concern that I have with this patient's medication regimen is that the patient is taking a benzodiazepine, gabapentin, Norco, and states that she periodically drinks alcohol. I would want to have a discussion with her regarding her amount of drinking and if she concurrently takes her medications when drinking. Another consideration regarding the patient's reported pain, an X-ray of the shoulder would be helpful in understanding if there is something wrong with the patient's musculoskeletal system. My ethical standards regarding this case would be that I would want to teach the patient the correct laws that I am bound to being a nurse practitioner in the state she is residing in. According to Rosenthal et al., (2021) "The patient must understand the risks and benefits of using opioids to treat chronic, noncancer pain" (p. 192). A lack of understanding on the patient's part if she cannot get her medication filled as requested could make a poor outcome for patient satisfaction in my healthcare practice. 

Pain Contract

If this patient wants to continue using narcotic medications that I will be prescribing her, it will be prudent to have a pain contract with the patient. A pain contract is an agreement between me and the patient that shows the standards of care between the two parties. An example of a pain contract used in regards to opioid medication was used in a study performed by McCann et al., (2018). In the McCann (2018) study, it was found that having a structure that shows the amount of time between visits, the appropriate amount of opioid medication prescribed per visit is within limits for the safety of the patient and prescriber. An example of a pain contract is to have an agreement that states to continue to be prescribed opioids from this prescriber, at each visit, a contract will be written regarding the use and timing of prescription fillings with an agreement for the patient to either wean off of opioid medications or to stay at the current medication dose. The contract will then be signed and reviewed at each scheduled visit (McCann et al., 2018). Having this structure will help set the boundary and limitations for the prescriptions. An example of a pain contract can be found here by clicking this link https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/agreement.pdf

Registry

To help ensure the safety of practice, updating a controlled medication through a prescription registry is required. In the state of California, a resource is called the controlled substance utilization review and evaluation system, otherwise known as the CURES system (State of California, 2022). The state that I live in is Arizona. Arizona has a registry that is called the Arizona State Board of Pharmacy Controlled Substances Prescription Monitoring Program (CSPMP) (Arizona State Board of Pharmacy, 2022). 

Refills

In order to refill this patient's prescriptions, there will be different laws that the patient is not used to. According to Prevention Solutions (2022) "Under federal law, prescriptions for Schedule II substances cannot be refilled, and can only have a 30 day supply. Prescriptions for Schedule III and IV controlled substances can be refilled up to five times in six months" (para. 6). The patient is taking Norco which is a class II medication and diazepam which is a class IV medication. These rules will apply for this patient. To refill the Norco, the medication will need to be ordered through an electronic system, no paper prescription is allowed (Prevention Solutions, 2022). When the medication is prescribed, the order needs to have all pertinent information related to the use of the medication to show that the medication is needed for a legitimate reason and that all of the correct patient information is detailed. In a controlled state such as Texas, nurse practitioners must maintain a prescriptive authority agreement or protocol with a physician (American Medical Association [AMA], 2022). 

Protocol for Furnishing Controlled Substances

To prescribed schedule II and III controlled substances in a restricted state, there are protocols for nurse practitioners to follow with a patient-specific approach. In the state of California, which is a restricted practice state for nurse practitioners, California Legislative Information (2022) states the following:

The furnishing or ordering of drugs or devices by a nurse practitioner occurs under physician ans surgeon supervision. Physician and surgeon supervision shall not be constued to require the physical presence of the physician, but does include (1) collaboration on the development of the standardized procedure, (2) approval of the standardized procedure, and (3) availability by telephonic contact at the time of patient examination by the nurse practitioner (para. 6). 

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