NR 603 week 7 discussion PDF

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week 7 discussion assignment...

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1. The patient is a 58-year-old woman with chronic pain due to inflammatory arthritis. She presents for her first appointment with you in a primary care office. She states that she is aware that she is asking for an early refill of her Oxycontin however she is traveling out of state and she is concerned that she may have a flare up on her trip.  Apply the steps in SBIRT to this scenario Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a tool used by primary care providers to identify those at risk for substance use disorder and mental health problems and provide interventions and services to help reduce the complications arising from dependence and other severe symptoms (Hargraves et al., 2017). The primary care provider is the first point of contact for the patients and the primary care provider can identify those at risk and intervene early for better health outcomes and provide additional referral services (Hargraves et al., 2017). It is important as primary care provider to determine if the patient has taken opioid in the past and has developed tolerance or addiction as this can help develop a trusting relationship between patient and provider (Torres et al., 2017) The patient should be screened using the DAST drug screening questionnaire to help in developing a plan that would benefit the patient by reducing the use of opioid, providing education on the effects of opioid addiction, and referring the patient to specialized services who specialize in substance abuse (opioid addiction) (CMS, 2021).  Identify additional questions for this patient When were you diagnosed with inflammatory arthritis? When did you start taking pain medications for your pain? What medications have you taken and are taking for pain? How long have you been taking oxycontin? Who prescribes the oxycontin for you? Have you followed up with your prescriber? How frequently are you taking oxycontin? What is the dosage of the oxycontin you are taking? Have you tried any other pain medication? Do you see pain specialist for pain management? When was your last refill for oxycontin?

How often are you having “flare-ups”?  Develop a treatment plan for this patient In the given case, the patient could be referring to rheumatoid arthritis as inflammatory arthritis and the first line treatment therapy for inflammatory pain management is nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids (Bullock et al, 2018). The patient needs to be educated on the effects of long-term use of opioids such as dependence, constipation, nausea, headache, insomnia, and anxiety. The patient should be educated on regular exercise (Poudel et al., 2021). The patients need to be educated on multiple providers involved in the care and management of her arthritis. The patient needs referral to rheumatologist for further evaluation of arthritis and management, and better health outcomes (Bullock et al. 2018). The patient would benefit from physical and occupational therapy to help improve joint movement and strength (Bullock et al, 2018). The patient needs to follow up with the original provider and the rheumatologist for evaluation and management of arthritis and need for pain management. 2.The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.  Initiate office-based buprenorphine/naloxone (Suboxone) with a plan for observation.  Include your rationale for each treatment decision  Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions. The patient in the case is has admitted to addition to pain medications, is showing signs of withdrawal and possibly has some underlying mental health condition and thus would benefit from combined approach of psychotherapy and medication (Zoorob et al., 2018). As the COWS score indicated the patient to be in moderate withdrawal, it is important to obtain baseline urine drug screening and consent the patient to treatment plan and begin treatment (Zoorob et al., 2018). The patient received buprenorphine in the office for withdrawal symptoms and should be monitored for 60 minutes after the first dose is administered followed by titrating the dose of buprenorphine in the office until the symptoms of withdrawal subside (Zoorob et al., 2018). The patient should follow up in 24 hours to a week after receiving initial treatment of buprenorphine in the office (Zoorob et al., 2018). The patient needs weekly follow up until a stable dose of buprenorphine is reached and then the follow up can be biweekly to monthly but may need increased follow up visit if there is any occasional opioid use (Zoorob et al., 2018). The patient should be referred to psychiatrist, behavioral therapist, and counseling, and care coordination with social service or case management for better health outcome (Zoorob et al., 2018). The patient may be switched to methadone if the patient is unable to stop opioid use when on buprenorphine and continued therapy (Zoorob et al., 2018). The follow up plan would include random drug screening at office visit to detect

rebound to addiction and have proper and complete documentation of any increase or decrease in the dosage of buprenorphine and any adverse effects (Zoorob et al., 2018).  Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on a benzodiazepine for an extended amount of time. It is not safe to abruptly stop taking benzodiazepine for a patient who has been taking it for extended period and should be tapered on a varying schedule of 8 weeks to 1-2 years (Ogbonna & Lembke, 2017). Xanax should be reduced to 5% to 25% from the starting dose initially and then continue to taper at the same rate every four week as tolerated by the patient (Ogbonna & Lembke, 2017). In the given case the patient in the outpatient setting and the tapering should begin by taking 2mg in the morning, 1mg in the afternoon, and 2mg in the evening for the first week as tolerated by the patient (Ogbonna & Lembke, 2017). During week 2, the dose of Xanax should be tapered to 1mg TID up to week 4 (Ogbonna & Lembke, 2017). Beginning week 4 the dose of Xanax is tapered to 1mg in morning and 1mg in the evening, and 0.25mg in the afternoon for the next two weeks, then the tapering of the dose continues by 25% every two weeks as tolerated by the patient and then eventually is discontinued (Ogbonna & Lembke, 2017).

References: Bullock, J., Rizvi, S. A. A., Saleh, A. M., Ahmed, S. S., Do, D. P., Ansari, R. A., & Ahmed, J. (2018). Rheumatoid arthritis: A brief overview of the treatment. Medical Principles and practice: international journal of the Kuwait University, Health Science Centre. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422329/ Centers for Medicaid & Medicare services (CMS) (2021). Screening, brief intervention, & referral to treatment (SBIRT) services. https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/SBIRT_Factsheet_ICN904084.pdf Centers for disease control and prevention (CDC) (2020). Arthritis. https://www.cdc.gov/arthritis/pain/index.htm#:~:text=Such%20guidelines%20suggest%20the %20following%20for%20managing%20arthritis,loss%2C%20if%20overweight%20or %20obese.%20More%20items...%20 Fraenkel, L., Bathon, J. M., England, B. R., St Clair, E. W., Arayssi, T., Carandang, K., … Akl, E. A. (2021). 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis care & research, 73(7), 924–939. https://doi.org/10.1002/acr.24596 Hargraves, D., White, C., Frederick, R., Cinibulk, M., Peters, M., Young, A., & Elder, N. (2017). Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multi-practice evaluation portfolio. Public health reviews, 38, 31. https://doi.org/10.1186/s40985-017-0077-0

Ogbonna, C. I., & Lembke, A. (2017). Tapering patients off benzodiazepines. American Family Physician. https://www.aafp.org/afp/2017/1101/p606.html Poudel, P., Goyal, A., Bansal, P., Lappin, S. L. (2021). Inflammatory Arthritis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507704/ Torres, M., Harris, J., Chang, Y.-W., Held, J., & Eskander, M. (2017). The general surgeon's role in enhancing patient education about prescription opioids. The Bulletin. https://bulletin.facs.org/2017/08/the-general- surgeons-role-in-enhancing-patient-educationabout-prescription-opioids/ Zoorob, R., Kowalchuk, A., & Grubb, M. M. de. (2018). Buprenorphine therapy for opioid use disorder. American Family Physician. https://www.aafp.org/afp/2018/0301/p313.html...