[ANSWERED 2023] ML is a 54 yo Hispanic female with hx of chronic shoulder and back pain that began 10 years ago when she was in a boating accident.

Written By: Dan Palmer, RN

ML is a 54 yo Hispanic female with hx of chronic shoulder and back pain that began 10

ML is a 54 y o Hispanic female with hx of chronic shoulder and back pain that began 10

You are a new FNP in a restricted state and have your DEA license, and state furnishing for schedule II-V controlled substances. You are working at a busy family practice group, and you have a patient, ML, that is establishing care for the first time with your practice and comes to you with the following scenario:

  • ML is a 54 yo Hispanic female with hx of chronic shoulder and back pain that began 10 years ago when she was in a boating accident.

  • She lives in both US and Mexico, making regular visits across the border. Lately, she has stayed in the US due to Covid border crossing constraints, living with her daughter’s family.

  • She had rotator cuff surgery in 2011 and reports to you that due to a long operation and poor positioning, she has suffered from not only pain, but also chronic numbness and tingling in her R shoulder.

  • As “la abuela” (grandma), she is the primary caregiver of the children and homemaker for her family. Her pain is exacerbated with housework, and especially with the prolonged carrying of her grandchildren; one of which is 10 m.o.

  • Currently, her med list is as follows

    • Losartan 50 mg BID for HTN

    • Gabapentin 300 mg po BID for pain

    • Atorvastatin 40 mg daily for cholesterol

    • Diazepam 5 mg po up to TID prn pain

    • Norco 5/325 mg – takes up to two, sometimes up to 4-5x a day, prn pain

  • She is a smoker, only smokes outside the house, and drinks 2-3 cans of beer on the weekends, but more on family celebrations.

  • She denies recreational drugs and denies past overdoses.

  • She has recently moved to CA more permanently to stay to take care of children during Covid/school closures.

  • She asks you to refill all her meds for 6 months, like her doctor in Mexico did, so she doesn’t have to make another co-pay and come back and see you so often. It’s hard for her to get an appointment, and with Covid, her daughter has to take off of work to watch the kids so that she can come to you by bus (since there is only one family car).

  • Here VS are 135/75, 80, 97.5, 20 and PE unremarkable other than R shoulder exam with pain with ROM, but full ROM, no tenderness, otherwise normal, back exam including SLR are normal/neg

In 600 or fewer words, but a minimum of 250, please describe your approach with this patient. In your response, include the following:

  • What concerns do you have about her current regimen, and what alternatives will you discuss and offer? What other screenings might you apply? What are your own ethical standards on this case that you might consider in addition to legal standards?

  • Provide a sample of an appropriate pain contract that would suit this patient and address her specific safety concerns (cite it and attach the actual contract you found – you do not have to make your own – there are plenty online).

  • Include your steps to ensure safe prescribing. Include the registry you will search prior to any prescribing; name the CA registry, and if you are in a different state, you should name that registry also.

  • If you were to keep her current list, what are the laws surrounding refills and the amounts you are allowed to dispense with the schedule II and III medications in the state of CA? In your own state?

  • Which medications on her list may you call into the pharmacy, and which would you need a written script or electronic order? What are some elements required to include on the prescription form (paper or electronic signature) for the scheduled medications?

  • After you prescribe, how, when, and where would you (or your staff) go about making a report of your scheduled prescription in the state registry so that other prescribers and pharmacies could be aware?

  • In restricted states, APRN prescribers must follow a standardized procedure or protocol for furnishing schedule II and III controlled substances with a patient-specific approach. Please outline the minimum required components of a protocol. You may outline this in bullet form. Alternatively, you may find an appropriate protocol, clinical guideline, or standardized procedure from a literature search and attach it in lieu of outlining your own protocol.

Expert Answer and Explanation

What concerns do you have about her current regimen, and what alternatives will you discuss and offer? What other screenings might you apply? What are your own ethical standards on this case that you might consider in addition to legal standards?

The main concern in the current regimen of ML is the combination of medications she is taking. In addition, she also consumes alcohol every week. The danger of a potentially fatal overdose increases when opioids are used with other central nervous system depressants such as alcohol, benzodiazepines, or xylazine. Benzodiazepines increase the brain’s concentration of the inhibitory neurotransmitter GABA (National Institute on Drug Abuse, 2022). Concurrent use of opioids, benzodiazepines, and gabapentin among patients is linked to a number of negative consequences (Olopoenia et al., 2022).

I will add urine drug testing. Urine test has been recommended for patients getting long-term opioid or benzodiazepine therapy, and it is a crucial part of monitoring patients undergoing long-term opioid therapy (Kale, 2019).

In addition to legal standards in managing ML’s pain, I will incorporate an ethical patient-centered approachit is based on a foundation of trust between patients and physicians and is one of the main goals of pain treatment. This type of therapy entails a thorough assessment to determine any possibly curable sources of pain, as well as quantifiable treatment results with an emphasis on function and quality of life optimization. It is the responsibility of clinicians to enhance patient safety (CDC, 2023).

I will encourage the patient to try non-pharmacologic approaches to pain management. Pain and function may be improved by noninvasive, nonpharmacologic treatments, all without the possibility of significant side effects (Dowell et al., 2022).

Provide a sample of an appropriate pain contract that would suit this patient and address her specific safety concerns (cite it and attach the actual contract you found – you do not have to make your own – there are plenty online).

SAMPLE PAIN MANAGEMENT CONTRACT

You have agreed to receive opioid (narcotic) medications for the treatment of chronic pain. These medications are being prescribed to decrease your pain and/or increase your ability to function. Opioid medications are just a part of the medical care which may be needed to accomplish this. Other treatments including non-opioid medications, exercise and physical therapy, psychological counseling or other therapies or treatments may also be prescribed.

Please read this contract carefully. If you do not understand any of the information contained below, or require additional clarification on the policies of this office regarding the prescribing of opioid medications, please ask. You will be required to sign this contract before receiving any opioid medications.

I, ______________________________, understand that adhering to the following is important in continuing to receive opioid medications prescribed by Dr. ______________________________.

  1. I understand that I will:
    • Take medications only as they are prescribed by this physician. This includes the prescribed dose and frequency.
    • Not increase or change medications without the approval of this physician.
    • Not request or attempt to get opioid or other medications from any other physician unless specifically directed by this physician.
    • Tell this physician of all the medications that I am taking.
    • Only obtain my medications from one pharmacy. If I need to change or obtain medications from a different pharmacy, I will tell this physician immediately.
    • Safeguard and protect my prescriptions and medications. I understand that these will not be replaced if they are lost, left behind, or destroyed. If my medication is stolen I will complete a police report understanding that only one stolen prescription may be replaced in a year.
    • Agree to participate in psychiatric or psychological treatment or counseling if needed.
  1. I understand that in the event of an emergency, this physician should be contacted and the problem will be discussed with the emergency room or other treating physician. No more than three days of medications may be prescribed by the emergency room or other physician without this doctor’s approval.
  2. I understand that I will consent to random drug screening. A drug screen is a laboratory test in which a sample of my urine or blood is checked to see what drugs I have been taking.
  3. I understand that this physician may stop prescribing opioid medications or change the treatment plan if the clinic finds that I have broken any part of this agreement.

I have read the Pain Management Contract and, without question understand all of the information and responsibilities contained in this contract. By signing this contract, I affirm that I have read, understand, and accept all of the terms of this contract.

_______________                                                                    ________________

Patient Signature                                                             Physician Signature

Date:                                                                                         Date:

(North Dakota Workforce Safety Insurance, n.d.).

Include your steps to ensure safe prescribing. Include the registry you will search prior to any prescribing; name the CA registry, and if you are in a different state, you should name that registry also. 

Once I become an NP and obtain my prescriptive authority, I will make sure to use CURES or California Controlled Substance Utilization Review and Evaluation System. The database CURES contains prescriptions for Schedule II, III, and IV controlled substances that are filled in California. CURES must be consulted before a healthcare provider can prescribe, order, administer, or provide a Schedule II–IV controlled substance to a patient who is under their direct care, as of October 2, 2018.

I will gather relevant information by looking up CURES on the following:

• If the patient isn’t taking enough medication

• If the patient is receiving other medications that you are unaware of;

• If the patient sees multiple doctors, prescriptions should be coordinated (State of California Department of Justice, 2019).

If you were to keep her current list, what are the laws surrounding refills and the amounts you are allowed to dispense with the schedule II and III medications in the state of CA? In your own state?

A law known as the Controlled Substance Act (CSA) established government policy governing the production, distribution, import/export, and use of restricted substances. It establishes the legal basis for the regulation of controlled substances and provides the structure for classifying them (State of California Department of Justice, 2019)

In the United States, Schedule II controlled substances are those that have a high potential for abuse and dependency, pose a serious risk to patient safety, and have a legitimate medicinal application. Substances classified as Schedule II necessitate a written or electronic prescription from a medical professional. Oral prescriptions are only permitted in case of emergency. A written, electronic, or oral prescription may be used to fill a Schedule III substance. The prescription may be filled or renewed up to six months after the date of issuance and up to five times before the practitioner must renew it (State of California Department of Justice, 2019)

Which medications on her list may you call into the pharmacy, and which would you need a written script or electronic order? What are some elements required to include on the prescription form (paper or electronic signature) for the scheduled medications? 

With the exception of Norco, a Schedule II substance, all of the prescriptions on ML’s list can be called into the pharmacy. To renew the Norco, she will either an electronic order or a printed prescription. Prescriber name, license number, contact details, DEA number, patient name, date of birth, medication name, strength, dose, frequency, route, indication, number of pills (whether tablets, capsules, or liquid), and the number of refills if necessary are some of the elements that must be included on the prescription form (Rosenthal & Burchum, 2021).

After you prescribe, how, when, and where would you (or your staff) go about making a report of your scheduled prescription in the state registry so that other prescribers and pharmacies could be aware?

Health and Safety Code Sections 11164.1, 11165, 11165.1, and 11165.4, which are codified in Assembly Bill 528, require that the dispensing of a controlled substance be reported to CURES 2.0 within a working day of the medication being released to the patient or the patient’s representative as of January 1, 2021. Previously, reporting was required to be done seven days following dispensing. Assembly Bill 528 mandates that, beginning on January 1, 2021, the direct dispensing of a Schedule V medicine be reported to CURES in addition to the previous obligations that apply to Schedules II, III, and IV (Medical Board of California, 2023).

In restricted states, APRN prescribers must follow a standardized procedure or protocol for furnishing schedule II and III controlled substances with a patient-specific approach. Please outline the minimum required components of a protocol. You may outline this in bullet form. Alternatively, you may find an appropriate protocol, clinical guideline, or standardized procedure from a literature search and attach it in lieu of outlining your own protocol.  

SCHEDULE II PATIENT SPECIFIC PROTOCOL

1) Schedule II controlled substances may be ordered when the patient has one of the following:

a. Pain from cancer, post-operative pain, and trauma.

b. Pain unresponsive to or inappropriately treated by CS III-V substances

c. Attention Deficit Hyperactivity Disorder (ADHD)

d. Neuropsychiatric Conditions

2) Limit order for acute and chronic conditions as specified above in Schedule III Protocol.

3) No refills for CS II medications are authorized except where authorized by the DEA.

4) Pain Management Protocol or Department guidelines is/are adhered to if appropriate.

SCHEDULE III PATIENT-SPECIFIC PROTOCOL

1) Schedule III substances may be furnished or ordered when the patient is in one of the following

categories, including but not limited to the following conditions:

a. Acute Illness, Injury or Infection, such as cough, fractures

b. Acute intermittent but recurrent pain, such as headache

c. Chronic continuous pain

d. Hormone replacement

2) Limit order for acute illness, injury or infection to a maximum of [Insert number of days of

treatment – recommend following CDC’s Guidelines] days & no refills without reevaluation.

3) For chronic conditions:

a. Pain management protocol or department guidelines is/are adhered to, if appropriate.

b. Amount given, including all refills (maximum of 5 in 6 months per DEA regulations, is

not to exceed a 120-day supply as appropriate for the condition.

c. Treatment plan must be established in collaboration with the patient’s primary care

provider and reviewed, with documentation, every 6-12 months.

d. No further refills without reevaluation.

4) Education and follow up is provided (California Association of Nurse Practitioners, n.d.)

References

California Association of Nurse Practitioners. (n.d.). Ordering scheduled controlled substances policy (Sample protocols for Furnishing Standardized Procedures). https://canpweb.org/canp/assets/File/Sample%20Furnishing%20SPs.pdf

CDC. (2022, November 3). Prescription Drug Monitoring Programs (PDMPs) | Healthcare Professionals | Opioids | CDC. Www.cdc.gov. https://www.cdc.gov/opioids/healthcare-professionals/pdmps.html

Dowell, D., Ragan, K., Jones, C., Baldwin, G., & Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR. Recommendations and Reports71(3). https://doi.org/10.15585/mmwr.rr7103a1

Kale, N. (2019). Urine Drug Tests: Ordering and Interpretation. American Family Physician99(1), 33–39. https://www.aafp.org/pubs/afp/issues/2019/0101/p33.html

Medical Board of California. (2023). Prescribing Rules | MBC. Www.mbc.ca.gov. https://www.mbc.ca.gov/Resources/Medical-Resources/CURES/Prescribing-Rules.asp

National Institute on Drug Abuse (2022, April 21). Benzodiazepines and Opioids. National Institute on Drug Abuse. https://nida.nih.gov/research-topics/opioids/benzodiazepines-opioids

National Institute of Drug Abuse (2021, June). Prescription Opioids DrugFacts. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugfacts/prescription-opioids

North Dakota Workforce Safety Insurance. (n.d.). Sample pain Management Contract.https://www.workforcesafety.com/sites/www/files/documents/medical_providers/resources/SampleNarcoticContract.pdf

Olopoenia, A., Camelo-Castillo, W., Qato, D. M., Adekoya, A., Palumbo, F., Sera, L., & Simoni-Wastila, L. (2022). Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study. The Lancet Regional Health – Americas13, 100302. https://doi.org/10.1016/j.lana.2022.100302

Ortiz, N. R., & Preuss, C. V. (2021). Controlled Substance Act. In www.ncbi.nlm.nih.gov. StatPearls Publishing.

Rosenthal L., & Burchum J., 2021. Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants. Health Sciences

State of California Department of Justice. (2019, February 11). Controlled substance utilization review and evaluation system. State of California – Department of Justice – Office of the Attorney General. https://oag.ca.gov/cures

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FAQs

Managing High Blood Pressure Effectively with Losartan

Discovering effective ways to manage high blood pressure is crucial for maintaining your well-being. Losartan, an oral medication, plays a key role in this process. In this guide, we’ll explore the significance of Losartan in hypertension treatment and offer valuable insights for optimizing its benefits.

The Role of Losartan in High Blood Pressure Treatment

Your doctor may prescribe Losartan as part of your hypertension treatment plan. However, it’s essential to recognize that beyond medication, lifestyle adjustments contribute significantly to managing high blood pressure. These include weight control and dietary changes, particularly reducing sodium intake. Always consult your doctor before making any alterations to your diet.

Understanding High Blood Pressure

Many individuals with high blood pressure may not experience noticeable symptoms. It’s not uncommon to feel normal despite having elevated blood pressure levels. Adhering to your prescribed medication regimen and attending regular doctor appointments is crucial, even if you feel well.

Long-Term Management

It’s important to acknowledge that Losartan is not a cure for high blood pressure but rather a means of control. Consistency in medication adherence is paramount for effectively lowering and maintaining blood pressure levels. In some cases, lifelong medication may be necessary to prevent severe complications such as heart failure, stroke, or kidney disease.

Guidelines for Taking Losartan

To maximize the benefits of Losartan, it’s crucial to follow the recommended guidelines. The medication comes with a patient information insert, and it’s imperative to read and follow the instructions diligently. If any questions arise, consult your doctor for clarification.

Administration and Dosage

Losartan may be taken with or without food. If swallowing tablets poses a challenge, pharmacists can assist in preparing an oral suspension.

Dosage for High Blood Pressure

  • Adults: Initially, 50 milligrams (mg) once daily, with the possibility of dosage adjustments.
  • Children 6 to 16 years: Dosage based on body weight, typically starting at 0.7 mg per kilogram of body weight per day, with adjustments made by the doctor. Generally not exceeding 50 mg per day.
  • Children under 6 years: Dosage determined by the doctor.

Lowering Stroke Risk and Managing Enlarged Hearts

  • Adults: Initial dosage of 50 mg once a day, with potential adjustments based on blood pressure response. Additional medications may be added.
  • Children: Dosage determined by the doctor.

Diabetic Nephropathy

  • Adults: Initial dosage of 50 mg once a day, with adjustments based on blood pressure response.
  • Children: Dosage determined by the doctor.

Managing Missed Doses and Storage

In the event of a missed dose, take it as soon as possible. However, if it’s near the next scheduled dose, skip the missed one. Avoid doubling doses. Proper storage is vital—keep the medicine in a closed container at room temperature, away from heat, moisture, and light. Ensure it is not frozen, and dispose of any outdated or unneeded medication as directed by your healthcare professional.

In conclusion, understanding the role of Losartan, adhering to prescribed dosages, and incorporating lifestyle changes are key elements in effectively managing high blood pressure. Always consult your healthcare provider for personalized guidance and to address any concerns.

ML is a 54 yo Hispanic female with hx of chronic shoulder and back pain that began 10 years ago when she was in a boating accident.

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