tricky practice scenarios

TRICKY P RACTICE S CENARIO SAN EXPERT PANEL DISCUSSION

• INTRODUCE YOU TO DANIEL – CASE STUDY

•EXPERT PANEL WILL ASSIST TO BREAKDOWN THE CASE

•APPROACH TO QSCRIPT HIGH -RISK ALERTS

TO DAY’S S ES S IO N

INTRO DUCING: Da n ie lAge: 46 years of age

Alle rg ie s: a m o xic illin

Pa t ie n t s m e d ica l h ist o ry:

- Bod y Ma ss In d e x (BMI) – 32 - Le ft a n kle fra c t u re (Ma rch 20 21) con t in u e s t o e xp e rie n ce h ig h le ve l p a in , w e a rin g

m oon b oo t on p re se n t a t ion- Typ e II d ia b e t e s - 20 18- De p re ssio n MVA 20 12- Non -sp e c ific LBP p ost MVA 20 12

Soc ia l: live s w it h lon g -t e rm p a rt n e r (Ma re e ), 2 t e e n a g e d e p e n d a n t s, u n e m p loye d (p re viou s fin a n c ia l con su lt a n t ), w o rk cove r c la im from MVA 20 12- se t t le d

Da n ie l is w a it in g fo r a n o rt h op a e d ic re vie w le ft foo t fra c t u re a n d is on a w a it in g list t o se e a p a in sp e c ia list .

INTRO DUCING: Da n ie l

Current medications:

o Tra m a d o l 50 m g IR PRNo Oxycod on e /Na loxon e 30 /15m g BDo Ta p e n t a d o l 50 m g SR BD o Pre g a b a lin 150 m g BDo Pa ra ce t a m o l 665m g TDSo Na p roxe n 1g d a ily o Esom e p ra zo le 40 m g BDo Se rt ra lin e 10 0 m g d a ilyo In su lin d e g lu d e c /in su lin a sp a rt (Ryzod e g ) 70 /30 10 u n it s n oc t eo Me t fo rm in XR 2g m a n e

Da n ie l re p o rt s t h a t h e is a lm ost ou t o f a ll m e d ica t ion s a n d is con ce rn e d t h a t w it h ou t t h e m h e w on ’t b e a b le t o g e t t h rou g h t h e d a y.

QScrip t a le rt – In c re a se d p a t ie n t ove rd ose risk—a ve ra g e t o t a l d a ily op io id s o f 10 0 m g OME o r g re a t e r

• ABRUPT CESSATION OF OPIOIDS WOULD CAUSE MORE

HARM

• SET EXPECTATIONS /CONTRACT

• PRESCRIBE SMALL QUANTITY OR VIA STAGED SUPPLY

• PUT IN PLACE RISK - MITIGATION STRATEGIES TO AVOID

PATIENT HARM

• DOCUMENT YOUR CLINICAL DECISION MAKING

• A RED ALERT ALONE DOES NOT NECESSARILY INDICATE

PATIENT HARM

DR CHEW ’S ADVICE

MELANIE’S ADVICE• History including

• Level of Function

• Pharmacological and Non - Pharmacological Analgesia what helps, what

doesn’t

• Brief Pain Inventory

• Patient Education over several appointments :Role of pain, How it changes the

brain due to inflammation and the stress response and that bio - plasticity can

be reversed to IMPROVE QUALITY OF LIFE. Opioids upregulate pain, Manage

stress improves pain.

• ESTABLISH MUTUAL TREATMENT GOALS

• UTILISE OTHER SERVICES – PHYSIO, Exercise Physiology, Psychology,

Consumer Groups APMA, Tai Chi classes

• WEIGHT MANAGEMENT eg Saxenda

• EXPLAIN WHAT THE PLAN IS AND THAT BOTH PRESCRIBER AND PATIENT

HAVE RESPONSIBILITY TO ENSURE THE PLAN WORKS

INTRO DUCING: Da n ie l

Current medications:

o Tra m a d o l 50 m g IR PRNo Oxycod on e /Na loxon e 30 /15m g BDo Ta p e n t a d o l 50 m g SR BD o Pre g a b a lin 150 m g BDo Pa ra ce t a m o l 665m g TDSo Na p roxe n 1g d a ily o Esom e p ra zo le 40 m g BDo Se rt ra lin e 10 0 m g d a ilyo In su lin d e g lu d e c /in su lin a sp a rt (Ryzod e g ) 70 /30 10 u n it s n oc t eo Me t fo rm in XR 2g m a n e

Da n ie l re p o rt s t h a t h e is a lm ost ou t o f a ll m e d ica t ion s a n d is con ce rn e d t h a t w it h ou t t h e m h e w on ’t b e a b le t o g e t t h rou g h t h e d a y.

QScrip t a le rt – In c re a se d p a t ie n t ove rd ose risk—a ve ra g e t o t a l d a ily op io id s o f 10 0 m g OME o r g re a t e r

• SEE DANIEL AS A WHOLE AND NOT NECESSARILY DEFINED

BY HIS MEDICINES

• NOT JUST ABOUT OPIOIDS OR OTHER DRUGS OF

DEPENDENCE

• COMBINATION OF MEDICINES, INTERACTIONS, ADVERSE

EFFECTS AND WITHDRAWAL POTENTIAL

• PREGABALIN: INDICATION?

• SERTRALINE: EFFECTIVE?

• TYPE 2 DIABETES: CONTROLLED?

J O Y’S ADVICE

Daniel has adopted other treatment options for pa in management and is focused on weight loss with modest improvements .

Recent consultation with pain specia lis t and they have informed him to come off his opioid.

CAS E CO NTINUED: Daniel

MELANIE’S ADVICE• Mutual treatment goal

• no withdrawal

• Improved function

• GIVEN THE LENGTH OF TIME ON OPIOIDS IT IS ADVISABLE TO 'GO SLOW' - AT

AN AGREED PACE WITH THE PATIENT (Flexible, 10% a fortnight/ month)

• NO ONE SINGLE WAY TO DE - PRESCRIBE OPIOIDS

• Must be titrated to patient vs activity and side effects.

• OPIOID ROTATION AN OPTION (always reduce dose by at least 30%)

• DEPRESCRIBING ONE OPIOID MEDICATION AT A TIME MIGHT BE ANOTHER

• Care with Tapentadol due to low opioid 20% of analgesic effect.

ENLIST THE HELP OF A PHARAMCISTS FOR POSSIBLE STAGED SUPPLY

May not be able to stop all opioids. If meeting functional and treatment goals

with no escalation of dose etc , then a halt/pause maybe appropriate

• NOT LIKELY TO BE SUD

• MORE LIKLEY TO BE A PANIC REACTION THINKING HE WAS

GOING TO HAVE HIS OPIOIDS CEASED ABRUPTLY

• REASSURANCE ABOUT THE PLAN TO DEPRESCRIBE – AT A

RATE THAT THE PATIENT FEELS COMFORTABLE WITH BUT

WHICH CONTINUES TO PROGRESS

• REINFORCE THE ONE PRESCRIBER, ONE PHARMACIST

AGREEMENT

DR CHEW ’S ADVICE

• GAIN UNDERSTANDING OF THE INDIVIDUAL’S HEALTH

LITERACY AND CONTEMPORARY UNDERSTANDING OF

CHRONIC PAIN

• DISCUSS THE POTENTIAL GAINS TO BE MADE BY OPIOID

TAPER, GIVE DANIEL A SENSE OF CONTROL OVER THE

PROCESS

• ENSURE NON - PHARMACOLOGICAL INTERVENTIONS

MAXIMISED AND MENTAL HEALTH STABLE

J O Y’S ADVICE

SC

IE

NC

E

CL

AS

Daniel has steadily reduced some of the opioids with minimal dis turbance to his function and pain experience.

At his regular consultation he is vis ibly dis tressed.

CAS E CO NTINUED: Daniel

• PREFERABLY AVOID PRESCRIBING HYPNOTICS

• ENCOURAGE GOOD SLEEP HYGIENE

• SHORT TERM USE ONLY IF USING HYPNOTICS – NO LONGER

THAN A WEEK

• POSSIBLY CEASE ANY FURTHER REDUCTIONS IN OPIOIDS

UNTIL PATIENT IS LESS DISTRESSED

• AVOID INCREASING THE OPIOID DOSE – AN INCREASE IN

PAIN IS NOT UNEXPECTED GIVEN THE PSYCHOLOGICAL

DISTRESS

DR CHEW ’S ADVICE

SIMPLE PHONE CALL: DISCUSION TO UNDERSTAND TREATMENT

GOALS, SHARE CONCERNS AND HOW TO MAXIMISE SAFE CARE

• PRESCRIBE REDUCED QUANTITY

• DEPENDING ON THE NEEDS OF PATIENT AND PRESCRIBER -

RECOMMEND STAGED SUPPLY / DAAS / HOME MEDICINE REVIEW

• PHARMACIST SHOULD DOCUMENT THEIR CLINICAL INTERVENTION

AND ADVICE PROVIDED TO PRESCRIBER AND PATIENT

J O Y’S ADVICE

MELANIE’S ADVICE

RESPECTFUL CONVERSATIONS ARE REALLY IMPORTANT

EARLY CONVERSATIONS WITH THE PATIENT'S PHARMACIST

MAY AVOID ANY PROTENTAIL PROBLEMS LATER ON

BOTH PRESCRIBER AND PHARMACIST ARE EQUALLY LIABLE

FOR THE CARE OF THE PATIENT – THERFORE BOTH SHOULD

BE WILLING TO HAVE THOSE CONVERSATIONS TO ASSIST IN

SUPPORTING THE PATIENT AND MAINTAIN THEIR

ENGAGEMENT

Important to facilitate to reduce negative impacts on patient

so they do not feel more stigmatized by system.

Q UES TIO NS FRO M THE AUDIENCE