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