NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID

NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID

Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.

The Assignment

Answer the following questions using the patient examples described above.

Patient 1

  • What are the concerns of the patient remaining on the opioid medication and clonazepam?
  • How might you educate the patient about these risks and concerns?

The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:

  • How would you instruct the patient to taper off clonazepam?
  • What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
  • How would you start the new recommended psychotropic medication for the patient?
  • Discuss one legal, ethical, or social consideration with the treatment plan.

Patient 1: NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID

The case of the 36-year-old male patient who presented to the clinic with a prescription for an opioid analgesic medication from a work accident presented to be a complex challenge in medication management. The primary risk in this medication regimen is the risk of respiratory depression, which can be a significant side effect after taking opioids, such as benzodiazepine. In their study, Boon et al. (2020) identified that when benzodiazepines are prescribed together with opioids, it can have potential harm to taking medication alone. Benzodiazepine and opioids both cause respiration depression, which increases the patient’s risk for potentially lethal apnea.

Educating this patient regarding the identified risks is also essential to approaching the conversation with empathy and emphasizing the importance of safety. Therefore, ongoing patient education should be keen on the synergistic impacts of medications on the central nervous system and how it is likely to result in excessive sedation, cognitive impairment, and an increased risk of falls and injuries. During patient education, explaining that while each medication may benefit the individual, taking them concurrently increases their risks for other related health conditions is critical.

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Following the patient’s position to discontinue clonazepam, it is important to recommend a carefully structured tapering plan. Abrupt discontinuation of benzodiazepine is likely to contribute to severe withdrawal symptoms such as rebound anxiety, insomnia, and, in some cases, seizures (Brandt et al., 2024). The gradual tapering plan entails the reduction of the dose by 5-10% every 2-4 weeks. The nurse should monitor the patient closely for any withdrawal symptoms or exacerbation of anxiety.

To address the patient’s concern regarding panic attacks, the alternative medication that should be considered should not interact with opioids. Selective Serotonin Reuptake Inhibitors (SSRIs) have been described as a first-line choice for panic disorder and with a more favorable safety profile when combined with opioids (Garakani et al., 2020). A medication in that class is sertraline, which has been shown to have efficacy in the treatment of panic disorder and has no significant interactions with opioid medications. When starting the new psychotropic medication, it is essential to initiate a low dose and titrate slowly (Baldacci et al., 2023). Sertraline’s initial dose is 25 mg daily for the first week, which will be increased to 50 mg daily in the subsequent week. Other adjustments may be made based on response and tolerability, and patients may be instructed to follow up with their regular NPs or MDs every 2-3 weeks.

A significant level of ethical consideration is the need to provide the best for the patient and achieve a balance between pain management and the risk of medication addiction. The prescriber has a legal obligation to manage the patient’s chronic pain and, at the same time, safeguard from a possible opioid addiction.

De-Prescribing

What is the importance of de-prescribing? How might you assist a patient to taper from a medication safely or transition to a new medication?

In this Assignment, you will use the following patient examples to write a 5- to 6-page paper on considerations you have for how you might de-prescribe. Support your answers with five (5) evidence-based, peer-reviewed scholarly literature resources outside of Required Learning Resources in this course.

Note: APA style format guidelines will apply.

Patient Examples:

Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.

Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.

Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety as lorazepam has been effective.

Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To prepare for this Assignment:

  • Review the assigned Learning Resources for this week.
  • Review the definitions presented in your text and resources for de-prescribing and tapering.
  • Consider the importance of de-prescribing.
  • Based on the example(s) provided, consider how you might de-prescribe a patient.

The Assignment

Answer the following questions using the patient examples described above.

Patient 1

  • What are the concerns of the patient remaining on the opioid medication and clonazepam?
  • How might you educate the patient about these risks and concerns?

The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:

  • How would you instruct the patient to taper off clonazepam?
  • What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
  • How would you start the new recommended psychotropic medication for the patient?
  • Discuss one legal, ethical, or social consideration with the treatment plan.

Patient 2

  • The patient reports withdrawal symptoms when previously tapering off the alprazolam. What symptoms are common withdrawal symptoms from this medication?
  • Provide the patient education of withdrawal symptoms that range from common and less serious to withdrawal symptoms that are a cause for concern and that should prompt patient should seek medical attention.
  • Given the patient’s history of having withdrawal effects from attempting to taper off alprazolam, what longer-acting benzodiazepine would you choose to convert the patient to?
  • What is the dose you would prescribe and how would you taper off the medication?

Patient 3

  • Review the potential risks, benefits, and side effects of continuing lorazepam throughout the pregnancy and postpartum for both the patient and fetus.
  • Review other alternative medications to treat generalized anxiety disorder. Include risks, benefits, and potential side effects to both the patient and the developing fetus. Keep in mind, the patient is looking to breast feed for 6 months postpartum.
  • The patient agrees that it would be safest for her pregnancy and fetus to discontinue the lorazepam. How would you recommend she discontinue lorazepam? Provide education on potential side effects from tapering off the medication, including common side effects to more serious side effects and when to seek medical attention.
  • The patient would like to forgo medications at this time, given she is early in her pregnancy and is concerned about “damage” to the fetus if she were to continue medications. Provide education to the patient about the risks of untreated anxiety symptoms during pregnancy for both the patient and the fetus.

Patient 4

  • Review potential side effects for elderly on benzodiazepines providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?
  • How would you evaluate the patient for these side effects?
  • The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?
  • Review with the patient and daughter potential side effects of tapering off the medication. Review with them common side effects to more serious side effects and when to seek medical attention.
  • NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Walden Writing Center Sample PaperLinks to an external site. provides an example of those required elements.

By Day 7

Submit your Assignment by Day 7 of Week 5.

submission information

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Rubric

NURS_6630_Week5_Assignment_Rubric
NURS_6630_Week5_Assignment_Rubric
Criteria Ratings Pts
Patient 1: Describes concerns for patient remaining on the medication and how these risks and concerns will be addressed to the patients. Describes how to assist Patient 1 in tapering medication, as well as what other medication might be prescribed with considerations of legal, ethical, or social considerations to the plan.

20 to >18.0 ptsExcellentThe response comprehensively describes medication risks and concerns. The response comprehensively and clearly explains how the patient will be educated. The response comprehensively and clearly explains considerations for medication tapering. The response comprehensively and clearly reflects on legal, ethical, or social considerations of the plan.

18 to >15.0 ptsGoodThe response clearly describes medication risks and concerns. The response clearly explains how the patient will be educated. The response clearly explains considerations for medication tapering. The response clearly reflects on the legal, ethical, or social considerations of the plan.

15 to >10.0 ptsFairThe response inaccurately or vaguely describes medication risks and concerns. The response inaccurately or vaguely explains how the patient will be educated. The response inaccurately or vaguely explains considerations for medication tapering. The response inaccurately or vaguely reflects on legal, ethical, or social considerations of the plan.

10 to >0 ptsPoorThe response vaguely or inaccurately describes medication risks and concerns, or it is missing. The response includes inaccurate and vague examples that does not explain how the patient will be educated, or it is missing. The response vaguely or inaccurately explains considerations for medication tapering, or it is missing. The response includes inaccurate and vague examples that does not reflect on legal, ethical, or social considerations of the plan, or it is missing.
20 pts
Patient 2: Describes common withdrawal symptoms and patient education information. Describes which benzodiazepine might be prescribed to convert the patient, as well as the specific dosing and tapering information.

20 to >18.0 ptsExcellentThe response comprehensively and clearly explains withdrawal symptoms. The response comprehensively and clearly provides patient education information. The response comprehensively and clearly identifies a benzodiazepine for the patient. The response comprehensively and clearly details dosing and tapering information.

18 to >15.0 ptsGoodThe response clearly explains withdrawal symptoms. The response clearly provides patient education information. The response clearly identifies a benzodiazepine for the patient. The response clearly details dosing and tapering information.

15 to >10.0 ptsFairThe response inaccurately or vaguely explains withdrawal symptoms. The response inaccurately or vaguely provides patient education information. The response inaccurately or vaguely identifies a benzodiazepine for the patient. The response inaccurately or vaguely details dosing and tapering information.

10 to >0 ptsPoorThe response vaguely or inaccurately explains withdrawal symptoms, or it is missing. The response includes inaccurate and vague examples that does not provide patient education information, or it is missing. The response vaguely or inaccurately identifies a benzodiazepine for the patient, or it is missing. The response includes inaccurate and vague examples that does not detail dosing and tapering information, or it is missing.
20 pts
Patient 3: Describes potential risks, benefits and side effects of lorazepam, as well as alternative medications that might be prescribed for the patient. Describes how the patient might discontinue lorazepam, with necessary patient education regarding discontinuing medication and patient/fetus needs.

20 to >18.0 ptsExcellentThe response comprehensively and clearly describes risks, benefits and side effects of lorazepam. The response comprehensively and clearly identifies potential alternative medications. The response comprehensively and clearly describes how the patient might discontinue the medication. The response comprehensively and clearly provides necessary education for discontinuing the medication for patient and fetus.

18 to >15.0 ptsGoodThe response clearly describes risks, benefits and side effects of lorazepam. The response clearly identifies potential alternative medications. The response clearly describes how the patient might discontinue the medication. The response clearly provides necessary education for discontinuing the medication for patient and fetus.

15 to >10.0 ptsFairThe response inaccurately or vaguely describes risks, benefits and side effects of lorazepam. The response inaccurately or vaguely identifies potential alternative medications. The response inaccurately or vaguely describes how the patient might discontinue the medication. The response inaccurately or vaguely provides necessary education for discontinuing the medication for patient and fetus.

10 to >0 ptsPoorThe response vaguely or inaccurately describes risks, benefits and side effects of lorazepam, or it is missing. The response includes inaccurate and vague examples that does not identify potential alternative medications, or some or all are missing. The response vaguely or inaccurately describes how the patient might discontinue the medication, or it is missing. The response includes inaccurate and vague examples that does not provide necessary education for discontinuing the medication for patient and fetus, or some or all are missing.
20 pts
Patient 4: Describes potential risks and side effects of continuing benzodiazepine. Describes how to taper the medication and education regarding the tapering NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID

20 to >18.0 ptsExcellentThe response comprehensively and clearly describes potential side effects and risks. The response comprehensively and clearly describes how to taper the medication. The response comprehensively and clearly provides necessary patient education for tapering.

18 to >15.0 ptsGoodThe response clearly describes potential side effects and risks. The response clearly describes how to taper the medication. The response clearly provides necessary patient education for tapering.

15 to >10.0 ptsFairThe response inaccurately or vaguely describes potential side effects and risks. The response inaccurately or vaguely describes how to taper the medication. The response inaccurately or vaguely provides necessary patient education for tapering.

10 to >0 ptsPoorThe response vaguely or inaccurately describes potential side effects and risks, or it is missing. The response vaguely or inaccurately describes how to taper the medication, or it is missing. The response includes inaccurate and vague examples that does not provide necessary patient education for tapering, or some or all are missing.
20 pts
Paper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references

5 to >4.0 ptsExcellentPaper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references outside of course resources.

4 to >3.0 ptsGoodPaper demonstrates some critical thinking and/or vague synthesis of literature with four (4) evidence-based, peer reviewed scholarly references outside of course resources.

3 to >1.0 ptsFairPaper demonstrates vague critical thinking and/or little synthesis of literature with three (3) evidence-based, peer reviewed scholarly references.

1 to >0 ptsPoorPaper demonstrates no critical thinking and/or synthesis of literature with two (2) or less evidence-based, peer reviewed scholarly references.
5 pts
Written Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided, which delineates all required criteria.

5 to >4.0 ptsExcellentParagraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.

4 to >3.0 ptsGoodParagraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the Assignment is stated yet is brief and not descriptive.

3 to >1.0 ptsFairParagraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the Assignment is vague or off topic NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID

1 to >0 ptsPoorParagraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion was provided.
5 pts
Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 ptsExcellentUses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGoodContains one or two grammar, spelling, and punctuation errors.

3 to >1.0 ptsFairContains several (three or four) grammar, spelling, and punctuation errors.

1 to >0 ptsPoorContains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
Written Expression and Formatting: The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 to >4.0 ptsExcellentUses correct APA format with no errors.

4 to >3.0 ptsGoodContains one or two APA format errors.

3 to >1.0 ptsFairContains three or four APA format errors.

1 to >0 ptsPoorContains many (five or more) APA format errors.
5 pts
Total Points: 100 NURS-6630 Week 5: Assignment De-Prescribing – Anxiolytics and Anxiety – A 36-year-old male prescribed opioid analgesic medication and clonazepam 1mg BID