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.
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
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK5Assgn_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
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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.
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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.
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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.
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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
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Paper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references
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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.
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Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation
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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.
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