Description
Question 1:
My concern for this patient is her Norco taken up to 4-5 times per day prn and diazepam along with occasional beers. Patients should never combine opioids and benzodiazepines they increase the risk for side effects and ultimately overdose that can result in death. It is important to keep in mind how these two drugs are metabolized one pill may not be fully excreted by the time she takes another 1-2 pills. Both of these drugs affect the central nervous system, causing sedation and suppressed breathing, taking these both increase the risk of accidental overdose that can be fatal (Dey & Vrooman, 2023).
Alternatives would be trying out, physical therapy, acupuncture, corticosteroid shots, lidocaine patches, and changing out Norco for Tramadol extended release. Tramadol is another opioid analgesic working directly on opioid receptors in the central nervous system reducing feelings of pain interrupting the way nerves signal pain between the brain and body (Healthdirect, 2023). Adding Tramadol extended release, I would no longer prescribe the Diazepam, along with Tramadol suggest for her to take Naproxen and Ibuprofen to help with inflammation. I am choosing Tramadol extended release due to her needing around the clock pain relief, as she is a working grandma who is in charge of duties at home (Tramadol: Medlineplus Drug Information 2023).
Screenings to check for, mental health conditions, respiratory or neurological conditions and doing labs such as a CBC to get a baseline. It is important to check her kidney and liver functions since the medications she has been taking are harsh on the physical body and dosages may need to be corrected based off lab values. The Nevada Prescription Monitoring Program (PMP) is a requirement that every provider prescribing controlled substances must review their patients PMP before prescribing more and throughout their treatment (Prescription Monitoring Program (PMP), 2021). Specifically, Medicaid only will pay up for a 34-day supply and a refill will only be paid for when 90% of the prescription is used which is important to educate our patients being that in Nevada many of the population is on this insurance (Prescription Monitoring Program (PMP), 2021). Other laws here is APRN’s are unable to prescribe controlled substances for more than 90 days and even at the 90-day mark there are requirements including referring a patient to a pain management specialty provider. Ethically speaking I would not be prescribing medications ahead for 6-months whether there were no laws I want to ensure I am having regular follow ups with my patients and evaluations and doing diligent efficient care.
Question 2: https://www.semanticscholar.org/paper/Breaking-the-pain-contract%3A-A-better-agreement-for-Tobin-Forte/9fd5e196f2f02262e4e3f1b2f6186060902846e9
Question 3 and 6:
The registry for Nevada to use before prescribing and after in order to make a report of what scheduled medications, I am prescribing would be the Nevada Prescription Monitoring Program. This is where providers are able to look at a data base that shows the patients-controlled substance medication history. California’s registry is Controlled Substance Utilization Review and Evaluations System (CURES). Both of these registry’s are available for pharmacies and providers prescribing where they register an account and are able to access that helps them be able to determine if it is still medically necessary and appropriate.
Question 4:
In both Nevada and California law you are not allowed to dispense or refill a controlled substance prescription that is more than 6 months old after the issue date, cannot be refilled more than 5 times exceeding a 120-day supply for schedule III and IV, and no prescription for a Schedule II can be refilled a new prescription must be written each time (Pharmacy, 2021; Justia Law, 2020).
Question 5:
In Nevada as of January 2022 it is mandated that all controlled substance prescriptions must be prescribed electronically directly to the pharmacy on the e-script along with the regular requirements for a prescription to have it must have the DEA number, telephone number of the APRN and, time and date of the transmission (MacMenamin, 2020). The other medications listed Losartan and Atorvastatin that are not controlled substances and are able to be written or called into a pharmacy.
Question 7:
Protocol guideline for the APRN and physician to agree and fill out for the APRN to prescribe controlled substances. https://dev.nevadanursingboard.org/wp-content/uploads/2019/10/APRN-Protocol-for-Prescription-of-Schedule-II-Controlled-Substance-Drugs.pdf
Outlined laws and protocol for prescribing controlled substances. https://medboard.nv.gov/uploadedFiles/mednvgov/content/Resources/Prescribing%20Controlled%20Substances%20in%20Nevada.pdf
Dey S, Vrooman BM. Alternatives to Opioids for Managing Pain. [Updated 2023 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574543/
MacMenamin, L. (2020, December 1). Electronic prescribing regulations in Nevada. Retail Association of Nevada – Looking Out For Business. https://rannv.org/electronic-prescribing-regulatio…
2020 Nevada revised statutes :: Chapter 453 – Controlled Substances :: NRS 453.256 – prescriptions; requirements for dispensing certain substances; penalty. [effective January 1, 2021.]. Justia Law. (2020). https://law.justia.com/codes/nevada/2020/chapter-453/statute-453-256-d-1/#:~:text=1.,II%20must%20not%20be%20refilled.
Nevada State Board of Pharmacy. (2021). Prescription Monitoring Program (PMP). PMP. https://bop.nv.gov/links/pmp/
Pharmacy, C. S. B. of. (2021, February 21). Frequently asked questions. FAQs – California State Board of Pharmacy. https://www.pharmacy.ca.gov/licensees/faqs.shtml
Tramadol. healthdirect. (2023, July 6). https://www.healthdirect.gov.au/tramadol#:~:text=Tramadol%20works%20directly%20on%20opioid,the%20brain%20and%20the%20body.
U.S. National Library of Medicine. (2023, April 13). Tramadol: Medlineplus Drug Information. MedlinePlus. https://medlineplus.gov/druginfo/meds/a695011.html#:~:text=Tramadol%20is%20used%20to%20relieve,pain%20around%2Dthe%2Dclock.
