opioid-addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the CNS. Although the combined use of these drugs increases the risk of severe side effects, the harm caused by untreated opioid addiction can outweigh these risks. These medications are often used with counseling and Tapering of chronic opioid therapy (CDC, 2022a) Sometimes, clinicians must decide whether to decrease or discontinue chronic opioid therapy. Many factors may contribute to this decision: Patient request; lack of response; signs of substance abuse disorder, overdose, or other serious adverse events; or early signs of overdose risk. Therefore, any tapering schedule must be patient-specific to minimize withdrawal symptoms while maintaining adequate pain management. A general recommendation is to begin with a 10% decrease of the initial dose per week. Some patients who have taken opioids for a long time may require slower tapers (e.g., 10% per month). Adjust the rate and duration of the taper based on the patient’s response. It is advisable to slow or pause a taper to manage withdrawal symptoms rather than reversing the taper. It is essential to discuss the risk of overdose if a patient quickly returns to a prescribed higher dose. Consider prescribing naloxone to reverse possible overdose symptoms. After achieving the smallest available dose, the interval between opioid doses increases, and opioids stop when taken less than once daily.
behavioral therapies for patients undergoing MAT, and patients can be treated with them indefinitely. Careful patient monitoring is necessary when prescribing benzodiazepines or other CNS- depressant agents in combination with MAT and appropriate and continued patient counseling (FDA, 2022b).
Patients at high risk of harm, such as pregnant women or those with substance abuse disorder, may require coordination with treatment experts. Withdrawal symptoms are especially concerning in pregnant patients due to the risks to the mother and fetus. It is crucial to ensure patients receive appropriate encouragement and psychosocial support, including consultations with mental health providers and treatment for opioid use disorder as needed. Reassure patients that most people have improved function, without worse pain, after tapering opioids. In addition, some patients experience less pain after a taper, even though the pain may worsen initially. Self-Assessment Quiz Question #9 Any tapering schedule must be patient-specific to minimize withdrawal symptoms. The CDC recommends what percentage while maintaining adequate pain management?
a. 10% decrease of the initial dose per week. b. 15% decrease of the initial dose per week. c. 25% decrease of the initial dose per week. d. 45% decrease of the initial dose per week.
DRUG DIVERSION
● Failure to document administration or waste ● Holding onto medications prior to administration ● Removals right before the end of the shift or after discharge ● Removals for individuals not assigned to the employee Other red flags demonstrated in individual patterns include (1) frequent or explained callouts or tardiness, (2) regularly disappearing from the workspace, (3) excessive drowsiness or sleeping on the job, and (4) volunteering to come in early or stay late. Evidence-based practice! According to the CDC, Drug diversion has led to many outbreaks of hepatitis C and other bloodborne infections since 1983. https://www. myamericannurse.com/drug-diversion-in-healthcare/ Behaviors include subtle changes in appearance, increasing isolation from colleagues, inappropriate verbal/emotional responses, diminished alertness, confusion, or memory lapses (National Council State Boards of Nursing [NCSBN], 2018b). Many healthcare workers with substance use disorders are unidentified, unreported, and untreated. These individuals continue practicing and endangering the lives of others (NCSBN, 2018b). Healthcare Consideration: Misuse and abuse are distinct from medication mismanagement problems, such as forgetting medications and confusion or understanding about proper use. Medication mismanagement problems can also have severe consequences for patients, but they have different risk factors and typically require different types of interventions (SAMHSA, 2018). The effects of substance use disorder can seriously compromise the culture of safety in healthcare systems. Nurses dealing with substance use disorders cannot provide safe and appropriate patient care if their ability to function is impaired. Healthcare organizations must ensure adequate systems and processes are in place to prevent drug diversion and protect patients from safety threats due to impaired nurses. It is essential to maintain a drug and alcohol-free working environment.
Diverting controlled substances has far-reaching consequences, including legal and financial, threatening patients, healthcare workers, facilities, and the public (Nyhus, 2021). The risk to consumers is high, including unrelieved pain, unsafe care from impaired healthcare workers, and risk of infection from contaminated syringes (Nyhus, 2021). Healthcare Consideration: In 2020, over 4 months, a nurse tampered with approximately 75% of fentanyl given to patients. https://www.myamericannurse.com/drug-diversion- in-healthcare/ Drug diversion is defined as “any criminal act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient,” including everything from outright theft of the drug to doctor shopping, prescription forging, manufacture, or sales of counterfeit medicines and international smuggling (Council of State and Territorial Epidemiologists [CSTE], 2019). Diversion can occur at any point—from the manufacturer’s distribution to the wholesalers to pharmacies and, in turn, to the patient. The most common types of drug diversion include ● Stealing syringes/vials ● Under-dosing patients ● Replacing controlled substances with saline ● Pulling duplicate/multiple doses ● Creating false verbal orders ● Failing to waste or document waste (Nyhus, 2021). Other signs include selling prescription drugs, doctor shopping , utilizing illegal internet pharmacies, drug theft, prescription theft and forgery, and illicit prescribing (Health and Human Services, 2016). Some drugs are more diverted than others, including opioids which are the most commonly diverted class, benzodiazepines, barbiturates, and amphetamines (National Association of Drug Diversion Investigators [NADDI], 2021). Healthcare workers can also divert medications through false documentation, scavenging wasted medications, and theft by tampering (CSTE, 2019). Red flags include ● Cancelled transactions ● Changes or omissions in documentation
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Book Code: AUS3024
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