Complete the following case studies:

1. The patient is a 58-year-old woman with chronic pain due to inflammatory arthritis. She presents for her first appointment with you in a primary care office. She states that she is aware that she is asking for an early refill of her Oxycontin however she is traveling out of state and she is concerned that she may have a flare up on her trip.

Apply the steps in SBIRT to this scenario
Identify additional questions for this patient
Develop a treatment plan for this patient
2.The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.

Initiate office-based buprenorphine/naloxone (Suboxone) with a plan for observation.
Include your rationale for each treatment decision
Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions.
Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on a benzodiazepine for an extended amount of time.

Differential Diagnosis and Primary Care

Student’s Name

Institutional Affiliations

Differential Diagnosis and Primary Care

Case Study 1

Substance abuse and misuse are serious public health problems. They are associated with negative therapeutic outcomes among patients who are receiving treatment. Therefore, nurses who are handling patients who are using or will be using drugs with a high potential of abuse should be able to conduct screenings to determine possible risks of substance or drug abuse for early management (Hargraves et al., 2017). The 58-year-old woman described in the case study has presented to the clinic for an early refill of her Oxycontin, a drug she is using to treat chronic pain due to inflammatory arthritis. Oxycontin/Oxycodone is an opioid that has a high potential for abuse (National Institute on Drug Abuse, 2018). Using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool, the nurse is able to conduct a quick assessment of the patient, provide brief intervention, and make an appropriate referral to treatment. SBIRT is an evidence-based tool recommended by the World Health Organization for use in the assessment of patients at risk of substance or drug abuse (Fu et al., 2021).

When applying the steps of SBIRT in the current scenario, it is imperative that the nurse considers the patient’s history, her current medications, allergies, and concerns. During the screening phase, the nurse assesses the severity of Oxycontin use to identify the best level of treatment.  It is during this stage that the nurse asks the patient questions aimed at revealing risky drug use behaviors (Hargraves et al., 2017). Examples of additional questions that the nurse can ask the patient include; For how long have you been using Oxycontin? Are there any other drugs you are using in addition to Oxycontin? Are you taking the medication(s) as prescribed? Have you ever experienced blackout when using these drugs? Has drug use affected your social or work life in any way? Have you ever experienced withdrawal symptoms? Do you have abnormal cravings for the drug before the recommended time of use arrives? Are you willing to continue/stop using the drug? By asking these questions, the nurse will be able to establish the patient’s risk of drug abuse.

The next step after Screening is the administration of a Brief Intervention that focuses on increasing the patient’s understanding and awareness regarding appropriate substance/drug use and her motivation towards adopting appropriate drug use behaviors. For the current scenario, the nurse utilizes research-based guidelines or evidence to educate the patient about appropriate oxycontin use. Additionally, the nurse assesses her readiness to use the drugs as prescribed and sets goals with her to prevent drug abuse and misuse (Hargraves et al., 2017). The Brief Intervention phase is followed by the Referral to Treatment stage.

The nurse develops a treatment plan and makes necessary referrals for the patient during the Referral to Treatment phase. The best treatment plan for the patient is that which will prevent Oxycontin abuse and misuse while at the same time addressing the patient’s concerns of developing a flare-up on her trip. Her treatment plan should include the following; Provide Oxycontin refill that is enough for her trip and remind her about the dosage, educate the patient to adhere to the prescription and finish her dose, educate the patient to identify withdrawal signs, and advise her to use ice packs or heating pads during the trip to manage symptoms in case she develops a flare-up on her trip. Ariana et al. (2021) support the effectiveness of heat therapy and cold rub gel in improving pain in patients with knee arthritis. The nurse should also refer the patient to a mental health professional for psychological assessment and stress management. It is important to conduct weekly follow-ups to monitor the patent’s progress.

References

Ariana, M., Afrasiabifar, A., Najafi Doulatabad, S., Mosavi, A., & Behnammoghadam, M. (2021). The effect of local heat therapy versus cold rub gel on pain and joint functions in patients with knee osteoarthritis. Clinical Nursing Research, 10547738211035502. doi: 10.1177/10547738211035502.

Hargraves, D., White, C., Frederick, R., Cinibulk, M., Peters, M., Young, A., & Elder, N. (2017). Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multi-practice evaluation portfolio. Public Health Reviews, 38, 31. https://doi.org/10.1186/s40985-017-0077-0

Fu, R., Yuan, C., Sun, W., Wang, W., Zhang, L., Zhai, J., Guan, Q., Wu, X., Long, J., Zhao, M., & Du, J. (2021). Effectiveness of E-SBIRT intervention in community healthcare institution in China: study proposal for a randomised controlled trial. General Psychiatry, 34(5), e100486. https://doi.org/10.1136/gpsych-2021-100486.

National Institute on Drug Abuse. (2018, September 27). Office-based buprenorphine treatment for OUD [Video]. YouTube. https://www.youtube.com/watch?v=H0vWVLuXTW0

Case Study 2

Patients who are struggling with prescription pain pills can develop opioid use disorder (OUD) which requires appropriate treatment. Buprenorphine is an evidence-based medication for treating OUD (National Institute on Drug Abuse, 2018). The 24-year-old man described in the case study appears to be in opioid withdrawal and it would be necessary to initiate an office-based buprenorphine/naloxone (Suboxone) with close monitoring and observation. The appropriate dose to prescribe is 2 mg per day. The rationale for selecting 2 mg of buprenorphine/naloxone is that the recommended dose for induction is 2-4 mg per day and the combination will help to minimize the potential for misuse and diversion/relapse. Additionally, the patient has attained a sufficient level of withdrawal with a Clinical Opioid Withdrawal Scale (COWS) score of 15 which is above the required minimum score of 6 (National Institute on Drug Abuse, 2018). The nurse should observe the patient in the course of medication and stabilize when necessary by increasing the drug dose from 4 mg per day to 12 mg per day.

It is imperative to develop a treatment plan that will enable the patient to obtain the best possible outcomes. The patient’s treatment plan should include the following; provide him with buprenorphine/naloxone tablets that he will be able to use for about 1 month before requesting a refill, educate him about the importance of adhering to medications, educate the patient about the drug’s side effects and advise him to report to the clinic in case they occur, monitor the patient on a weekly basis to determine whether the prescribed dose is working for him, and conduct urine tests during visits to assess the drug’s effectiveness (National Institute on Drug Abuse, 2018). Furthermore, the nurse should provide ongoing medication-assisted treatment (MAT) and psychosocial treatment interventions to improve the patient’s mental health and well-being (SAMHSA), 2021).

Safe Taper Schedule for Xanax

Medical detox is required to safety taper a patient who is taking alprazolam (Xanax) 2mg TID. The patient’s treatment plan should include the following; Reduce the drug dose by 25%, constantly hydrate the patient, tapering should be continued for 8 weeks, keep reducing the dose by 25% for every quarter, the nurse can administer cognitive behavioral therapy to support the detox experience (American Addiction Centers. 2022).

Tapering a Patient who Has Been on Benzodiazepine

It is important to avoid using Buprenorphine on a patient who has been on a benzodiazepine for a prolonged period of time to avoid extremely dangerous interaction. To taper such a patient, the nurse should reduce the dose by 50% every 2 to 4 weeks then maintain it for one to two months. Thereafter, the nurse should reduce the dose by 25% every 14 days (National Center for PTSD, 2021).

References

American Addiction Centers. (2022). How to taper off Xanax safely. https://americanaddictioncenters.org/xanax-treatment/weaning-tapering

National Center for PTSD. (2021). Effective treatments for PTSD: Helping patients taper from benzodiazepines. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Academic_Detailing_Educational_Material_Catalog/59_PTSD_NCPTSD_Provider_Helping_Patients_Taper_BZD.pdf

National Institute on Drug Abuse. (2018, September 27). Office-based buprenorphine treatment for OUD [Video]. YouTube. https://www.youtube.com/watch?v=H0vWVLuXTW0

Substance Abuse and Mental Health Services Administration (SAMHSA). (2021).  MAT medications, counseling, and related conditions. https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions