Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

The patient is a 32-year-old single, white male currently employed as a teacher. Past medical history of disc herniation at L4-L5. Past psychiatric history of anxiety. He presents for illicit prescription opioid use. The patient was prescribed a short course of opiates after sustaining a back injury while weightlifting. After the prescribed course was finished, the patient started buying pills on the street at escalating doses. He is currently using 3–4 oxycodone per day but is trying to cut back. The patient drinks alcohol socially with friends (4–5 drinks per week) and is a non-smoker. He denies heroin or other illicit substance use. Current symptoms include slightly dilated pupils, rhinorrhea, anxiety, poor sleep, and restlessness. Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

QUESTION #1: Which screening tool would you use to assess active opioid withdrawal?

1. Clinical Opiate Withdrawal Scale (COWS)
2. Alcohol Use Disorders Identification Test (AUDIT)
3. Urine Toxicology

ORDER HERE A PLAGIARISM-FREE PAPER 

DEFENSE:

• Please answer the question and describe the utilization of the selected screening tool to assess opioid withdrawal. Be sure to describe scoring and assessment.
• In your defense, compare the remaining two screening tools and their potential usefulness for this patient. Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

The COWS is administered and the patient scores a 15 (moderate withdrawal). Urine toxicology screen is also administered and is positive for opiate derivatives. The patient refuses to initiate office-based medication-assisted treatment (MAT) for opioid use disorder (OUD) as he is ambivalent about starting a daily medication he would be “dependent” on. He wants to try to stop opioid use on his own. He subsequently experiences increasing anxiety and worsening sleep. Although he actively tries to cut down on buying pills, he feels withdrawal by the evening when he only uses 4 pills per day. He snorted heroin one time because he could not find pills to buy. He did not show up for work the next morning due to the profound withdrawal he experienced. The patient still has some ambivalence about starting MAT but is provided psychoeducation on treatment options. He is now open to MAT. The patient worries that his minimal residual back pain will worsen without opioid agonist therapy. He is worried about side effects as he maintains his role as a teacher.

QUESTION #2: Which medication-assisted treatment for OUD would you suggest initiating?

1. Methadone
2. Buprenorphine/naloxone
3. Extended-release buprenorphine
4. Naltrexone

DEFENSE:

• Please discuss the appropriateness of each treatment option. When considering MAT for OUD, be sure to weigh the options of a mu opioid receptor full agonist vs. partial agonist vs antagonist.
• Discuss potential side effects that the patient may experience.

• Consider: To have the best chance at abstinence from opioid use using MAT, it is important that patient preference be considered. Patients who have been using pills often prefer the act of taking daily medication to know that they are accessing treatment.

• Choose your selected treatment for this patient and propose a strength, dosage, and administration route. Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

 QUESTION #3: Why is naloxone added to buprenorphine in suboxone?

The patient is initiated on oral buprenorphine/naloxone SL 8/2 mg/day. He has not used illicit pills since starting buprenorphine/naloxone. He reports improved anxiety but still has insomnia at times. He has not missed work since induction of buprenorphine/naloxone.

QUESTION #4: The patient is now stable and would like to continue progression of treatment. Which of the following options do you now advise? Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

1. Monthly subcutaneous buprenorphine
2. Naltrexone
3. Other:_________

DEFENSE:

• Consider: It is possible to switch from a mu opioid receptor agonist to the partial agonist buprenorphine and then to the antagonist naltrexone for maintenance treatment of OUD.
• Consider: Mannelli P, Peindl KS, Lee T, Bhatia KS, Wu LT. Buprenorphine-mediated transition from opioid agonist to antagonist treatment: state of the art and new perspectives. Curr Drug Abuse Rev. 2012 Mar;5(1):52-63. doi: 10.2174/1874473711205010052. PMID: 22280332; PMCID: PMC3496559.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3496559/
• Propose a dosage and discuss the route of administration.

Psychopharmacology

Question 1

The best screening tool to use to assess active opioid withdrawal would be the Clinical Opiate Withdrawal Scale (COWS). COWS measures the intensity of the withdrawal which ranges from mild, moderate, to extreme. The tool has a subjective component, which includes 20 items describing symptoms, which are rates (Nuamah et al., 2019). The scores reflect the severity of each of the items in the tool. Mild scores range between 5 and 12 points. moderate ranges between13 and 24, moderately severe ranges between 25 and 36, and severe is above a 36 score.

Question 2

The preferred initial treatment for OUD in this case is buprenorphine as an opioid agonist. It is preferred for individuals with moderate to severe OUD. A distinct advantage of buprenorphine is that is has lower potential of causing respiratory depression compared to methadone.  Methadone doses usually exceed legal dosage allowed for adults, which buprenorphine is within the threshold (Deyo-Svendsen et al., 2020). Buprenorphine is also associated with lower risk of injury, poisoning, alcohol-related mortality, cancer, and suicide-related mortality (Santo et al., 2021). Potential side effects of buprenorphine include constipation, adrenal insufficiency, respiratory distress, overdose, dependence, nausea, fatigue, and sweating, among others. The recommended dose is 8mg BUP BID PO Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment

Question 3

Naloxone added to buprenorphine in suboxone because it helps to decrease the likelihood of misuse of the drug combination. People who have OUD may misuse buprenorphine because of its side effects.

Question 4

I would consider administering naltrexone and include adjunctive psychosocial support for the client if they select. LAI naltrexone is preferred for OUD treatment maintenance given its efficacy. The dosage would begin with 25mg, another 25 mg an hour later, then 50mg per day by mouth.

ORDER HERE 

References

Deyo-Svendsen, M., Cabrera Svendsen, M., Walker, J., Hodges, A., Oldfather, R., & Mansukhani, M. P. (2020). Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice. Journal of primary care & community health, 11, 2150132720931720. https://doi.org/10.1177/2150132720931720

Nuamah, J. K., Sasangohar, F., Erraguntla, M., & Mehta, R. K. (2019). The past, present and future of opioid withdrawal assessment: a scoping review of scales and technologies. BMC medical informatics and decision making, 19(1), 113. https://doi.org/10.1186/s12911-019-0834-8

Santo, T., Jr, Clark, B., Hickman, M., Grebely, J., Campbell, G., Sordo, L., Chen, A., Tran, L. T., Bharat, C., Padmanathan, P., Cousins, G., Dupouy, J., Kelty, E., Muga, R., Nosyk, B., Min, J., Pavarin, R., Farrell, M., & Degenhardt, L. (2021). Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis. JAMA psychiatry, 78(9), 979–993. https://doi.org/10.1001/jamapsychiatry.2021.0976 Psychopharmacology in Advanced Practice Psychiatric Nursing Assignment