De-Medicating
De-Prescribing
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De-Prescribing
De-prescribing is the act of adjusting medications or stopping them when the health status of the patient changes to reduce the burden of medication or if the medication causes potential harm to the patients. The primary goal of de-prescribing is to reduce polypharmacy and prescribing potentially inappropriate medications, leading to enhanced patient’s safety. Thus, the essays purpose is to outline considerations to follow when de-prescribing a patient prescribed with opioid and clonazepam.
Summary of the Case Study Patient
Patient 1 is a 36-year-old male. He has been prescribed opioid analgesic medication by his primary care physician for the past three years for a work accident. The patient has chronic pain and attends a pain clinic. The clinic determines that remaining on opioid medication is the best course of treatment. The patient is also taking clonazepam 1mg BID for relaxation and panic attacks.
Overview of the Concerns of the Patient Remaining on the Opioid Medication and Clonazepam
Prescribing opioid medication and clonazepam is not recommended. Clonazepam is a benzodiazepine, and should be prescribed for short periods because they produce physical and emotional dependence due to addiction despite being used as prescribed by the healthcare provider (Reid Finlayson et al., 2022). Similarly, stopping the medication abruptly results in the worst withdrawal symptoms, including rapid heart rate, changes in blood pressure, dizziness, tremor, nausea, irritability, and seizures(NAMI[National Alliance on Mental Illness], 2024). These withdrawal symptoms also occur when the drug dosage is reduced. The effects are worsened if clonazepam is taken with opioid medications because of the adverse side effects, including difficult and slowed breathing and even death (Boon et al., 2022). Combining the two medication increases the risk of suicide, overdose death, increased utilization of healthcare services, and poor treatment outcomes. The side effects are attributable to clonazepam prolonging the duration and intensity of opioid effects, leading to drug abuse to enhance opioid medication effects (Centers for Medicare & Medicaid Services [CMS], 2019). Thus, Patient I should be concerned about his risk of overdose death, suicide, and adverse outcomes if he remains on opioid medication and clonazepam.
How I Might Educate the Patient about the Risks and Concerns of Combining Opioid Medication and Clonazepam
Medications are an important aspect of the care delivery process. As a result, Rameshkumar & Haputhanthrige(2022) maintain that providing patients with clear instructions regarding their prescriptions reduces medication errors, improves adherence, and patient satisfaction. Failure to take medication as recommended increases mortality and morbidity rates. For these reasons, Patient I needs to be educated about the risk factors for combining clonazepam and opioid medications. The first strategy I will consider when educating the patient about the risks and concerns is communicating clearly in a clear and simple language when discussing the risks and concerns with the patient. Refraining from using medical jargon will enhance the patient’s understanding of the need to de-prescribe one of the prescriptions. Secondly, I will use visuals aids, especially diagrams, to illustrate the life threatening effects of his prescriptions. Thirdly, I will customize the educational intervention to the patient’s cultural background and health literacy level. Fourth, I will actively engage the patient in the educational intervention by encouraging him to ask questions, make decisions, and address concerns related to his prescriptions. Fifth, I will repeat information to reinforce retention and comprehension. Lastly, I will provide the patient with written materials regarding the adverse consequences of combining opioid medication and clonazepam.
How I Would Instruct the Patient to Taper off Clonazepam
Stopping Clonazepam suddenly without guidance or supervision from a healthcare provider could be detrimental to the patient’s health and well-being. Specifically, sudden cessation may result in a coma or fatal seizure (Reid Finlayson et al., 2022). As for the case study patient, he is already on opioid and clonazepam, increasing his risk if he abruptly stops clonazepam. In this case, I will review with the patient his current therapy benefits and risks, and consider whether tapering down both or either of the prescription would be necessary based on his unique circumstances. I will also conduct functional assessment for the patient, ensuring his treatment goals are met. I will also monitor the patient for any abuse or misuse of the prescribed medication, including adjusting frequency or dosage other than the recommended prescription. Any case of abuse or misuse, I will discuss my concerns with the client and consider reducing Clonazepam and opioid medications through tapering. I will also discuss with the patients regarding the diverse approaches to tapering his Clonazepam. I will let the patient know that tapering may take years or months. Thus, the first strategy will be reducing his Clonazepam dose by 10-25% per week or every two weeks. However, I will closely monitor him to prevent adverse events. The patient will know that immediate tapering will result in severe withdrawal, increase suicidal thoughts, and disrupt his sleep (CMS, 2019). Therefore, gradual tapering will be necessary to safeguard the patient’s health and wellbeing
Other Medications I would recommend for the Treatment of His Panic Attacks
The other medications I would recommend for patient one for his panic disorders is the selective serotonin reuptake inhibitors. The side effects of these drugs are low and are recommended as the first line of treatment for panic disorders (Edinoff et al., 2021). Under SSRIs, the patient may be prescribed sertraline (Zoloft), poroxetine (Pexeva, Paxil), and fluoxetine (Prozac) to relieve his panic attack symptoms. The drugs are often co-prescribed with opioid medication for chronic pain. Therefore, if one of the SSRIs is not working effectively for the patient, the patient can combine or switch to another drug to enhance treatment effectiveness. Nonetheless, the patient should know that it may take days to notice symptoms improvement after starting a new treatment. Thus, the patient with be assessed after 7 days to determine the effectiveness of the new prescriptions.
How I Will Start the Newly Recommended Medication for the Patient
The newly recommended medication is SSRIs. They are the first line of recommended medications for panic disorders. The drugs are effective and safe and most patients’ response to the drug is favorable (Edinoff et al., 2021). In this case, the following strategies will be used to start the medication on Patient 1. The first strategy is starting with a low dose to ensure the patient does not abandon the new treatment before benefitting from it. Since the patient had a negative experience with Clonazepam, the patient will be prescribed with a quarter of the initial start does and it will be gradually increased up to the maximum recommended levels. For instance, if the patient is prescribed Zoloft, he will start with 25mg/day, gradually increased to 100mg/day to 200mg, which is the maximum recommended dose. The interval between the first dose and the gradual increase will be seven days based on the patient’s response. After the 7 days, I will aim for a higher dose because patients diagnosed with panic disorder requires maximum dose to record maximum benefits or before switching to another medication. Therefore, the highest does will be prescribed if the patient tolerates it. However, the patient will be e informed that it may take months before being confident that he has overcome his panic attacks. In this case, the full effect of the new recommended medication will be done months after meaningful improvements have been reported in the first one to one and half months after the start of treatment.
One Legal/Ethical/Social Consideration with the Treatment Plan
Treatment planning is a crucial aspect in the healthcare delivery process. Therefore, healthcare providers must comply with the ethical standards when designing their patient’s treatment plan. One ethical consideration is respecting patient’s autonomy. Patient’s decision need to be considered in their treatment process. The decisions should be based on their cultural and belief system (Zhang et al., 2021). Based on the principle of autonomy, patients also have a right to refuse treatments or medications and the treatment plan goals should align with their goals.
Conclusion
De-prescription should be done with precautions, especially when opiod medication is taken with Clonazepam. Abrupt withdrawal of Clonazepam can be life-threatening for the patient. Therefore, de-prescription of clonazepam should be gradual and it should be replaced with selective serotonin reuptake inhibitors, which are efficient and tolerable. However, patient’s autonomy should be considered when switching medication.
References
Boon, M., van Dorp, E., Broens, S., & Overdyk, F. (2020). Combining opioids and benzodiazepines: effects on mortality and severe adverse respiratory events. Annals of Palliative Medicine, 9(2), 54257-54557. https://doi.org/10.21037/apm.2019.12.09
Centers for Medicare & Medicaid Services[CMS].(2019). Reduce the risk of opioid overdose deaths by avoiding and reducing co-prescribing bednzodiazepines. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19011.pdf
Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., & Kaye, A. M. (2021). Selective serotonin reuptake inhibitors and adverse effects: a narrative review. Neurology International, 13(3), 387-401. https://doi.org/10.3390/neurolint13030038
NAMI [National Alliance on Mental Illness].(2024). Clonazepam(Klonopin). https://www.nami.org/about-mental-illness/treatments/mental-health-medications/types-of-medication/clonazepam-klonopin/#:~:text=The%20use%20of%20clonazepam%20with,also%20found%20in%20cough%20syrup.
Rameshkumar, T., & Haputhanthrige, I.U. (2022). Patients’ knowledge about medicines improves when provided with written compared to verbal information in their native language. Plos one, 17(10), e0274901. https://doi.org/10.1371/journal.pone.0274901
Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D. E., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: an Internet survey. Therapeutic Advances in Psychopharmacology, 12, 20451253221082386. https://doi.org/10.1177/20451253221082386
Zhang, H., Zhang, H., Zhang, Z., & Wang, Y. (2021). Patient privacy and autonomy: a comparative analysis of cases of ethical dilemmas in China and the United States. BMC Medical Ethics, 22, 1-8. https://doi.org/10.1186/s12910-021-00579-6
