Exploring Non-Clinical Prescribing in Primary Care

Introduction

The objective for this task is to examine a non-clinical recommending scene dependent on a genuine clinical situation of a patient thought about under the management of Designated Medical Prescriber (DMP) General Practitioner (GP).

The healthcare practitioner doing this appraisal is a substance abuse practitioner working in essential consideration. Tom, a pseudonym utilized in accordance with Nursing Midwifery Council (NMC, 2018) to keep up patient's namelessness and classification.

In “The inner consultation model” by Roger Neighbour (1987) was utilized as because it can be considered as most apt for gratifying the needs of patient. This model is extremely admired as it is oriented towards patients and also considers the sentiments of the clinician.

Independent prescribing

Independent prescriber (IP) is a specialist considered to be viably completed an NMC Independent Nurse Prescribing Course and is appropriately now qualified for making any type of prescription, including drugs and medicines documented in the BNF, illegal medication and each controlled medication included in drug categorization of 2-5 (Royal College of Nursing) (RCN,2014) . Department of Health (DoH, 2006) defines IP as Health Care Practitioners who are tasked with medical prescribing and are accountable for patients’ assessments for either diagnosed or undiagnosed conditions concerning their underlying clinical care which necessitates medication prescription.

IP is one crucial element of clinical management of patient that demands an underlying patient assessment, conception of analysis, an alternate on protected and proper treatment and plan of action for checking progress in agreement with patient and IP is accountable and responsible in any occurrence of element in patient’s care (DoH, 2006).

On completing this course the clinician will be able to work independently in performing assessment of the entire patient inside her sphere of skills with a full patient assessment with increased knowledge and understanding of her role and able to identify her limitation, and expressing at the time of seeking support and assistance when receiving and referring patients to other specialists. Hence improving existing practice, will help patients receive their appointments care, treatment, and medication on time as the nurse will be take charge of patient care. It will be more cost effective whilst enhancing the provision of health service (RCN 2014).

According to Stuttle (2016) Independent Prescribers profited on both services and patient. They declared patient will encounter less waiting in receiving medication and diminished quantities of undesirable appointments diminishes the danger of hospitalization and quicker recuperation. Tom had the chance to be evaluated and checked on rapidly and having his medicine prescribed rapidly under the management of DMP as expressed by Stuttle (2016), this also gave DMP and other GP’s deal with complicated cases.

Presenting complaint

Tom, is a Caucasian, 47years old with a long history of opioid addiction/ dependence mainly Heroin and cocaine that he injects in his groin. He was triaged and listed onto s ubstance misuse clinic due to having severe withdrawal symptoms. (LO3)

Medical History

History of presenting complaint

Reported to be withdrawing from heroin and crack cocaine, complaining of watery eyes, and running nose,

Stomach cramps

headaches,

persistent flu-like symptoms and nausea

Previous medical history,

Sciatica leg pain 7 years ago

History of substance misuse

Social/Family History (L03b)

Tom is white Caucasian, single unemployed and has no family.

He lives rough in sheltered accommodation and has a background marked by opioid and medication abuse (Williams et al., 2018).

He has been injecting heroin and cocaine in his groin.

Misuse of Drug and history of Abuse

He announced prolonged background of opioid abuse.

No background of liquor or cigarette tobacco smoking.

Injecting heroin and cocaine in his crotch to deal with his substance abuse issue.

Allergy status

Not known

Current medication

None

Over the counter and/or Herbal Prepations

Nil

Diagnostic test

Urine test was mentioned and obtained for biochemical assessment. Urine examination showed that Tom was certain for Benzodiazepines. Opiates/Heroin

Differential diagnoses

Opioid Addiction- The patient attests having opioid dependence issue. Lacaze-Masmonteil and O'Flaherty (2018) caution that opioids are profoundly addictive. It is affirmed by biochemical tests of urine that identified sedatives and heroin.

Anxiety- According to Craske and Stein (2016) the problem of anxiety can co-happen with substance-use issue, liquor use, significant depression and character issue and that is the method of reasoning concerning why it was remembered for the differential findings

Definitive Diagnosis

The conclusive finding for Tom was opioid withdrawal condition. Opioid withdrawal manifestations regularly present themselves because of unexpected discontinuance of short-acting narcotics, for example heroin, oxycodone, and hydrocodone (Kosten and Baxter 2019). As indicated by Kosten and Baxter (2019) and Voelker (2018) the toxicology tests of urine help to preclude different medications that may cause comparable withdrawal side effects. Toxicology of urine is regularly positive for chemicals, for example, codeine, propoxyphene, oxycodone, and heroin for within 12 to 36 hours following consumption. Moreover, fundamental panel for metabolism, electrocardiography and a total blood count are important to govern electrolyte irregularities (Shah and Huecker 2019).

Medications Considered/treatment

Methadone was the first drug considered as it reported a greater half-life of 15 - 22 hours. The potentiometer produces fewer withdrawal symptoms compared to morphine and heroin (Traeger et al., 2017). It helps in decreasing the recurrence of infusions and the danger of HIV disease (Robertson et al., 2019). Methadone is additionally connected with diminishing the degree of medication longings, which assists patients with defeating illicit drug use conduct. Moreover, methadone is related with decreased degree of medication desiring, which encourages patients to defeat opioid dependence propensity and lessen sedate selfish practices (Wang 2018).

Buprenorphine-An opioid mu receptor at the same level does not stimulate complete agonists as methadone. Buprenorphine helps reduce the risk of euphoria and respiratory depression (Birch et al., 2017). But it increases the risk of depression and allows the continued use of sedatives. Moreover, buprenorphine is also prohibited in this case, as continuous patient care is required, which may cause the patient to experience increased pain and withdrawal symptoms (Brown, 2018).

Treatment

Prescribed medication

Agonists of opioids were fundamentally the class of medications that were thought about. Methadone was the principal prescription that was placed into thought. Methadone has a more drawn out half-life, contrasted with morphine and heroin, subsequently is less strengthening and causes less withdrawal indications. In addition, methadone decreases the recurrence of infusions, in this way, diminishing the danger of disease by human immunodeficiency virus infection. Furthermore, methadone is related with diminished degree of medication longing for, which causes patients to defeat opioid fixation propensity and decrease tranquilize using selfish practices (Wang 2018).

It has been stated patients should be thoroughly examined before prescribing opioid medications. It has been further suggested that nurses need to make sure opioids are safely prescribed. Methadone hydrochloride 1mg/1ml oral solution : To take 30mls once daily for one week, or increase 5 to 10mg daily if required until no further signs of withdrawals or evidence of or increase (30mls maximum weekly dose) (BNF,2019)(National Institute for Health and Care Excellence (NICE,2019) The prescription decision was approved by the GP .

List of non-pharmacological treatments that have been considered

Counselling

Psychosocial and behavioural therapies plays a crucial role in the treatment of substance misuse

Pharmacodynamic

Methadone is a strong agonist of µ-opioid receptor (Medicines.org.uk 2019b). It has analgesic activities via an affinity for receptors similar to Morphine. Methadone is utilized in detoxification, maintenance of patients with opiate abstinence syndrome and is recommended for severe chronic pain (Kharasch et al, 2009). Its pharmacodynamic properties, for example, absence of pain, respiratory wretchedness, reliance, and resistance are principally activated by MOR enactment (Hopper et al., 2016). Resistance is characterized as diminished narcotic agonist pain-relieving power after the past presentation to the equivalent narcotic. Cross-resistance is a magnificent coming about because of diminished reaction to a narcotic agonist after past introduction to an alternate narcotic. A test study has indicated that methadone is a narcotic less touchy to resistance since its ED50 was not modified after the past presentation to morphine. Constant narcotic treatment may likewise create narcotic incited hyperalgesia (OIH) which sharpens patients or triggers intense torment scenes (Johnson and Jones, 2017). (LO1)

Pharmacokinetics

Up taking of methadone within the gastrointestinal tract is acceptable with top plasma levels accomplished around 1 to 5 hours after consumption. Auto-stimulation of liver microsomal proteins prompts moderate lessening at plasma levels. The medication is frequently very much disseminated in all tissues and can be discharged in breast milk and diffuses through the placenta. Around 60 - 90% of the medication is attached on plasma proteins. N-demethylation of the medication in the liver creates idle metabolites, for example, 2-ethylidine-1,5-dimethyl-3,3diphenylpyrrolidine and different types of pyrroline and pyrrolidines. These metabolites are discharged via urine and excretion. (Medicines.org.uk 2019b). (LO1)

Cost

Methadone oral solution 1mg/1ml is £1.35 per 100mls excluding VAT (BNF,2019)

Side effects

Demonstrating weakness, sleepiness, feeling high, constipation, dry mouth, cerebral pains, feeling high, gaining weight, perspiring. Medicines.org.uk (2019b)

Unwanted impacts incorporate lymphocytosis, expanded prolactin level (Mersey Care NHS Trust 2014)

Serious side effects

Respiratory depression

Shortness of breath

Chest pain

contraindications

Liver disease, cardiac conduction abnormalities,

Abnormalities in the electrolyte level,

Advanced ischaemic heart disease and in patients who are hypertensive to methadone (Medicines.org.uk 2019b).

Drug Interactions

Methadone can interact with other drugs; however, Tom is not taking any prescribed or OCT/Herbal preparations therefore the risk of drug interaction is minimised.

Caution

Family background concerning unexpected death (monitoring via ECG is suggested)

Tom to avoid activities such as functioning machinery and driving due to potential drowsiness. (BNF,2019)

Advice

Advise Tom that he may have constipation during maintenance with methadone to take laxatives, eat well balanced diet and drink plenty of fluids.

To report immediately any increasing side effects

Advised on risks of injecting heroin and discussed safer ways of using drugs such as smoking if he wishes to go back to his old habit.

If Tom develops serious side effects such as chest pain, slowed breathing, confusion, or any lightheadedness to seek medical advice immediately.

Follow up

To be reviewed next day if feeling unwell or weekly for 2 weeks until no further sings of withdrawal nor evidence of intoxication and in 3 months’ time if Tom is stable on his dose. (NICE,2015)

To assess whether tom has relapsed or is adhering to treatment plan

Random urine screens as is important, to reduce illicit use.

Closing consultation

Prescription and consultation evaluated to guarantee security during prescribing, further records set up to augment coherence of care (NMC,2018).

Section A: Consultation

Since the consultation model has been developed and widely used in Primary Care, most medical professionals are GP, ensuring that patient consultation are safe with style and competence (RCGP,2012). A systematic literature review undertaken by Bhanbro et al (2011) to determine whether NMP working in primary care could provide similar care to GP. The review focused at seventeen studies on outcome of patient after discussion with NMP, looking at effectiveness, equality, and admission on Healthcare. Findings report have shown patients to book faster and more conveniently with NMP than GP.

The NMP is also very much acknowledged and supported by patients with the general viewpoint proposing that the NMP improves patient's comprehension about their health conditions (Bissel et al, 2008). However, there is almost no proof contrasting patient interviews with an NMP and a GP which could recommend the outcomes being one-sided and decreases the general dependability (Bhanbro et al,2011). To ensure effective care is provided Health care practitioner must have the ability to monitor the patient as soon as the medication is started by an IP.NICE (2018) asserts HCP to adhere to “The prescribing Competency Framework” by the Royal College of Pharmaceutical Society (RPS,2016).

Models of consultation are fundamental bit of appraisal and conclusion during patient’s venture, in this way it is urgent for practitioner to play out this in an all encompassing methodology so as to advance prosperity and making safe and proof based management plan based on individualised needs (Nutall and Rutt-Howard, 2015). The Calgary Cambridge Model (C-CM) is a popular consulting model for general medical students and GP’s developed by Silverman,Kurts &Draper in 1988, states we will carry out about Two hundred thousand consultations in our profession. For that reason our approach needs to ensure effective communication in resolving patients complaints and major concerns, job satisfaction and overall outcomes of health for HCP’s (Silverman etal,2008) . The model contains five fundamental steps that consolidate physical, mental, and social parts of that are easy to utilize, (RCGP 2012) with two strings that runs all through, “building relationships and providing structure”. This model is extensively promoted and is mostly used with medical students and GP’s, it is extremely approved with Royal College of General Practitioners (Kessler et al,2012).

C-CM provides easy to use structure that compliments nursing’s holistic assessment (Munson 2007). However the C-CM may not suit everyone especially nurses because of being highly tasked, tailored and structured containing a ‘closing session’ task which may appear challenging especially for ten minute consultation time in GP (RCGP,2012).

C-CM is patient centred and focuses on "holistic" approach to medical professional integrity, which is at the effective for the patient and physical, psychological and social counselling integration (Trinh et al, 2018).

Similarly, to Silverman et al (2008) , is The Inner consultation model of shared “patient/doctor's agenda" by Roger Neighbour (1987) used by the Nurse in this prescribing episode. It consists of five stages that promotes collaboration and are easier to remember compared to Silverman el at (2008).Initial stage is 'connecting', it looks at building rapport toward the beginning of the consultation (RPS, 2016).

Similarly, Godsell et al (2013) and Workman (2013) described rapport as ability to form and support a working relationship and is considered overly critical in establishing trust. The meeting among Tom and the HCP was their first presentation, so it was essential that trust was worked to empower a helpful relationship from start to finish of consultation process. Where rapport and trust are successfully established, a therapeutic relationship can develop.

The second step of the conclusion, “summarising” this is important part of ensuring that Health care Practitioner ‘ understands the reason why patient has attended and give them an opportunity to add or adjust information (Hopper et al., 2016). The nurse under supervision made sure that she took a complete history of Tom which included social factors, drug abuse and Mental health condition which was then explained to Tom , was correct and was satisfied.

This is a very crucial step in consultation and there is evidence that it increases patient satisfaction when they feel they are listened to and can make decision to their treatment plan (Neighbour,1987).Thirdly, the “Handing over” thus when information was shared with Tom. The nurse made sure Tom understood and accepted the management plan. He appeared happy and agreed to take some responsibility to comply with his treatment plan proposed. The nurse explained to Tom why he was prescribed methadone. And this gave Tom an opportunity to negotiate his treatment plan if he does not agree with the decision of consultation promoting ‘shared’ care (Stewart et al,2013).

Security netting is the 4th step in meeting process. Palatable security netting is a best quality level indicative procedure for overseeing vulnerability (Benditz et al., 2017). It is estimated that around 50% of patients are diagnosed without a constant diagnosis. Therefore, it is important to identify the differences (RCGP,2015). Safety netting for Tom involved if he develops any serious side effects from Methadone as previous advised to seek emergency GP appointment. However, it has been showing that there was little advice for doctors to follow safe practices, i.e. many HCP do not include this in an examination (Banerjee et al., 2018).

However, in this case, the nurse eliminated this procedure. The significance of care based on evidence and additional research to find uncertainty about safety netting and practical use of methadone for Tom (Cox, 2018). The final phase is the fifth step. "housekeeping", which states that HCP is in the best position to attend the next patient consultation. The focus is on their opinions and feelings to prevent hostility that affects the next meeting, such as error recognition and inappropriate decisions (RPS, 2016). Tom’s scenario was consulted with GP to guarantee safe prescribing and documentation and referrals completed to augment the coherence of care approach. (LO3,LO5)

Factors Affecting your Prescribing Decision

The key underlying issues affecting prescribing decision in Prison sectors entails various factors detailing the required resources to influence effective dose management.

IP can feel pressure into the overall responsibility to prescribe and sign repeat prescription for patients in their care. Often at times, in the nursing practice, aspects of organizational change, roles aspects, governance issues and limited support can impact on the prescription of the medication to the patient. (Bowskill et al, 2014). Similarly Courtenay and Griffith (2010), indicated that prescriber’s decision can be influenced by pressures from patients and other prescribers. Narcotic withdrawal side effects are upsetting to the patient. Pergolizzi Jr et al (2019) has seen that the dread of withdrawal side effects may add to proceeded narcotic abuse. However, the nurse followed the RPS Prescribing Competency Framework and decision of her prescribing is based on Tom’s best of interest. Prescribing Methadone orally for Tom and collecting it daily at the pharmacy under supervision will be overpowering for him, nonetheless, to set up adherence and concordance of his treatment plan. The nurse explained to Tom that having his medication oral and under supervision will significantly reduce risks of overdose, intoxication, HIV transmissions, injecting and criminal behaviour. Wang (2018) certifies that methadone treatment diminishes danger of backslide.

A systematic review conducted in US with 223 prisoners prescribed methadone before starting their sentence found in favour of continuing methadone maintenance (Hedrich D., Alves P, et al (2012). Results were complex by the fact that 97% detoxification prisoners were released on methadone script. This showed that t firm evidence that while patients are in prison the opioid maintenance programme reduces drug use and injecting. Similarly a Cochrane review in (2009) established that methadone was effective in retaining patients in the treatment process and reducing the cessation of the heroine as measured through self-report assessment and urinalysis (Mattick et al., 2009).

In addition, having methadone in closed environment such as prisons, ensures maximum benefits of treatment are obtained thus gaining good quality of life back. Possible side effects of methadone and adverse reaction were discussed and information on Methadone and opioid dependence treatment was provided (NICE,2015). Tom was further informed on how to access self-help and local groups for further support if needed.

Weiss & Britten (2009) describe concordance as a consultation exercise that requires HCP and a patient. In addiction concordance is essential in improving the prescribing process and reducing the overall drug interaction, hence increasing its effectiveness. However, Blackburn, Swidrovich and Lemstra (2013) thinks adherence to medication must be explained clearly to a degree which individual obtain drugs well known to possess well-being.

NICE (2014) points the prescriber on the importance of patient participation before prescribing to establish concordance. There is a need for concordance with the patient on the medication process being initiated. As this enables Tom to understand the importance of the drug, improve and promotes adherence levels. Tom was encouraged to enrol in educational courses and physical exercise classes as relapse prevention.

However, if Tom has any concerns with prescribed medication, he will bring it up in consultation to promote concordance (Tabiano et al ,2015). Engaging in effective communication with Tom is key to ensuring that he agrees and engages positively in the medication process. Jorge et al (2011) reveals that concordance is scarcely accomplished among patients who administers oral drug contrasted with different courses which advances consistence. Keeping up concordance is extremely significant in patient's treatment as it bolsters safe recommending, diminishes unfriendly medication collaborations, while bringing down expense and misuse of prescriptions for National Health Service (NHS) Beckwith and Franklin (2011) (LO2,LO4)

Section B: Pharmacology

Pathophysiology

Opioids are synthetic or natural chemical which interacts with the opioid receptors on the nerve cells in the body and brain reducing pain feelings. Addiction is a severe persistent condition that can cause serious health, economic and social issues.

in this case Tom has a persistent condition which eventually results in severe health issues, as he is addicted to Heroin. Heroin is an opioid which is very addictive in nature, and when administered into the body, heroin metabolises into Morphine and then it binds to specific receptors in brain which are known as Opioid receptors. In response to this binding the brain discharges the neurotransmitter Dopamine. The release of Dopamine gives the person a feeling of pleasure (Dixon, 2020). But as in the case of most of the drugs, this feeling is only temporary. So, the person wants this feeling of pleasure again and thus he starts taking frequent doses of Heroine. When a person starts taking doses of Heroin again and again, heroin tolerance may develop in his body and the Dopamine which was once released by the Brain is not released now, which makes the person start taking higher and more frequent doses of Heroine to get the same feeling of pleasure he got the first time (Dixon, 2020). After injecting heroin in the body, there is a rush of good feeling in the person body which is then followed by red and warm flushing of skin and dryness in the mouth (Solomon, 2016). After this rush of good feeling, the person then feels a state of drowsiness. As the central nervous system is depressed, the brain is not functioning properly, and the person may be disoriented. Tom shared that he lost his house, job, and family due drug use. Drug addiction has resorted him into committing petty crimes to fund his behaviour Some other harmful effects of this includes depression of the respiratory system, nausea, hypotension, convulsions, spasm in muscles, hypotension etc (Herbert D. Kleber, 2007).

Clinical Application

Methadone is shown for the issue of reliance on narcotic medications and narcotic withdrawal disorder (World Health Organization) (WHO, 2007). Mersey Care NHS Trust (2014) includes that methadone is utilized by and by to assist patients with conquering opioid habit issues by diminishing or forestalling upsetting withdrawal side effects, which are frequently experienced when one is falling off sedative medications. Tom was cautioned against taking liquor when under methadone treatment since Nolan, Klimas and Wood (2016) have noticed that present use may prompt deadly opioid over dosage. The ability of methadone in relieving the symptom of opioids was noted in 1947.(WHO, 2007). Within the next two years, for detoxification, it turned out to be the preferred medication in Kentucky’s national narcotic hospital (58). The opioid addicts taking methadone found relived symptoms in withdrawal. There was no experience of euphoria with addiction and the addicts had been requesting their available and usual dose of injected morphine. However, following chronic administration, methadone’s sudden cessation produced a longer duration albeit milder withdrawals to following syndrome compared the cessation of morphine (Isbell et al,1947).

In 1964, Rockefeller Medical Research institute’s scientists started evaluating the maintenance of methadone as a means of medication assisted treatment of long term for opiate addiction. This established the relieving of opiate withdrawal be methadone, although is also blocked the superimposed opiates’ sedating and euphoric effects when at steady state (WHO,2007). Therefore, major components of both negative and positive reinforcing effects of opiates that is short acting, with methadone, were lowered and subsiding of the craving allows the addicts concentrating on the activities not related to drugs (NICE,2015).

Section C: Legal, Ethical and Professional

As a feature of prescriber’s job, taking decisions is one of pivotal component as the patient must be completely included and offer agree to their treatment plan following significant moral standards. Beauchamp and Childress (2001) audited four fundamental standards of Non-maleficence, Autonomy, Beneficence, and Justice. As noted above in every stage of consultation consent was obtained from Tom. Everything discussed was kept confidential respecting Tom’s autonomy (NMC, 2018).

The prescribed medication was based on fairness, equity, and equality respecting Tom’s rights. Beneficence is described as having an aim to do good by action planned to benefit others. The nurse followed the principles by following the NICE guidelines on Heroin dependence. Methadone was prescribed as the first line treatment that is cheap and cost effective, however provides safe and better service for Tom. All this was recorded as documentation is the key to prescribed (NMC, 2018). (LO5)

Conclusion/Personal Development

This has been especially acceptable experience of learning as the HCP has had the option to consider this examination in other patients' discussions.

This has given the nurse greater understanding of physiology advice on prescribing whilst her confidence increased in making clinical decisions and prescribing safely following the national guidelines and BNF, especially when dealing with opioid dependence patients. The nurse is positive that rapport was established at the first experience with Tom.

On finish of the recommending course, the nurse will have the option to work freely in facilities and ready to endorse medicine which will be increasingly powerful and give better by and large occupation fulfilment. This will also be saving time for GP’s and patient will be seen without delay. The nurse’s knowledge and understanding of relevant ethical & legal implications has greatly developed enabling her to work towards

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