Practical Outpatient Prescribing The Speaker and Program Planners - - PowerPoint PPT Presentation

▶
practical outpatient prescribing
SMART_READER_LITE
LIVE PREVIEW

Practical Outpatient Prescribing The Speaker and Program Planners - - PowerPoint PPT Presentation

Jun 10, 2023 296 likes •682 views

Practical Outpatient Prescribing The Speaker and Program Planners have no commercial interest as defined by Accreditation Council for Continuing Medical Education Catherine Chichester Monica Delehanty Anne Rogers Peggy Spencer William

slide-1
SLIDE 1

Practical Outpatient Prescribing

The Speaker and Program Planners have no commercial interest as defined by Accreditation Council for Continuing Medical Education Catherine Chichester Monica Delehanty Anne Rogers Peggy Spencer William Schaffer Leah Vosmus James Wolak No commercial relationships or conflicts of interest to disclose among the presenter and the planners.

slide-2
SLIDE 2

Community Health and Counseling Services

slide-3
SLIDE 3

Stimulant Prescribing in Adults for the Bangor Municipal Substance Work Group

W Allen Schaffer, MD, FACP, FAPA Chief of Psychiatry, CHCS February 2018

slide-4
SLIDE 4

W Allen Schaffer, MD, FACP, FAPA

  • Chief of Psychiatry: Community Health and

Counseling Service. Board Certified in Psychiatry and in Internal Medicine

  • Attending Psychiatrist: St Joseph Hospital,

Wellspring Residential Programs, Aroostook County Mental Health Service (interim)

  • Formerly: Chief of Psychiatry, Eastern Maine Medical Center
  • Chief Medical Officer, Acadia Hospital
  • Director Substance Treatment Service, Acadia Hospital
  • Attending Physician, Maple Leaf Treatment Center, Underhill, VT
slide-5
SLIDE 5

Schedule II Narcotics - Stimulants

  • We tend to view stimulants as “different” but

the Rx rules are actually the same

  • Primary care is attempting to move free-

standing stimulant prescribing to Behavioral Health prescribers.

  • Community providers are restricting use of

stimulants with their narcotic prescribing

  • Patients seeking stimulants are self-referring

to Behavioral Health prescribers

slide-6
SLIDE 6

BOLIM on Schedule II Rx (Board of Licensure in Medicine)

  • “the Board will judge the validity of clinician’s

treatment of the patient based upon available documentation, rather than solely on the quantity and duration of medication administration.”

  • “Board expects that clinicians will incorporate

safeguards into their practice to minimize the potential for abuse and diversion of controlled substances.”

slide-7
SLIDE 7

BOLIM Principles for Rx Schedule II

  • Evaluation of the patient
  • Treatment plan: objectives, adjustments
  • Informed consent /agreement for treatment
  • Periodic review of Treatment efficacy
  • Consultation or referral
  • Medical Records
  • Reportable Acts: PMP, UDS, pill counts
slide-8
SLIDE 8
  • Changes in regional Rx practices
  • Comparability with other Agencies
  • State oversight of Schedule II prescribing
  • Federal standards for Schedule II
  • Risk recognized for adverse outcomes
  • Risk recognized for diversion
  • Prescriber Monitoring Program (PMP) use

Stimulant Rx: New Environment

slide-9
SLIDE 9

Attention to Stimulant Rx

  • Influx of patients expecting free-standing

stimulants

  • Wide variation in Community Rx practices
  • Recidivism in existing stimulants Rx
  • Splitting of prescribers
  • Influx of opioid replacement patients unable

to obtain stimulants from prescriber

  • Accountability of Prescriber for diversion
slide-10
SLIDE 10

Stimulant Rx practices

  • 1. Stimulants free-standing for ADHD
  • 2. Stimulants with Opioid Agonists
  • 3. Stimulants with Anxiolytics
  • 4. Stimulants with Antipsychotics
slide-11
SLIDE 11

1.Free-standing Stimulants for ADHD

  • Documentation of diagnosis
  • Children are different
  • Medical contraindications under-recognized
  • Clear distinction from Anxiety disorders
  • Step Tx: Behavioral, alpha agonists, Rx

alternatives bupropion, atomoxetine

  • Lifelong Rx: not recovery oriented
slide-12
SLIDE 12
  • 1. Free-standing Stimulants for ADHD
  • Indications must be specifically documented
  • A history of sustained childhood Rx needed
  • Step Tx must have been completed
  • Specific treatment goals/duration
  • Scheduled re-evaluation of benefits
  • Addiction hx cleared: sober 1 year & no hx of

cocaine dependence.

slide-13
SLIDE 13

2.Stimulants & Opioid Agonists

  • SAMHSA protocols do not support use
  • Two addictive agents in same addict
  • Need for stimulants usually indicates dosage
  • f opioid agonist is too high
  • Regional Mental Health prescribers not Rx
  • Patients seeking stimulants are self-referring
  • High potential for diversion
slide-14
SLIDE 14
  • 2. Stimulants with Opioid Agonists
  • Practice should be discontinuing stimulant

prescription for patients in opioid replacement.

  • Stimulant discontinuation should allow dosage

reductions for methadone/Suboxone

  • Stimulant taper is not necessary, but can help

with therapeutic alliance

  • Protocol: 30-90 day notice to patient possible
slide-15
SLIDE 15
  • 3. Stimulants with Anxiolytics
  • Limited indications, must be carefully

documented

  • Generally contraindicated
  • Stimulants:Glutamate/dopamine/norepinephrine

stimulation and GABA down regulation

  • vs
  • Anxiolytics: GABA agonists/glutamate antagonists
  • Two addictive controlled substances working in
  • pposition
slide-16
SLIDE 16
  • 3. Stimulants with Anxiolytics
  • Current regimens should be identified and

taper of one agent discussed with patient

  • ongoing medication regimen containing both

benzos and stimulants should be subject to peer review

  • new patients should be informed that they

cannot continue an existing regimen containing both agents

slide-17
SLIDE 17
  • 4. Stimulants with Antipsychotics
  • Limited indications, must be carefully

documented

  • Generally contraindicated
  • Dopamine agonist vs Dopamine antagonist
  • Can create or increase psychosis
  • Can increase anxiety/agitation
  • Should prompt full review of regimen
slide-18
SLIDE 18
  • 4. Stimulant with Antipsychotics
  • Patient stability is THE MOST IMPORTANT

CONSIDERATION

  • If not carefully and symmetrically

implemented we may destabilize patients

– Decreasing stimulant unilaterally can sedate – Decreasing antipsychotic unilaterally can create psychotic regression

slide-19
SLIDE 19
  • 4. Stimulant with Antipsychotics
  • This is the most complicated transition
  • This has a high benefit/risk outcome
  • This is an opportunity to reduce dosages of

antipsychotics as countervailing stimulant doses are reduced

  • This is a sensitive negotiation with patient-

safety implications

  • We can improve the care of SPMI clients by

bringing these changes

slide-20
SLIDE 20

Stimulants use by Specialists

  • Off label uses (usually low dose)
  • Treatment-resistant Depression
  • Brain injury
  • Cognitive impairment
  • Pervasive Development Disorders
slide-21
SLIDE 21

Recognizing that……

  • There will be individual exceptions
  • Patient well-being and stability is the primary

concern

  • Documentation of exceptions must be

completed and supported by clear explanations of risk/benefit and of treatment goals directed toward Recovery

slide-22
SLIDE 22

Rx Concept

  • “One Controlled Substance per Brain”

– Optimizes medication effect – Reduces drug interaction – Enhances patient safety – Minimizes diversion – Reduces documentation and UDS burden – Elevates the Standard of Practice

slide-23
SLIDE 23

Stimulant Prescribing Changes: How do we do this?

  • Organizational leadership support
  • Stop starting these Rx
  • Preparation for the change in policy
  • Talking points for patients
  • Education and Negotiation
  • Timing and time, this is not usually an

emergency

  • Reasonable expectations
slide-24
SLIDE 24

Delivering the Message

  • “We have a new Policy and we have to do

this”

  • “There are new Agency guidelines and this is

the way we are going”

  • “We are using some newer methods…”
  • “I think we may be able to help you feel better

by reducing some medications…”

  • “If we make some changes in your medication

we can help you move toward your goal of….”

slide-25
SLIDE 25

Upgrading UDS

  • Molecular testing vs dipstick or lab routines
  • Specific and quantifiable results
  • Alcohol metabolites identify problematic use
  • Quantified results allow tracking of use

– Of special interest in THC

  • One UDS identifies all substances of interest
  • Methods not subject to question/contention
slide-26
SLIDE 26

Next Steps

  • Create peer review process for complicated

cases

  • Create systematic monitoring practices
  • Implement the Prescription Monitoring

Program (PMP) tool in each clinic

  • Implement state of the art Urine Drug Testing

– Molecular and quantified testing – Include alcohol in your testing

slide-27
SLIDE 27

ADDENDUM

  • Free-standing Rx for Adult ADHD
  • Minds are made up, so no arguments on merit
  • 1. Prescriber behaviors
  • 2. Best Practices if you choose to Rx
slide-28
SLIDE 28

Prescriber Behaviors: Adult ADHD Rx

  • Skeptic

– Uncertain of dx and Rx merit

  • Accommodator

– Ambivalent re issue – Responds to patient requests for Stimulants – Conceptualizes “good candidates”

  • Enthusiast

– Stimulants benefit many dx and sx – Often a revenue/volume building tool

slide-29
SLIDE 29

Skeptical prescribing

  • Not convinced that dx is significant
  • Subscribes to alternative tx
  • Concerned about academic and workplace

abuse of drug

  • Not wanting to Rx without clear end point
  • Agency can offer support by excluding free-

standing stimulants in adults except in specific protocols

slide-30
SLIDE 30

Skeptic: what medications merit lifelong Rx?

  • Life-long EVIDENCE-BASED:
  • Insulin, ACE/ARB for renal sparing, Beta-blockers post MI,

ASA preventive, COPD, hypothyroidism

  • Life-long PERHAPS:

– biologics for RA, MS, IBD, CLL, antidepressants, mood stabilizers

  • Life-long NOT ESTABLISHED:

– oncologic, reproductive/growth hormones, Stimulants

slide-31
SLIDE 31

Skeptical Prescribing

  • Once started: when and how to d/c the drug?
  • Schedule II monitoring requirements
  • Dosage creep
  • Diversion
  • Aging and contraindications
  • Pressure for colleagues and competitors
slide-32
SLIDE 32

Skeptical Prescribing

  • Normalization versus pathology of attention

complaints

  • Most common cause of adult fatigue and poor

focus is poor sleep

  • Mountains of energy drinks and OTC remedies in

stores

  • Improved performance/wellbeing on stimulant is

NOT diagnostic: MOST people will feel a boost

  • MJ use is common and impairing
slide-33
SLIDE 33

Accommodating Prescribing

  • Adult ADHD is real, Stimulants have some

value

  • Needs some point of view on eligibility
  • Case by case decisions
  • Dosage creep
  • Documentation burden for Schedule II
  • These drugs are “crowd pleasers”
  • What is “end point of treatment”?
slide-34
SLIDE 34

Enthusiast Prescribing

  • Stimulants are useful/essential for full

function in many adults

  • Contraindications are few, risks acceptable
  • Dosages need to be adjusted upward
  • Geriatric benefit
  • Life long treatment
slide-35
SLIDE 35

So you want to Rx Stimulants for Adult ADHD?

  • Define the criteria for your Rx

– Age range, need, potential benefit

  • Document the basis for Rx

– Childhood treatment hx with success – Specific sx to benefit

  • Create Treatment Plan

– Date for re-evaluation – Date for termination

slide-36
SLIDE 36

So you want to Rx Stimulants for Adult ADHD?

  • Clinic routine

– Same day Rx, ie Tuesday is Stimulant day – Only 28 or 72 day Rx: removes urgent refills

  • PMP

– routine

  • What does a negative UDS test mean?

– It means you probably made a mistake in Rx

slide-37
SLIDE 37

Keys to Safety: Prescriber & Patient

  • Take the same care when writing Stimulant Rx

as you would when writing a Morphine Rx

  • Think “one controlled substance per brain”
  • Avoid countervailing Rx
  • Create your own Point of View, define it,

communicate it, and stick to it.

slide-38
SLIDE 38

End