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Nursing Capstone Project Sample

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How PDMP and utilizing evidence-based guidelines prior to prescribing benzodiazepines and opioids to the adult population can reduce mortality and overdose of the drugs

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Nature of the DNP Project

Most people in America always describe drug problem as opioid and benzodiazepines epidemic but provides no solution that can be used to fix this current problem facing the country. Reports indicate that more than 100 Americans always day each and every day from the drug overdoses (Hedberg, 2011). Management of combined dose of opioid and benzodiazepines is very important as it impacts on the lives of so many Americans. As per the review done by the American Food and Drug Administration (FDA), the growing prescription of combined benzodiazepines and opioid medication have always resulted into major side effects, that include comprised breathing and even deaths. Even as the opioid alone has become a major problem in the US, overdose deaths that involve sedative and anti-seizure medications within benzodiazepine category have risen in the recent times (Hedberg, 2011). A combined prescription of opioid and benzodiazepines have increased for more than three times with fatal overdose being reported to have increased by more than 4 times within the last 20 years as established by numerous scholarly research (Ong, Olson, Cami, Liu, Tian, Selvam & Mandl, 2016). Cases of overdose have risen in the recent past, suggesting that people are currently using opioid and benzodiazepines at a riskier rate than it has ever been before.

In order to minimize the potential negative impact of opioid and benzodiazepine prescription, several government agencies and stakeholders in health have always come together to design clinical practice guidelines that help in promoting more effective treatment of pain while at the same time reducing the number of people who suffer from opioid and benzodiazepines overdose or disorders (Hedberg, 2011). Prescription Drug Monitoring Programs (PDMPs) have always been established to clearly indicate the guidelines necessary to be undertaken before a physician prescribes opioid and benzodiazepines.

It has always expected that such guidelines would help reduce the prescription related overdose deaths among the patients and adult populations. Even with this however, not much evidence has been established on how utilizing evidence-based guidelines and PDMP prior to prescribing treatment of opioid and benzodiazepines can reduce the overall overdose effect and mortality rate that are associated to the prescription of these two drugs. The present DNP project seek to establish how accessing PDMP and utilizing evidence-based guidelines prior to prescribing treatment compared to not using the PDMP and evidence-based guidelines assist in the reduction in the mortality and overdose rate over a 6-month period. That is, the paper seeks to establish how the utilization of the available Prescription Drug Monitoring Programs as well as evidence-based guidelines can help in reducing the general mortality and side effects associated with the prescription of opioid and benzodiazepines (Hedberg, 2011).

Description of the Problem, Environment and Target Population

The risk of overdose, death and even addiction are increased when patients tend to be prescribed for higher doses of combined opioid and benzodiazepines. A recent study had shown that nearly 70% patients using prescribed opioids also had benzodiazepines prescribed for them, putting this group of patients into higher risk of overdose (Ong, Olson, Cami, Liu, Tian, Selvam & Mandl, 2016). Misused of prescription of opioid and benzodiazepine is a major risk factor to overdose and death. The year 2014 saw Americans filled more than 200 million prescriptions for the opioid pain relievers alone, making the drug classified as the most prescribed medication within America. Even with high rate of prescription however, studies have established that patients who have central pain syndrome always respond in a better way to the anticonvulsant and antidepressant medications that the opioid and benzodiazepines (Ong, Olson, Cami, Liu, Tian, Selvam & Mandl, 2016).

Chronic prescription of opioid and benzodiazepines has also been reported to increase the general pain sensitivity as well as exacerbating pain circumstances. A study carried out by Dobscha (2013) within the recent past reported that combined opioid and benzodiazepines were prescribed to close to 90% of the patients following their individual nonfatal overdose. Of the patients who received combined prescription, more than 60% did remain on high dose of prescription even after the overdose (Dobscha, 2013).

The 2013 national survey on drug use and health reported that at least 4 million people in the US were current users of non-medically prescribed opioid and benzodiazepines. Literature affirms that this non-medical usage of opioid and benzodiazepines as well as some other prescription drugs always constitute very risky and hazardous behavior which scholars point out that should always be discouraged at all cost (Kim, McCarthy, Courtney, Lank & Lambert, 2017). The medication therapy that is attached to opioid and benzodiazepines focuses on both nonmedical use as well as making an important trial of treating addiction and medical illness (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007). The combined usage of opioid and benzodiazepines is strongly associated with high rate of mortality, with the main cause of death among individuals using these drugs for the non-medical functions being trauma and overdose (Kim, McCarthy, Courtney, Lank & Lambert, 2017). Some researchers have even established that the injection route used for opioid and benzodiazepines can increase the risk of one being exposed to a number of communicable diseases like viral hepatitis, HIV plus some other infectious agents.

Moreover, Benzodiazepines is known to be having numerous safety risks. Other than the overdose, they are very much associated to falls, motor vehicle accidents, fractures and can as well lead to higher rate of addiction and misuse. Within the last 2 decades, the number of elderly persons who receive combined opioid and benzodiazepines prescriptions grew by close to three-quarters, from around 9 million to more than 15 million (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007). The same study did also establish that the extent of distribution of these medications had grown by more than three-fold (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007). After making standardization of the doses of all these drugs, they did find out that people who had prescriptions did get more than three times more medications in the year 2014 than it had been in the earlier years. Benzodiazepines were frequently being prescribed for the anxiety disorders, as well as mood disorders like insomnia and depression.

Data generated from the Centers for Disease Control and Prevention shows that overdose deaths that are associated with combined opioid and benzodiazepines did rise from 0.58 in the year 1999 to more than 3.07 in the year 2013 (Kim, McCarthy, Hoppe, Courtney & Lambert, 2017). Higher doses, several treatment days and individuals combining their prescriptions with the illegally obtained opioid and benzodiazepines have always accounted for an increased overdose deaths within the population. Overdose deaths are typically experienced when benzodiazepine are combined with the other sedating dugs like the opioid (Lonsdale & Baker, 2013).

Based on these dangerous impacts associated with opioid and benzodiazepines, the Center for Disease Control and Prevention (CDC) and other government agencies have always come up with Prescription Drug Monitoring Programs (PDMPs) as well as evidence-based guidelines to assist in the reduction of the amount of co-prescribe benzodiazepines and opioids. The programs and clinical practice guidelines in this case have always sought to promote a more safer and effective chronic pain treatment while at the same time minimizing the number of individuals who misuse the two drugs, co-prescribed benzodiazepines and opioids or the number of people who overdose these two powerful drugs (Lonsdale & Baker, 2013).With the introduction of properly outlined guidelines, it has always been expected that co-prescribed benzodiazepines and opioids overdose and deaths among the elderly persons in the US can drop by more than 50 percent (Freynhagen, Geisslinger & Schug, 2013).

A more recent national guideline for the prescription of opioids was released in 2016 by the center for disease control and prevention. Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger (2018) reported that such guidelines are then to make sure that patients get access to a safer and effective treatment of pain while at the same time reducing the possible incidences of co-prescribed benzodiazepines and opioids related deaths, overdose and disorders. Even with these guidelines in place, however, not much scholarly works have been done on how accessing PDMP and utilizing evidence-based guidelines prior to prescribing treatment compared to not using the PDMP and evidence-based guidelines assist in the reduction in the mortality and overdose rate over a 6-month period (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). The present project seek to fill this gap by investigating how the utilization of the available Prescription Drug Monitoring Programs as well as evidence-based guidelines such as those offered by CDC can help in reducing the general mortality and side effects associated with the prescription of opioid and benzodiazepines.

Purpose of the project

Prescription of opioid and benzodiazepines are very important in improving the general functioning as well as quality of life for the patients who might be living under chronic or acute conditions. Even though there are some other prescribed drugs that have the risk of being misused, of greater concern has always been the misuses of the prescription of opioid and benzodiazepines, which has been reported within the recent past to be having high potential of abuse and can always result into life-threatening adverse events when they are taken in excess or in combination with other prescribed drugs (Dowell, Haegerich, & Chou, 2016).

Prescription opioid and benzodiazepines abuse and overdose is a major public health concern within America. The overall death rates that are associated with drug overdose have shown consistent increase since 1980s, making drug overdose one of the most causative agents of injury death in the US (Dowell, Haegerich, & Chou, 2016). In 2013 alone opioid analgesics did comprise of around 16000 deaths, very high such that it even exceed the number of deaths reported from other classes of drugs A national survey conducted in relation to Health and Drug Use in 2014 did estimate that close to 2 million residents of the US had addiction to the opioid pain reliever (Dowell, Haegerich, & Chou, 2016). These figures exclude the other 3 million or more adult patients who are likely to be suffering from the opioid use disorder since the national survey in this case never included people who get legitimate opioid prescriptions.

Any public health response to this problem must have its focus on trying to prevent new cases of the opioid and benzodiazepines addiction or ensuring effective prescription of the two drugs so as to prevent drug related overdose and injury deaths. Such response should also ensure that the prescribers continuously meet the important needs experienced by patients who are experiencing a lot of pain (Freynhagen, Geisslinger & Schug, 2013). It is recognized very widely that a kind of multi-prolonged strategy is required to address the crisis associated with opioid and benzodiazepines. A successful response to the problem could target the points along the whole prescription spectrum of production of drug, distribution, dispensing after prescribing, and lastly, treatment that can result into abuse and provide chances to intervene for the main purpose of trying to prevent and to treat any form of misuse, abuse and overdose of the two drugs (Freynhagen, Geisslinger & Schug, 2013).

The present project seek to investigate how the utilization of the available Prescription Drug Monitoring Programs as well as evidence-based guidelines such as those offered by CDC can help in reducing the general mortality and side effects associated with the prescription of opioid and benzodiazepines. CDC has always lead the great effort of coming up with guidelines for prescribing opioid together with other drugs for treating the adult patients who might be suffering from chronic pain within the primary health care set-ups.

According to the guidelines, it is recommended that the prescribers should always prescribe very low doses of the drugs as possible. The prescribers are also required, as per the guidelines, to not prescribe very greater quantity than the one which is required for the expected time in which pain will be experienced to be severe enough to require opioid and benzodiazepines pain relievers (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). However, not every prescriber always use these guidelines and prescription drug monitoring programs. Some physicians are exposed to these guidelines and tend to utilize them while some other physicians are not much exposed to the guidelines. However, not many studies have always been carried out to help establish the significance outcome on patient safety and recovery among the prescribers who are accessed to the opioid prescription guidelines and prescription drug monitoring programs compared to the prescribers who are not exposed to such guidelines and monitoring programs (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). The present study seek to fulfill this purpose by establishing the extent to which the use of opioid prescription guidelines and prescription drug monitoring programs are effective in reducing the incidence of high mortality and overdose associated with prescription of opioid and benzodiazepines.

Significance of the DNP Project

Opioid together with other prescriptions such as benzodiazepines is almost being declared a national emergency in America by the current regimen. Opioid problem is classified as among the main causes of injury-related deaths in the US. The problem is so big that doctors and other members of health professionals are being called upon to come up with specific action plan so as to handle the problem. The actions include but not limited to: educating health providers on the specific guidelines on how to prescribe appropriate medication for the epidemic, availability of naloxone, having access to treatment, preventing the practice of abusing the drug, and sharing practices that are deemed as effective (Lonsdale & Baker, 2013). Most stakeholders including the center for diseases controls have always come up with guidelines and prescription drug monitoring programs to help avert the crisis associated with opioid prescription.

However, not much study has been carried out to investigate how such programs and guidelines are effective in reduction in the mortality and overdose rate associated with the two drugs (Lonsdale & Baker, 2013). The present study is of very great significance as it seek to establish the extent in which such programs and guidelines can help reduce the mortality and overdose rate that are associated with the combined prescription of opioid and benzodiazepines. First, the study seek to inform the prescribers on how effective such guidelines are programs are with regards to helping them curb the opioid and benzodiazepines prescription such as high mortality and overdose. The project will also be of great significance to some other stakeholders like the CDC as it will inform them on the level of effectiveness their programs are guidelines are and the areas which they need to improve on in order to make such programs and guidelines become more effective in reducing the mortality and overdose rate among adults who have these drugs prescribed to them.

Definition of Relevant Terms

Opioid-These are substances that generate the morphine-like effects and are always used medically to relief pain

Benzodiazepines: These are group of drugs that are used primarily to manage or treat anxiety though they are also very effective in the treatment of other numerous conditions.

PDMP -Prescription drugs monitoring programs

Mortality –Number of deaths that a rise from opioid and benzodiazepines prescriptions

Overdose- Excessive use of a drug that results into severe health effects that could even lead to death

Assumptions

The general assumption for this project is that utilization of prescription drug monitoring program (PDMP) and evidence-based guidelines prior to prescribing benzodiazepines and opioids to the adult population can reduce mortality and overdose of the drugs

Limitations

One major limitation of this study is the fact that it intend to measure the effectiveness of the monitoring program (PDMP) and evidence-based guidelines within a very short period of time, six month. It might not be very easy to measure the change of mortality and overdose incidences within a period of six months. Expanding the time period to maybe two years would help generate a more reliable result than the one generated for the six months period.

DNP Project Objectives

Based on the problem statement described above, this DNP project seeks to achieve the following objectives:

  1. To establish the proportion of prescribers of benzodiazepines and opioids who always have access to Prescription drug monitoring programs and utilizes evidence-based guidelines prior to prescribing the drugs to their patients
  2. To determine the extent to which the use of Prescription drug monitoring programs and utilizing evidence-based guidelines prior to prescribing benzodiazepines and opioids to the adult population can reduce mortality and overdose of the drugs
  3. To suggest ways in which access to Prescription drug monitoring programs and utilization of evidence-based guidelines prior to prescribing benzodiazepines and opioids can be made more effective in reducing mortality and overdose of the drugs

Summary

Co-prescription of benzodiazepines and opioids to the adult population is a major health risk in the US as high prevalence of mortality and overdose has been reported in this group. This first chapter has looked at the nature of DNP project which in this case is to analyze how PDMP and utilizing evidence-based guidelines prior to prescribing benzodiazepines and opioids to the adult population can reduce mortality and overdose of the drugs. The project specifically targets the opioid and benzodiazepines related mortality and overdose among the elderly who are commonly prescribed to these classes of drugs. The chapter has also described the purpose of the DNP Project, the significance of the project, definition of relevant terms, different assumptions, study limitations and lastly project objectives. The next chapter presents the general theoretical framework and the literature review for the project.

LITERATURE REVIEW AND THEORITICAL FRAMEWORK

Summary of Relevant Research

Thousands of people have died either directly or indirectly from opioid and benzodiazepines excessive prescriptions in the United States (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). This forced the patient advocacy groups as well as the pain specialists to lobby the state medical boards together with the state legislatures to make changes of the regulations and statutes so as to lift any form of prohibition of non-cancer pain use of opioid (Kim, McCarthy, Courtney, Lank & Lambert, 2017). In around 20 states, the statutes, guidelines, laws and regulations did liberalized the long lasting usage of opioids for the non-chancer pain, reflecting the generally prevailing thought at the period when there is absence of the clinically viable ceiling on the required maximum opioid dosing (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). By introducing pain as the fifth vital sign, there has been a major increase in the increased opioid sales.

Scholarly studies have shown consistent and strong linear relationships between the sales volume of opioid and mortality and morbidity that is associated with all these products (Kim, McCarthy, Courtney, Lank & Lambert, 2017). As the death associated with opioid continues to go higher, resulting into a general national epidemic together with public health emergency, a number of systematic reviews have always been used to assess the general effectiveness and efficacy of opioids for the chronic non-cancer pain (Kim, McCarthy, Courtney, Lank & Lambert, 2017). These forms of systematic reviews have always confirmed that the general effectiveness of the chronic opioid treatment for the chronic pains are much limited, with the effect on the improved human function being considered to be too small and safety profile of the opioids being poor (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007).

Numerous adverse events that are related to the usage of opioid, including the general infertility and hypogonadism, the neonatal abstinence syndrome, disorders that are related to sleep breathing, the opioid-induced hyperalgesia, and lastly, cardiac arrhythmias and lastly fructures and fall among the elderly (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007). The prescription of combined opioid and benzodiazepines has also been associated with frequent hospitalization and visit to the emergency department, having very higher rates of deaths from cases of unintentional poisonings, more also at dosage that is more than morphine milligram equal a day, which occurs general at home during the time of sleep (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007). Studies have also reported very minimal improvements in pain after a long term usage of opioid.

Evidence from the policy strategies by the state and the effects they have had in the general opioid and benzodiazepines prescription patterns always shows that the state governments are very much willing to promote effective and safe pain management while at the same time taking all the necessary precautions so as to curb the ever increasing deaths and morbidity that are related to opioid (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). However, there exist major variations in policy language. Some states always emphasize on the need to manage illicit trafficking and abuse of drug, while some other states encourages proper management of pain as they discourage any form of undue burden that might be placed on the practitioners as well as the patients (Glanz, Narwaney, Mueller, Gardner, Calcaterra, Xu & Binswanger, 2018). For instance, the Washington State experience is a good informative guideline policy that are applicable in this case.

The Washington state did respond to the opioid related mortality and morbidity in the year 2007 by having close engagements with different state agencies to work together with the practicing pain clinicians and the academicians so as to promulgate the dosing guidelines of co-prescribed opioid and benzodiazepines (Zador, Rome, Hutchinson, Hickman, Baldacchino, Fahey & Kidd, 2007). The major recommendation developed in this case was to look for the specialty consultation if the patient happens to reach the 120 morphine milligram equivalents in a single day without having properly improved pain or even function.

References

Hedberg, K. (2011). Prescription Opioid Overdose in Oregon: A public health perspective. Oregon Health Authority.

Ong, M. S., Olson, K. L., Cami, A., Liu, C., Tian, F., Selvam, N., & Mandl, K. D. (2016). Provider patient-sharing networks and multiple-provider prescribing of benzodiazepines. Journal of general internal medicine, 31(2), 164-171.

Dobscha, S. K. (2013). Prescription opioids and benzodiazepines: moving beyond “just say no”. Pain Medicine, 14(10), 1447-1449.

Kim, H. S., McCarthy, D. M., Courtney, D. M., Lank, P. M., & Lambert, B. L. (2017). Benzodiazepine-opioid co-prescribing in a national probability sample of ED encounters. The American journal of emergency medicine, 35(3), 458-464.

Zador, D., Rome, A., Hutchinson, S., Hickman, M., Baldacchino, A., Fahey, T., … & Kidd, B. (2007). Differences between injectors and non-injectors, and a high prevalence of benzodiazepines among drug related deaths in Scotland 2003. Addiction Research & Theory, 15(6), 651-662.

Kim, H. S., McCarthy, D. M., Hoppe, J. A., Courtney, D. M., & Lambert, B. L. (2017). Emergency Department Provider Perspectives on Benzodiazepine‐Opioid Co‐Prescribing: A Qualitative Study. Academic Emergency Medicine.

Lonsdale, D. O., & Baker, E. H. (2013). Understanding and managing medication in elderly people. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(5), 767-788.

Glanz, J. M., Narwaney, K. J., Mueller, S. R., Gardner, E. M., Calcaterra, S. L., Xu, S., … & Binswanger, I. A. (2018). Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy. Journal of general internal medicine, 1-8.

Freynhagen, R., Geisslinger, G., & Schug, S. A. (2013). Opioids for chronic non-cancer pain. BMJ, 346, f2937.

Dowell, D., Haegerich, T. M., & Chou, R. (2016). Prescribing Opioids for Chronic Pain—Reply. Jama, 316(7), 774-775.

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