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Event 4: Mr. Nguyen
Discharge, Taper Plan: Mr. Nguyen
You are preparing to discharge Mr. Nguyen, a 45-year-old, from the hospital with a prescription for oral ydromorphone 2 to 6mg q4h as needed. You anticipate the need for continuing opioids for 2-3 weeks given the patient’s condition.
Test Your Knowledge
Discharging Mr. Nguyen
What things would you want to cover when discharging Mr. Nguyen? More than one answer may apply.
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Discussion
Discharge should cover the following:
Provide a taper plan
Assure patient discharge teaching regarding safe use, storage, and disposal.
Provide no more than 2 weeks supply of opioids at time of hospital discharge, in some cases, less
Confirm appropriate referrals for substance use disorder treatment or mental health followup
Inform the patient who is the point-of-contact for questions about opioid prescriptions after discharge
Opioid Disposal
The nurse tells you, “I told Mr. Nguyen to store his opioids in a secure location where others cannot access it. What should I tell him about how to dispose of unused pills?”
What's your response?
Incorrect
Incorrect. Unused quantities can only be accepted at DEA sanctioned sites or takeback programs. The best method of disposal is prompt return of unused opioids to a DEA-approved takeback program or flushing the opioids. The FDA recommends flushing for medicines that are especially harmful or fatal with just one dose. Remind the patient of the dangers of prescription opioid diversion and the importance of secure storage of their medications. Sharing medications with others is never appropriate and is illegal. Instruct the patient and family on prompt disposal of controlled substances either through a DEA-approved takeback program or FDA guideline for safe disposal of medicine.
Incorrect
Incorrect. Unused quantities can only be accepted at DEA sanctioned sites or takeback programs. The best method of disposal is prompt return of unused opioids to a DEA-approved takeback program or flushing the opioids. The FDA recommends flushing for medicines that are especially harmful or fatal with just one dose. Remind the patient of the dangers of prescription opioid diversion and the importance of secure storage of their medications. Sharing medications with others is never appropriate and is illegal. Instruct the patient and family on prompt disposal of controlled substances either through a DEA-approved takeback program or FDA guideline for safe disposal of medicine.
Correct
Correct. Unused quantities can only be accepted at DEA sanctioned sites or takeback programs. The best method of disposal is prompt return of unused opioids to a DEA-approved takeback program or flushing the opioids. The FDA recommends flushing for medicines that are especially harmful or fatal with just one dose. Remind the patient of the dangers of prescription opioid diversion and the importance of secure storage of their medications. Sharing medications with others is never appropriate and is illegal. Instruct the patient and family on prompt disposal of controlled substances either through a DEA-approved takeback program or FDA guideline for safe disposal of medicine.
Incorrect
Incorrect. Unused quantities can only be accepted at DEA sanctioned sites or takeback programs. The best method of disposal is prompt return of unused opioids to a DEA-approved takeback program or flushing the opioids. The FDA recommends flushing for medicines that are especially harmful or fatal with just one dose. Remind the patient of the dangers of prescription opioid diversion and the importance of secure storage of their medications. Sharing medications with others is never appropriate and is illegal. Instruct the patient and family on prompt disposal of controlled substances either through a DEA-approved takeback program or FDA guideline for safe disposal of medicine.
Insurance Coverage Restrictions
The pharmacist says, “Mr. Nyugen’s insurance company restricts coverage on the number of tablets. How much should we give him?”
What’s your response?
Incorrect
Incorrect. The goal is always the shortest duration and the lowest effective dose. For some, it may be appropriate to discharge patients on acetaminophen or NSAIDs only or with only a very limited supply of short-acting opioids (e.g., 2-3 days), even if they were taking opioids before admission. Counsel Mr. Nguyen to taper the opioid as soon as possible, which can be as soon as 1-2 days or as slowly as 20% every week.
Incorrect
Incorrect. The goal is always the shortest duration and the lowest effective dose. For some, it may be appropriate to discharge patients on acetaminophen or NSAIDs only or with only a very limited supply of short-acting opioids (e.g., 2-3 days), even if they were taking opioids before admission. Counsel Mr. Nguyen to taper the opioid as soon as possible, which can be as soon as 1-2 days or as slowly as 20% every week.
Correct
Correct. The goal is always the shortest duration and the lowest effective dose. For some, it may be appropriate to discharge patients on acetaminophen or NSAIDs only or with only a very limited supply of short-acting opioids (e.g., 2-3 days), even if they were taking opioids before admission. Counsel Mr. Nguyen to taper the opioid as soon as possible, which can be as soon as 1-2 days or as slowly as 20% every week.
Incorrect
Incorrect. The goal is always the shortest duration and the lowest effective dose. For some, it may be appropriate to discharge patients on acetaminophen or NSAIDs only or with only a very limited supply of short-acting opioids (e.g., 2-3 days), even if they were taking opioids before admission. Counsel Mr. Nguyen to taper the opioid as soon as possible, which can be as soon as 1-2 days or as slowly as 20% every week.
Summary
The CDC guidelines state: long term opioid abuse often begins with treatment of acute pain. Three days or less will often be sufficient; more than seven days will rarely be needed.
According to the WA AMDG guidelines, a patient should not be discharged with more than 2 weeks supply of opioids. Additional opioid prescribing requires reassessment. For some minor surgeries, it may be appropriate to discharge patients on acetaminophen or NSAIDs only or with only a very limited supply of short-acting opioids (e.g., 2-3 days), even if they were taking opioids pre-operatively.
Be sure to:
Instruct the family on safe use (e.g. avoid alcohol) and the planned taper
Inform the patient and family which provider will be responsible for managing any opioids
Remind the patient of the dangers of prescription opioid diversion and the importance of secure storage of their medications.
Instruct the patient and family on prompt disposal of controlled substances either through a DEA-approved take-back program or FDA guidelines for safe disposal of medicine.
The goal is always the shortest duration and lowest effective dose that is no more than a 2-week supply.