The following case vignette provides key concepts that could be considered when developing a plan of care for a patient who may require a controlled substance to manage their health concerns. As with any clinical situation, there are many patient variables that must be considered, including comorbid conditions, social determinants of health and their personal choices. You may choose to include different or additional health history and physical examination points, diagnostic tests, differential diagnoses and treatments depending on your patient’s context however this case vignette focuses on the aspects relevant to controlled substances.
June is a 73 year old woman who is a new patient recently referred to the primary care clinic and seeing Matt, the NP. She is seeking a refill for her lorazepam, which she has been taking for anxiety/poor sleep since her husband’s death 10 years ago. Her prescribed dose is 1 mg at bedtime, but she has been taking 2 mg at bedtime for the last 2 to 3 months due to poor sleep. She also takes a tablet during the day with glass of scotch for anxiety. Her other medications include candesartan and paroxetine for depression. June is a patient in the clinic so Matt has her health history available on the EMR. Matt takes a full health history. Pertinent findings in relation to this CDS use vignette is reported here.
She tells Matt that she had an ED visit 2 months ago after a motor vehicle accident where she crashed car into a parked car while driving home from the grocery store. She received a refill for her lorazepam at that time. Finally, she fell at home 3 weeks ago after tripping while taking out the garbage. She did not present for assessment but thinks she sprained her wrist. She has been taking ibuprofen 2 to 3 times daily for pain and wants Tylenol with codeine (T3). Matt attempts to open discussion of benzodiazepine use and falls/accidents. She is surprised and says “this has never been an issue, no one ever told me this before”.
Clinical office – including a desk, two chairs, an exam table, an EMR on computer, a BP cuff/machine, and a stethoscope.
Matt is wearing shirt and slacks, with a lab coat. Brown short hair.
Matt: So I understand you need a refill on your medication today June.
June: Yes…I am almost out of my lorazepam prescription because I’ve needed to take an extra one at night for the last couple of months to help me sleep. Sometimes I need one through the day too because I get anxious. I tried having a shot of Scotch but that doesn’t help at all. I also want a few of those Tylenol with Codeine to help with the pain in my wrist. I fell a couple of weeks ago and the ibuprofen isn’t helping. My daughter gave me a couple of T3’s and they really worked!
Matt: OK…let’s talk about the wrist injury first. How did it happen?
June: I tripped on a mat while I was taking out the garbage. I was feeling a little dizzy that day like I get sometimes. I didn’t think it was anything so I didn’t get it checked. I don’t want people to think I’m sick all the time. I was in the ED a couple of months ago after a little car accident but everything was OK.
Matt is thinking about history questions for the wrist injury:
|OLDCARTS – for wrist pain
Matt: Now that you mention it, I do see a report here about the ED visit. So you weren’t hurt. What can you tell me about the accident? Were you feeling dizzy that day?
June: As a matter of fact, I think I was feeling a little dizzy that morning. I figured it’s because I haven’t been sleeping all that great…the anniversary of my husband’s death always makes me unsettled.
Matt: Do you remember if you took any extra lorazepam that day or the night before?
June: I’m not sure but I probably did because I hadn’t been sleeping well for a while before that.
Matt: What about any alcohol…did you have anything to drink that day before you went out?
June: Oh no…I’d never to that! I only have a drink if I know I don’t have to drive anywhere…usually in the afternoon while I’m watching my shows.
Matt: OK…what about the day that you fell and hurt your wrist…do you remember if you’d taken any extra pills or if you had anything to drink?”
June: Wow…that’s hard to remember…I’m not sure.
Matt thinks about the additional assessments for the wrist injury, falls risk and use of alcohol along with her benzodiazepines.
|Additional assessments for the wrist injury:||
Matt: I have to tell you that I’m a little worried about a couple of things June. You tell me that you are taking more lorazepam than what was initially prescribed and that you are also using alcohol. When you use this medication and along with your blood pressure medicine and the pill for your depression, they can work together to make you dizzy and disoriented. That could be the reason for your fall and even the car accident. Do you remember any other falls?”
June: I trip every once in a while but I figure that’s because I’m getting old and I’m not in shape like I used to be when I exercised a lot. Wow…this has never been an issue…no one ever told me this before!
Matt thinking about other tools her could use to assess June today. As Matt is discussing this with June he is thinking about the other tools he would use to confirm his diagnosis.
|He decides that he will use the following tools to assess June:||
(See the resources area for further information about these tools)
Matt: From what you’ve told me, your depression score hasn’t changed since the last time it was recorded on your health record and you tell me you’re feeling anxious but your score only shows this as mild right now. I’m not saying that this isn’t something that we need to talk about but I think your paroxetine is still at a good dose for you. I am concerned that you are drinking alcohol while taking the lorazepam.
Select lab tests you could order for June:
|What are your differential diagnoses for June’s symptoms in addition to her established diagnoses of hypertension and depression?||Answers:
|What is your leading or most likely diagnoses for June’s symptoms?||Answers:
|What would your treatment plan include today for June?
The BEST answers today are:
3. Continue current paroxetine dose.
|Is there anything else Matt should do before providing June with a prescription?||Answers:
Matt: OK June, here’s the plan I propose. I will give you a 30-day supply of your lorazepam as it was originally prescribed which is once daily at bedtime. I’m going to order an X-ray of your wrist to see if there are any broken bones. I’d like to suggest that you get some counseling to help with the anxiety because taking extra lorazepam is not safe when added to the other medications you take and I’m really worried about you getting hurt from a fall. Finally, I’d like to book an appointment to see you again in a week to look at the X-ray and talk some more about your symptoms.
June: You mean you aren’t going to give me something for this pain in my wrist?
Matt: No June…not until we see if there are any broken bones. I think we’d be better getting you in to see the clinic physiotherapist who can help you with some treatments for the pain and exercises to get it strong again. In the meantime, you can keep using your wrist support and take plain Tylenol for pain.
|What other education should Matt provide June about her prescription?||Answer:
Complete a treatment agreement for June using the McMaster Opioid Treatment Agreement Template.
Matt: Do you have any other questions?
June: No…I’m not happy that I can’t have any T3s but at least I might be able to sleep now that I’ll have enough of my other pills. I guess I have to come back in a week then.
Matt: I’d like to see you again after you’ve had your X-ray…yes but you can always call back if anything changes.
By the end of this learning outcome, the participant should be able to:
- Recognize misuse of prescription controlled substances through history, physical and diagnostic tests in an older adult.
- Predict risk for falls, depression, anxiety and substance misuse in an older adult.
- Manage safe prescribing of benzodiazepines in the older adult
- Examine the use of treatment agreements in the older adult.
- Recognize the impact of prescribed control drug substances on patient safety in the elderly population.