Week 5 Assignment: De-Prescribing

What is the importance of de-prescribing? How might you assist a patient to taper from a medication safely or transition to a new medication?

In this Assignment, you will use the following patient examples to write a 5- to 6-page paper on considerations you have for how you might de-prescribe. Support your answers with five (5) evidence-based, peer-reviewed scholarly literature resources outside of Required Learning Resources in this course.

Note: APA style format guidelines will apply.

Patient Examples:

Patient 1: A 36-year-old male presents to your office being prescribed by his primary care physician (PCP) for the past 3 years an opioid analgesic medication for a work accident. He has chronic pain and is attending a pain clinic. It is determined the best course of treatment for pain is to remain on opioid medication. The patient is also being prescribed clonazepam 1mg BID for “relaxation” and panic attacks.

Patient 2: A 42-year-old female on alprazolam 1mg BID for panic attacks. Panic attacks have been in remission and the patient wants to taper off the medication. But, every time she has attempted to do so in the past, she experienced withdrawal effects. She is wondering how to safely taper off the benzodiazepine medication without having withdrawal effects.

Patient 3: A 24-year-old female prescribed lorazepam 1mg TID for generalized anxiety disorder. She recently found out she is pregnant (9 weeks gestation). She was referred to you by her OB-GYN to discuss this medication for her current situation. The patient is wondering if she can stay on the lorazepam through her pregnancy and postpartum, as it is an effective medication for anxiety symptoms. She plans to exclusively breastfeed for the first 6 months postpartum. She has not had any other trials of medication to treat anxiety as lorazepam has been effective.

Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”

Learning Resources/Readings

• Goldin, D. S. (2023). Fast facts for psychopharmacology for nurse practitioners. Springer Publishing.
  • Chapter 6, “Anxiolytics and Anti-Anxiety Medications“ (pp. 85–110)
  • Chapter 11, “Sleep Disorders” (pp. 228–247)
• Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
  • Chapter 8, “Anxiety Trauma and Treatment” (pp. 359–378)
  • Chapter 10, “Disorders of Sleep and Wakefulness and Their Treatment: Neurotransmitter Networks for Histamine and Orexin” (pp. 401–448)
• Community Behavioral Health. (2019, February). Clinical guidelines for tapering benzodiazepines. https://cbhphilly.org/wp-content/uploads/2019/02/Helping-Patients-Taper-from-Benzodiazepines-FINAL-3.pdf
• National Center for PTSD. (2013). Effective treatments for PTSD: Helping patients taper from benzodiazepines. https://www.va.gov/painmanagement/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf
• Ogbonna, C. I. & Lembke, A. (2017). Tapering patients off of benzodiazepines. American Family Physician, 96(9), 606–608. https://www.aafp.org/pubs/afp/issues/2017/1101/p606.html
• Drugs.com. (2023). https://www.drugs.com/
• Note: Please use the following resource to check the most up-to-date box warnings, FDA approvals and indications, recommendations for follow-up evaluations, changes, etc.
• Anxiolytic Medication Table
  Note: Utilize the following medication table to familiarize yourself with the medications aligned with the topics presented this week.

Lorazepam	Clonazepam
Alprazolam	Diazepam
Chlordiazepoxide	Propranolol *
Buspirone	Duloxetine
Clonidine *	Catapres*
Guanfacine *	Fluvoxamine
Hydroxyzine	Atenolol*

*Indicates off-label use

Note: Also review SSRI/SNRI and TCA tables from previous weeks.

To prepare for this Assignment:

• Review the assigned Learning Resources for this week.
• Review the definitions presented in your text and resources for de-prescribing and tapering.
• Consider the importance of de-prescribing.
• Based on the example(s) provided, consider how you might de-prescribe a patient.

The Assignment

Answer the following questions using the patient examples described above.

Patient 1

• What are the concerns of the patient remaining on the opioid medication and clonazepam?
• How might you educate the patient about these risks and concerns?

The patient agrees that he should not continue both medications in combination. He would like to “get off” the clonazepam but worries about “bad withdrawals” that he’s heard about from stopping clonazepam “cold turkey” and is concerned about re-occurring panic attacks. How might you respond to the following:

• How would you instruct the patient to taper off clonazepam?
• What other medication would you recommend for the patient for the treatment of his panic attacks? Keep in mind, he will continue the opioid medication for pain relief.
• How would you start the new recommended psychotropic medication for the patient?
• Discuss one legal, ethical, or social consideration with the treatment plan.

Patient 2

• The patient reports withdrawal symptoms when previously tapering off the alprazolam. What symptoms are common withdrawal symptoms from this medication?
• Provide the patient education of withdrawal symptoms that range from common and less serious to withdrawal symptoms that are a cause for concern and that should prompt patient should seek medical attention.
• Given the patient’s history of having withdrawal effects from attempting to taper off alprazolam, what longer-acting benzodiazepine would you choose to convert the patient to?
• What is the dose you would prescribe and how would you taper off the medication?

Patient 3

• Review the potential risks, benefits, and side effects of continuing lorazepam throughout the pregnancy and postpartum for both the patient and fetus.
• Review other alternative medications to treat generalized anxiety disorder. Include risks, benefits, and potential side effects to both the patient and the developing fetus. Keep in mind, the patient is looking to breast feed for 6 months postpartum.
• The patient agrees that it would be safest for her pregnancy and fetus to discontinue the lorazepam. How would you recommend she discontinue lorazepam? Provide education on potential side effects from tapering off the medication, including common side effects to more serious side effects and when to seek medical attention.
• The patient would like to forgo medications at this time, given she is early in her pregnancy and is concerned about “damage” to the fetus if she were to continue medications. Provide education to the patient about the risks of untreated anxiety symptoms during pregnancy for both the patient and the fetus.

Patient 4

• Review potential side effects for elderly on benzodiazepines providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?
• How would you evaluate the patient for these side effects?
• The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?
• Review with the patient and daughter potential side effects of tapering off the medication. Review with them common side effects to more serious side effects and when to seek medical attention.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Walden Writing Center Sample Paper provides an example of those required elements.

By Day 7

Submit your Assignment by Day 7 of Week 5. 

submission information

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NURS_6630_Week5_Assignment_Rubric

NURS_6630_Week5_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning Outcome Patient 1: Describes concerns for patient remaining on the medication and how these risks and concerns will be addressed to the patients. Describes how to assist Patient 1 in tapering medication, as well as what other medication might be prescribed with considerations of legal, ethical, or social considerations to the plan.	20 to >18.0 pts Excellent The response comprehensively describes medication risks and concerns. The response comprehensively and clearly explains how the patient will be educated. The response comprehensively and clearly explains considerations for medication tapering. The response comprehensively and clearly reflects on legal, ethical, or social considerations of the plan. 18 to >15.0 pts Good The response clearly describes medication risks and concerns. The response clearly explains how the patient will be educated. The response clearly explains considerations for medication tapering. The response clearly reflects on the legal, ethical, or social considerations of the plan. 15 to >10.0 pts Fair The response inaccurately or vaguely describes medication risks and concerns. The response inaccurately or vaguely explains how the patient will be educated. The response inaccurately or vaguely explains considerations for medication tapering. The response inaccurately or vaguely reflects on legal, ethical, or social considerations of the plan. 10 to >0 pts Poor The response vaguely or inaccurately describes medication risks and concerns, or it is missing. The response includes inaccurate and vague examples that does not explain how the patient will be educated, or it is missing. The response vaguely or inaccurately explains considerations for medication tapering, or it is missing. The response includes inaccurate and vague examples that does not reflect on legal, ethical, or social considerations of the plan, or it is missing.	20 pts
This criterion is linked to a Learning Outcome Patient 2: Describes common withdrawal symptoms and patient education information. Describes which benzodiazepine might be prescribed to convert the patient, as well as the specific dosing and tapering information.	20 to >18.0 pts Excellent The response comprehensively and clearly explains withdrawal symptoms. The response comprehensively and clearly provides patient education information. The response comprehensively and clearly identifies a benzodiazepine for the patient. The response comprehensively and clearly details dosing and tapering information. 18 to >15.0 pts Good The response clearly explains withdrawal symptoms. The response clearly provides patient education information. The response clearly identifies a benzodiazepine for the patient. The response clearly details dosing and tapering information. 15 to >10.0 pts Fair The response inaccurately or vaguely explains withdrawal symptoms. The response inaccurately or vaguely provides patient education information. The response inaccurately or vaguely identifies a benzodiazepine for the patient. The response inaccurately or vaguely details dosing and tapering information. 10 to >0 pts Poor The response vaguely or inaccurately explains withdrawal symptoms, or it is missing. The response includes inaccurate and vague examples that does not provide patient education information, or it is missing. The response vaguely or inaccurately identifies a benzodiazepine for the patient, or it is missing. The response includes inaccurate and vague examples that does not detail dosing and tapering information, or it is missing.	20 pts
This criterion is linked to a Learning Outcome Patient 3: Describes potential risks, benefits and side effects of lorazepam, as well as alternative medications that might be prescribed for the patient. Describes how the patient might discontinue lorazepam, with necessary patient education regarding discontinuing medication and patient/fetus needs.	20 to >18.0 pts Excellent The response comprehensively and clearly describes risks, benefits and side effects of lorazepam. The response comprehensively and clearly identifies potential alternative medications. The response comprehensively and clearly describes how the patient might discontinue the medication. The response comprehensively and clearly provides necessary education for discontinuing the medication for patient and fetus. 18 to >15.0 pts Good The response clearly describes risks, benefits and side effects of lorazepam. The response clearly identifies potential alternative medications. The response clearly describes how the patient might discontinue the medication. The response clearly provides necessary education for discontinuing the medication for patient and fetus. 15 to >10.0 pts Fair The response inaccurately or vaguely describes risks, benefits and side effects of lorazepam. The response inaccurately or vaguely identifies potential alternative medications. The response inaccurately or vaguely describes how the patient might discontinue the medication. The response inaccurately or vaguely provides necessary education for discontinuing the medication for patient and fetus. 10 to >0 pts Poor The response vaguely or inaccurately describes risks, benefits and side effects of lorazepam, or it is missing. The response includes inaccurate and vague examples that does not identify potential alternative medications, or some or all are missing. The response vaguely or inaccurately describes how the patient might discontinue the medication, or it is missing. The response includes inaccurate and vague examples that does not provide necessary education for discontinuing the medication for patient and fetus, or some or all are missing.	20 pts
This criterion is linked to a Learning Outcome Patient 4: Describes potential risks and side effects of continuing benzodiazepine. Describes how to taper the medication and education regarding the tapering.	20 to >18.0 pts Excellent The response comprehensively and clearly describes potential side effects and risks. The response comprehensively and clearly describes how to taper the medication. The response comprehensively and clearly provides necessary patient education for tapering. 18 to >15.0 pts Good The response clearly describes potential side effects and risks. The response clearly describes how to taper the medication. The response clearly provides necessary patient education for tapering. 15 to >10.0 pts Fair The response inaccurately or vaguely describes potential side effects and risks. The response inaccurately or vaguely describes how to taper the medication. The response inaccurately or vaguely provides necessary patient education for tapering. 10 to >0 pts Poor The response vaguely or inaccurately describes potential side effects and risks, or it is missing. The response vaguely or inaccurately describes how to taper the medication, or it is missing. The response includes inaccurate and vague examples that does not provide necessary patient education for tapering, or some or all are missing.	20 pts
This criterion is linked to a Learning Outcome Paper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references	5 to >4.0 pts Excellent Paper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references outside of course resources. 4 to >3.0 pts Good Paper demonstrates some critical thinking and/or vague synthesis of literature with four (4) evidence-based, peer reviewed scholarly references outside of course resources. 3 to >1.0 pts Fair Paper demonstrates vague critical thinking and/or little synthesis of literature with three (3) evidence-based, peer reviewed scholarly references. 1 to >0 pts Poor Paper demonstrates no critical thinking and/or synthesis of literature with two (2) or less evidence-based, peer reviewed scholarly references.	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided, which delineates all required criteria.	5 to >4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria. 4 to >3.0 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the Assignment is stated yet is brief and not descriptive. 3 to >1.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the Assignment is vague or off topic. 1 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion was provided.	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation	5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains one or two grammar, spelling, and punctuation errors. 3 to >1.0 pts Fair Contains several (three or four) grammar, spelling, and punctuation errors. 1 to >0 pts Poor Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting: The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.	5 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains one or two APA format errors. 3 to >1.0 pts Fair Contains three or four APA format errors. 1 to >0 pts Poor Contains many (five or more) APA format errors.	5 pts

Total Points: 100