2855 Arbutus Street Vancouver, BC Canada V6J 3Y8 T: 604.736.7331 F: 604.738.2272 Toll-free: 1.800.565.6505 NP Controlled Drugs and Substances (CDS) prescribing Learning module: script A note about this document The following is the narrative script for the CDS Prescribing learning module. We are providing this document to support and augment your learning as you proceed through the module. It is not intended to replace the module in any way. Please email quality@crnbc.ca if you have questions. I N T R O D U C T I O N Welcome to CRNBC s self-directed learning module on NP Controlled Drug and Substance Prescribing. Please click on the flashing arrow at the bottom of your screen to advance through the slides and review the module design and navigation features. If you are already familiar with these options, then click directly on the Introduction section to begin your exploration. Click here to download the learning resources links Click here to download the workbook H O W T O W O R K T H R O U G H T H E M O D U L E How to Work Through the Module (Slide #1.1.1) Before we begin, here are a few tips to help you move through the module. At the bottom of the page you will see media navigation buttons. Clicking on the arrow on the left side allows you to start or pause the slide show. The arrows located on the right side enable you to forward/rewind. Use these navigation features to move to the next page, return to review information presented on a previous page or stop and take a break. On the left hand side you will also notice a symbol that looks like a speaker for adjustment of sound. On the right side of the page are a number of coloured tabs. Each tab includes a topic or section discussed in this module. While we recommend that you do the module from start to finish, at any time you can click on a tab to move to a new topic or go back and review. Each tab page will also give you links to specific topics in each section. You may zoom in directly to these topic areas by
accessing these links. You may also move directly to specific sections of the module but clicking on the list of slides located in the Menu option. Clicking the arrow located beside each of these sections allows you to further tunnel down to sub-sections and slides under each of these topic areas. At the bottom of the screen you will see links to supporting documents and websites. These links are also found in the Learning Resources section along with other additional resources. Use the workbook to write down ideas and questions as you work through the module. Since this tool can be completed electronically, we recommend that you save it to your computer so you can capture and save your reflections as you work through the module. If, at any time, you choose to leave the module, you will be asked if you would like the module to remember and bookmark your spot. A tutorial to review the navigation features of this module are available to you at any time. Just click on Navigation Overview at the top right of the screen to open and review this resource. Need More Information? (Slide #1.1.2) As CRNBC staff, we provide group and individual consultations and learning sessions. For information about standards, the role of CRNBC, or to arrange a consultation or education session, click the email address shown on your screen. You may also access this email address at any time by clicking on the symbol on the top right side of the screen. M O D U L E O V E R V I E W Introduction (Slide #1.2.1) Pain has become a public health issue that accounts for 78% of Emergency Room visits. Fifteen to twenty percent of Canadians experience chronic pain with limited access to appropriate and timely treatment. Fifty percent of these patients have had to wait 6 months or more for treatment and there are many areas in Canada that do not have specialized pain treatment services. Recognizing the need to improve Canadians access to health care, including pain management, the federal government amended new legislation giving Nurse Practitioners the authority to prescribe controlled drugs and substances. Since health programs are a provincial responsibility, the provincial government also enacted legislation to enable this federal legislation. This provincial legislation gives Nurse Practitioners prescribing authority for Controlled Drugs and Substances, or CDS, in British Columbia. Additionally, the College of Registered Nurses of British Columbia developed standards, limits, conditions and competencies for CDS prescribing to support the changes in federal and provincial legislation and guide CDS prescribing. The purpose of this module is to provide Nurse Practitioners with the knowledge of the relevant legislation and CRNBC Competencies, Standards, Limits and Conditions to prescribe CDS in British Columbia. College of Registered Nurses of British Columbia 2
Learning Goals (Slide #1.2.2) N P C O N T R O L L E D D R U G S A N D S U B S T A N C E ( C D S ) P R E S C R I B ING CDS prescribing is a complex area of practice with high rates of morbidity and mortality associated with drug interactions, overdose and addictions. The competencies associated with this practice are distinct and beyond those related to prescribing generally. As such, the CRNBC Standard for CDS prescribing outlines a number of related conditions including the requirement to successfully complete one of three foundational courses accepted by CRNBC in controlled drugs and substances prescribing and this CDS Prescribing Learning module. This module will build on the knowledge you gained in the Foundational Course on CDS prescribing with information and activities designed to support you in: Applying the relevant federal and provincial legislation, and CRNBC Standards, Limits, Conditions and Competencies for prescribing CDS in your context of practice. Recognizing the risks and mitigating factors associated with prescribing CDS. Utilizing pharmacovigilance and applying best practices to mitigate these risks Being aware and applying the requirements of the Controlled Prescription Program and PharmaNet when prescribing CDS. In addition, this module offers opportunities for you to: Continue to identify and use resources to develop your skills and knowledge in prescribing CDS, and Have a time out to reflect on the professional requirements of your nursing practice and create a plan for your ongoing professional development with CDS prescribing and, in doing so, support yourself in addressing Quality Assurance requirements. In summary, this module is one tool to support you in ensuring appropriate and effective CDS prescribing practices. If you would like further assistance with understanding the implications of the legislations and standards for your practice, you may wish to talk with a CRNBC Regulatory Practice Consultant. Module Organization (Slide #1.2.3) As you work through the module, you will encounter various learning activities that are easily recognized by their icons. The workbook icon indicates a learning activity that is completed in the Workbook that accompanies this module. The Workbook includes activities designed to guide you in exploring your understanding of CDS Prescribing within your context of practice. Where indicated, sample answers to selected learning activities are provided in the Perspectives section of the workbook. The workbook link is at the bottom of the screen. You will need to download the Workbook onto your computer or print out a hard copy in order to use the Workbook. We recommend College of Registered Nurses of British Columbia 3
that you save your responses to the various activities and add your completed Workbook to your professional development portfolio. The reflection icon indicates an activity which asks you to stop and reflect on ideas being discussed in the module. At each Reflection Point, questions or directions are provided to help you consider the relevance of the ideas. The Workbook provides space to record your thoughts and insights. A final activity in the module and workbook will guide you in reviewing your thoughts from these reflective activities and using your insights to create an action plan for your continued professional development. This module also allows you to tailor your exploration according to your unique learning needs and professional development interests. With this in mind, the final section of the module is Learning Resources. It contains references to documents, articles and web sites that offer further information and resources and is available as a pdf should you decide to save it to your desktop or print off as a hard copy. L E G I S L A T I V E A N D R E G U L A T I O N O V E R V I E W Overview (Slide #1.3.1) The changes in both federal and provincial legislation required regulatory colleges like CRNBC to develop policies to support the legislation to give NPs the authority to prescribe CDS in their jurisdiction and to ensure the safety of the public. Let s review the controls on practice, to get a better understanding of your responsibilities as a self-regulating professional as you consider and begin to integrate CDS prescribing into your practice. Federal and provincial legislation enables NPs to gain the authority to prescribe CDS. CRNBC has defined the standards, limits, conditions and competencies required to prescribe CDS, and employers may have further requirements and/or restrictions on CDS prescribing. Finally, NPs, as self-regulating professionals, are responsible to adhere to the CRNBC standards of practice, the NPs Scope of Practice and their individual competence within that scope of practice and the stream in which the NP is registered. Overview Continued (Slide #1.3.2) CRNBC s revised Scope of Practice for Nurse Practitioners includes specific Standards, Limits and Conditions for Controlled Drugs and Substances prescribing. You will be held accountable to these standards and the Limits and Conditions that will be placed on your practice when you prescribe CDS. We suggest that you go in and review this document and information on related competencies in detail by clicking on the links at the bottom of your screen. As you begin this review, you might find it useful to keep in mind: the impacts prescribing CDS might have on your practice College of Registered Nurses of British Columbia 4
potential associated risks, and the education and training needed to take on this responsibility You should also note some key requirements for Prescribing CDS including: Completion of a CRNBC accepted foundational course in CDS prescribing Completion of this learning module Knowing and applying the revised NP Standards, Limits and Conditions that incorporate CDS prescribing and obtaining and maintaining Competencies for prescribing CDS. Applying for the Controlled Prescription Program (CPP), and for your personal CPP forms, and Acquiring practitioner level access to Pharma Net through the Ministry of Health processes for your practice sites. Federal Legislation Introduction (Slide #1.3.3.1) Now, let s move to the federal legislation that enables NPs to prescribe CDS. This is legislation that you must know, and keep yourself current on, as you develop your CDS prescribing practice. You are already experienced in prescribing drugs and the federal legislation for prescribing CDS is covered in the foundational courses outlined in the Scope of Practice for NPs document, under the Standards, Limits and Conditions for CDS prescribing. Since this module provides a high-level summary of federal legislation, we strongly recommend that you complete your foundational CDS prescribing course prior to doing this module. As you are well aware, medications such as opioids and benzodiazepines are high risk drugs that can cause harm to individuals and society. These drugs are referred to collectively as controlled drugs and substances or CDS. CDS are regulated internationally to ensure that access is limited to medical and scientific purposes and are further regulated federally and provincially to minimize harm to the public and the potential for misuse, abuse, diversion and illicit use. International regulation begins with the International Narcotics Control Board and the United Nations International Drug Control Conventions. Canada, as a member of the United Nations, enacted the Controlled Drug and Substances Act or CDSA to meet its obligation under the United Nations drug control conventions. These regulations and acts can be accessed by clicking on the links at the bottom of your screen. Controlled Drug and Substances Act (Slide #1.3.3.2) The Controlled Drug and Substances Act outlines the punishment and enforcement of illegal exportation, possession, production and trafficking of a substance listed in its drug schedules. Regulations under the CDSA govern the activities of producers, distributors, importers, exporters, pharmacists, practitioners and hospitals. They also include provisions for record keeping, loss and theft reporting and security. College of Registered Nurses of British Columbia 5
The drug Regulations under this Act are essential for you to know and includes. New Classes of Practitioner Regulation Benzodiazepines and Other Targeted Substances Regulation Narcotic Control Regulation, and Food and Drug Act Regulation The New Classes of Practitioner Regulation designates NPs as practitioners and authorizes you, with certain exclusions, to possess, prescribe, and perform activities with: Any targeted substance listed in Schedule 1 and 2 of the Benzodiazepines and Other Targeted Substances Regulation Any of the narcotics in the drug schedules of the Narcotic Control Regulations except opium, diacetylmorphine (heroin) and coca and its derivatives, and Any of the listed substances in Part G of the Food & Drug Regulations except anabolic steroids, their salts and derivatives, not including testosterone. The CDSA and the New Classes of Practitioner Regulation grant prescribing authority to NPs with the provision that provincial laws and CRNBC Standards, Limits and Conditions are in place. It is important for you to be familiar with the various drug schedules included in the all relevant regulations and if you need clarification there are resources available to you through consultation with CRNBC, the College of Pharmacists as well as employers and other expert CDS prescribing practitioners. Now would be a good opportunity to take some time to review the federal legislation to refresh your memory on the information covered in your foundational course. Further information on these regulations can also be found by reviewing the links below and Learning Activity #1 in your Workbook can support you in your process of this review. Remember to save the Workbook to your computer so you can compete it electronically and capture your responses. Once you have completed this exercise then return to the module to continue your exploration. Provincial Acts and Regulation Slide (#1.3.4.1) Health care is a provincial responsibility, therefore, provincial legislation must be in place to support the enactment of the federal legislation in each province. You are required to understand your responsibilities in relation to the provincial legislation that supports the federal legislation and authorizes Nurse Practitioners to prescribe CDS in British Columbia. The provincial Acts and Regulations you must be familiar with include: Registered Nurses and Nurse Practitioner Regulation Pharmaceutical Services Act, and College of Registered Nurses of British Columbia 6
Pharmacy Operations and Drug Scheduling Act Understanding your responsibilities in relation to the provincial legislation is critical, so take time now to review the relevant provincial legislation by accessing the links below. The College of Pharmacists and the College of Physicians and Surgeons of BC are excellent resources for information and expertise in CDS prescribing. Keep this in mind and go to your Workbook to complete Learning Activity #2. If you have not already done so, save the Workbook to your computer so you can compete it electronically and capture your responses. Once you have completed this exercise then return to the module to continue your exploration. CRNBC Standards, Limits and Conditions (Slide #1.3.5.1) With the federal and provincial legislation in place, CRNBC developed specific Standards. Limits and Conditions to support the legislation and guide CDS prescribing practices. This document defines: the standards for prescribing CDS, limits on prescribing CDS, and the conditions attached to the prescribing of CDS. You are already familiar with the NP Standards for Prescribing. These standards have been revised to reflect the changes in legislation, by incorporating specific standards for prescribing CDS. In addition, some limits were set and some were removed and certain conditions were placed on prescribing specifically with CDS by NPs. It is important that you understand the Standards for Prescribing as well as the Limits and Conditions placed on CDS prescribing, therefore, we will take a closer look at these Standards, specifically related to: the Controlled Prescription Program medication reconciliation expectations when prescribing CDS considerations and documentation before initiating and continuing CDS prescribing client assessment security of prescription pads. and the issue of prescribing CDS for self and family members Take the time now to become familiar with the prescribing standards that incorporate CDS prescribing by completing the Work Book Activity #3. College of Registered Nurses of British Columbia 7
CRNBC Standards, Limits and Conditions Cont. (Slide #1.3.5.2) Now, let s move on to review the Limits and Conditions on Compounding, Administering, Dispensing and Medication Inventory Management. When you dispense medications, remember that you are required to meet the CRNBC Practice Standard on Dispensing Medications. You may want to review this practice standard by accessing the link below. If you manage a Medication Inventory you must be mindful of the legal requirements related to CDS. The CRNBC website has a number of resources including a Medication Inventory Management Practice Standard and an information guide for employers which are helpful in ensuring legal requirements are being met. As you read the section on Limits and Conditions, you will find that the drugs are listed by therapeutic category using the American Hospital Formulary Service Drug Information classification system. As you know from your current prescribing practice, this classification identifies the drugs NPs are authorized to prescribe without any restrictions, those drugs that cannot be prescribed by NPs and those that can be prescribed on a continuation basis only. You can find more information about the American Hospital Formulary Service on the site listed below. As you review these resources you might find it helpful to take a moment to reflect on how you apply this understanding to your practice. As you do so perhaps consider: how you would dispense CDS to meet legal requirements in your practice setting. the legal requirements and logistics of maintaining a medication inventory that includes CDS. what you are required to do if you experience a loss or theft of CDS from your medication inventory? You may want to capture your thoughts by jotting these down in the Notes for Reflection Page of the Workbook. Marijuana for Medical Purposes (Slide #1.3.5.3) NPs are not authorized to prescribe, issue a medical document for, nor dispense marijuana for medical purposes. However, you may encounter clients who are accessing these products or may ask you to prescribe it for them, therefore you may be interested in learning more about the parameters of the Federal Marijuana for Medical Purposes Regulation. The Standard and Guideline on Marijuana for Medical Purposes, published by the College of Physicians and Surgeons of BC is another resource that may be of interest to learn more about this issue. Links to both of these resource may be found at the bottom of your screen. As you review these, you might want to take a moment to consider your practice and the clients you may have that are using marijuana for medical purposes or who might ask you to prescribe marijuana for their condition. Consider how you would manage these patients and how you would respond to potential requests. If you wish, you can jot down some thoughts and ideas on the notes section of your workbook. College of Registered Nurses of British Columbia 8
Competencies for NP CDS Prescribing (Slide #1.3.5.4) In addition to the Standards, Limits and Conditions for prescribing CDS, CRNBC has developed a statement of the Competencies for NP Prescribing of Controlled Drugs and Substances. As you know, competencies are statements about the knowledge, skills and judgments required to perform safely within your nursing practice role. As you incorporate CDS prescribing in your practice, you will be addressing these competencies, in your continuing professional development, so let s go now to the competency statements for prescribing CDS which can be found at the bottom of your screen. As you review these statements, assess and reflect on each of these competencies and consider how you will achieve and incorporate them into your professional practice. Perhaps also consider practitioner colleagues experienced in CDS prescribing that you have a relationship with who might provide you with mentoring and support as you initiate CDS prescribing into your practice. Remember to capture these ideas by jotting them down in the Notes for Reflection Page of the Workbook. In this section we covered the legislation enabling NPs to prescribe CDS at both the federal and provincial levels and CRNBC s Standards, Limits, Conditions and Competencies for NP prescribing of CDS. This is information you must understand in relation to your role, and be current on when prescribing CDS, so please feel free to go back and review this information as needed as you proceed through the module. B C P R O G R A M S R E L A T E D T O C D S P R E S C R I B I N G Controlled Prescription Program (Slide #1.4.1.1) It is important to understand what activities are permitted and required under federal law, what applies provincially and any additional provincial laws relevant to CDS prescribing. As we learned previously in the module, the Pharmaceutical Services and the Pharmacy Operations and Drug Scheduling Acts govern drug programs administered by the College of Pharmacists of BC who are responsible to the minister. The Controlled Prescription Program goals are to prevent forgeries and reduce the inappropriate prescribing of selected drugs. This program issues duplicate pads printed for the purpose of the selected drugs which may only be prescribed using a special controlled prescription program pad. BC has its own Drug Schedule Regulation and the Drug Schedules I and IA include controlled drugs and substances and some require prescriptions written on the CPP duplicate forms Schedule IA, while others do not. Additionally the College of Pharmacists have a helpful document interpreting the BC Drug Schedule Regulation as it pertains to different classes of prescribers. For more information please click on the links below to access these sites. College of Registered Nurses of British Columbia 9
Controlled Prescription Program Cont. (Slide #1.4.1.2) Both federal and provincial laws apply to how Controlled Drugs and Substances are ordered, for example quantities prescribed at one time, refill options and documentation on specific forms. You must also be aware of record keeping, tracking, security of the CDS and CPP pads and practice pharmacovigilance at all times. The College of Pharmacists of BC have developed a number of resources that are useful in understanding the legislation and requirements when prescribing CDS. These resources should be used in conjunction with CRNBC resources and can be accessed on the College of Pharmacists website on the link below. As you review the information on this site, you may find the Prescription Regulation Document particularly helpful as it is a synopsis of federal and provincial laws and regulations governing the distribution of drugs by prescription in BC. Another resource, that complements our Dispensing Practice Standard and the Standards, Limits and Condition for CDS Prescribing is the Standards for Dispensing Practitioners from the College of Pharmacists of BC. The College of Physicians and Surgeons of BC also has a Prescription Review Program which is a quality assurance practice activity. The program assists physicians with the challenging task of prescribing opioids, benzodiazepines and other potentially addictive medications with appropriate caution. The work of the program is informed by the PharmaNet database. This program reviews prescribing practices and publishes good information about CDS prescribing and management of CDS. You can access these resources on the CPSBC website and other related resources on the CRNBC web site. Controlled Prescription Program Form (Slide #1.4.1.3) Once you have accessed the CRNBC web site to review information, let s take a few moments to look at how the Controlled Prescription Program works. As discussed previously, to prescribe CDS in BC, you must use a special controlled prescription program duplicate pad. You should obtain more specific information about the CPP program by clicking on the links below and we will begin our discussion here by highlighting some basics components of the CPP form. The CPP forms are pre-printed with the following information: Prescriber s name Prescriber s address College ID number Prescription folio number College of Registered Nurses of British Columbia 10
CPP prescription forms are personalized and numerically recorded and cannot be exchanged between prescribers. Pharmacies will not fill a CPP form that has the original prescriber crossed off and another prescriber s name written. Let s look more closely at how to complete the CPP form. Controlled Prescription Program Form Cont. (Slide #1.4.1.4) The CPP form is a legal document and the prescriber is responsible to ensure that all required information is included and legible. The College of Pharmacists of BC offers these General Guidelines when writing a prescription using a CPP form: Write or print clearly and legibly in lower case using a black or blue ink ballpoint pen. Make sure that you complete all the applicable boxes on the form. Ensure that the spelling of the drug is correct and the proper strength and directions for use are written. Avoid excessive quantities, and Avoid alterations on the form. Use a new form if corrections are required Now let s take a closer at principles to adhere to as you complete the top, middle and bottom sections of this form. Controlled Prescription Program Form Cont. (Slide #1.4.1.5) When completing the Top Section of the CPP form, the prescribing date indicates the date the prescriber saw the patient and is a legal prescription requirement that must be included. The prescriber must complete in full all the patient information including, personal health number, name, address and client s date of birth. When completing the middle section of the form, the prescriber must complete the drug name and strength section as well as the quantity section by stating the quantity of the prescription in both numeric and alpha forms. The total quantity of the drug must be explicit and cannot be inferred. The prescriber must complete the Directions for Use section by stating dosage instructions including the frequency, interval or maximum daily dose. Take as directed or Take as needed are not acceptable directions. Special instructions may also be included in this area on the prescription. Refills (Slide #1.4.1.6) Refills are another area that requires caution, so keep the following in mind. Part fills are not encouraged but a smaller portion of the total quantity on the prescription can be dispensed as a College of Registered Nurses of British Columbia 11
part-fill when the part fill quantities and the intervals between the part fills are clearly specified. For example, if a prescription is written as: Hydromorphone 2mg QID x 60 tabs x 1 refill Then 60 tablets will be dispensed one time only. Pharmacies will not honor the 1 refill on the prescription. However, if the prescription is written as: Hyrdomorphone 2 mg QID x 120 tablets. Dispense 60 tablets every 14 days Then 120 tablets will be dispensed over a 28-day period. The pharmacy will dispense 60 tablets every 14 days for each part fill. More than one medication or strength of medication can be included on the same CPP form provided the orders are legible and follow the General Guidelines for writing CPP prescriptions. Controlled Prescription Program Form Cont. (Slide #1.4.1.7) Completing the bottom section of the CPP form requires the prescriber s signature in the Prescriber s Signature box to authorize the prescription. Pharmacies will not honor the prescription if the prescriber s signature is missing. The prescriber should ensure their telephone contact information is on the prescription in the event the Pharmacist has any questions or concerns about the prescription. Additional information that will help you when prescribing CDS includes: Certain controlled drugs can be prescribed over the phone and/or written on a regular prescription pad. Please click of the link to Prescription Regulations on the College of Pharmacists of BC website for more information, and Review CRNBC Prescribing Standards of the NP Scope of Practice document PharmaNet (Slide #1.4.2.1) The Ministry of Health grants practitioner s access to PharmaNet. For more information please visit the PharmaNet website by clicking on the link below. PharmaNet is an on-line real-time system that captures all prescriptions for drugs and medical supplies dispensed from community pharmacies in BC. PharmaNet complies with the BC Freedom of Information and Protection of Privacy Act. It includes strict privacy and security measures to prevent unauthorized access and protect the information in its database. You can review this Act by clicking on the link below. Medication Reconciliation (Slide #1.4.3.1) The importance of taking a patient history when prescribing CDS cannot be over stated. Resources available to you to collect the necessary information to safely prescribe CDS include PharmaNet and Medication Reconciliation and the Best Possible Medication History or BPMH. College of Registered Nurses of British Columbia 12
Medication reconciliation is being implemented throughout Canada and is a critical component in reducing preventable errors related to medication administration, therefore, it is important for you to familiarize yourself with the requirements for medication reconciliation in your practice setting. NPs undertake medication reconciliation to ensure accurate and comprehensive medication information is communicated consistently across health transitions. It functions as an adjunct to PharmaNet and is useful when this service is not available. Medication reconciliation is a formal process in which healthcare providers work together with patients, families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care. Medication reconciliation requires a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully evaluated. It is a component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient. A Best Possible Medication History is created using a systematic process of interviewing the patient and family, and a review of at least one other reliable source of information to obtain and verify all of a patient's medication use both prescribed and non-prescribed. Complete documentation includes drug name, dosage, route and frequency. The BPMH is more comprehensive than a routine primary medication history which is often a quick preliminary medication history which may not include multiple sources of information. Because the BPMH is a 'snapshot' of the patient's actual medication use, and may be different from what is contained in their record, supports the rational why patient involvement is vital. The BC Patient Safety & Quality Council has several resources pertaining to medication reconciliation available on their website and the Institute for Safe Medication Practices Canada has many resources to facilitate medication reconciliation in a variety of settings. You can review this information by clicking on the links below. I N T E G R A T I N G C D S P R E S C R I B I N G I N T O P R A C T I C E Misuse and Diversion Introduction (Slide #1.5.5.1) Prescription drugs can and do cause harm and death. Canada is the world s second largest per capita consumer of prescription opioids. Public health and safety are concerns in countries where these drugs are readily accessible, like in Canada. Did you know that prescription drug abuse kills twice as many British Columbians as drinking and driving? There is a concern across Canada about prescription drug misuse, and a concerted effort is being made to address this challenge. First Do No Harm: Responding to Canada s Prescription Drug Crisis is a report on the first phase of a proposed pan-canadian strategy to reduce the misuse of prescription drugs. Reviewing this report College of Registered Nurses of British Columbia 13
will provide with valuable information as a new prescriber of CDS. As you are reading through this you may want to jot down some of your thoughts in the notes for reflection page of the Workbook. Drug Diversion (Slide #1.5.1.2) Drug diversion is a risk and can cause harm to many people in our communities resulting in drug addiction, overdose, drug-related emergency room visits and deaths. It is important to recognize that drug diversion can occur at any step in the drug distribution chain, from wholesaler, to prescribers, to pharmacies and ultimately to the patient as well as through other means such as acquiring from relatives or friends, buying on the street, theft from burglarized homes and robberies. For example, and as cited in an update from the College of Physicians and Surgeons of BC, in the teen/young adult population that abuse opioids, 89% of prescription opioids are directly or indirectly sourced from physicians with 17% prescribed directly, 11% purchased from a relative or friend, 5% stolen from a relative or friend, and 56% obtained free from a relative or friend. Diversion of prescription drugs away from their legitimate use occurs in many ways: Double doctoring involves obtaining multiple prescriptions from different practitioners. Prescription pad theft can result in forged and/or altered prescriptions. Prescriber fraud involves the writing of fraudulent prescriptions in return for money or favours Purchases from friends, family or others who have had these drugs legitimately prescribed for them, and Break-ins of prescriber s offices, pharmacies, manufacturers, wholesalers, courier companies, clinics and hospitals occur as well as theft from homes. Further information in this area can be found on the links below on CPSBC Prescribing Principles and the Centre for Addiction and Mental Health Assessment tools. It is important to ensure you understand your role in relation to the Regulations under CDSA referred to earlier in this module related to governing the activities of producers, distributors, importers, exporters, pharmacists, practitioners and hospitals as well as the record keeping, loss and theft reporting and security requirements to prevent these diversions and misuse of CDS. Prescribers have the first opportunity to identify and control drug diversion, misuse and abuse of controlled drugs and substances by practicing pharmacovigilance. The Prescription Review Committee of the CPSBC has published some documents entitled Prescribing Principles for Chronic Non-cancer Pain and Up-dates on Pharmacovigilance, Your Prescription; Your Responsibility. Additionally, there is a list of recommended resources from the Prescription Review Committee. College of Registered Nurses of British Columbia 14
Best Practices in Reducing Risk and Harm Introduction (Slide #1.5.2.1) As previously mentioned, pain is a public health issue and accounts for 78% of Emergency Room visits. Many Canadians experience chronic pain with limited access to appropriate and timely treatment. Many areas in Canada do not have specialized pain treatment services. Primary care providers write the majority of prescriptions for CDS and manage the majority of chronic pain patients. They often do not have sufficient support for education and preceptorships in chronic pain and addiction management. The management of acute and chronic pain and the use of prescription opioids are often linked, as is the treatment of anxiety and sleep disorders and the use of benzodiazepines. However, the use of these medications is associated with risk of harm such as addiction and death from overdose. A key challenge is when and how to use these medications effectively and safely, and can be addressed by first doing no harm by practicing pharmacovigilance. Controlled drugs such as opioids, benzodiazepines and targeted substances, cross the blood brain barrier to enter the central nervous system and affect mental activity, behavior and perceptions. These drugs are at risk for diversion, misuse, and can cause harm even when prescribed legitimately. Psychoactive drugs are emerging as a significant public health and safety concern in Canada. Given these concerns, let s look at ways that we can provide our patients with effective treatment using these prescription drugs while keeping society safe from misuse, diversion and the illicit use of these drugs and substances. Strategies and Resources (Slide #1.5.2.2) In response to the growing problem of prescription drug misuse, the National Advisory Council on Prescription Drug Misuse was formed and the strategies First do No Harm: Responding to Canada s Prescription Drug Misuse Crisis are in development. As you may have already reviewed, The First Do No Harm report recommends a strategy which addresses harms associated with prescription drugs with CDS and gives important considerations to their therapeutic use. It addresses drugs that are legal and have therapeutic uses but also have a high potential for harm. These drugs include: Opioid analgesics that contain oxycodone, hydromorphone, fentanyl, morphine and codeine Stimulants containing dextroamphetamine, methylphenidate and amphetamines Sedative Hypnotics containing diazepam and alprazolam and Drugs used to treat addiction-methadone and buprenorphine. The strategy was developed around 5 streams of action: Prevention College of Registered Nurses of British Columbia 15
Education Treatment Monitoring & Surveillance, and Enforcement The report identifies the issues as well as what is needed to improve this area of health care and will be conducted over a 10 year timeframe with the goal of achieving a pan-canadian Strategy to reduce the misuse and abuse of prescription drugs and improve the health of Canadians. The Pan- Canadian strategy Phase 1 was launched in March of 2013 and will be used by participants in Phase 2 with Phase 3 being the evaluation of the strategy. As a prescriber, this strategy will influence your practice and likely you will have an opportunity to contribute to and implement the reports recommendations. If you haven t already done so, you may wish to take some time now to look through the report which can be accessed at the link below and capture some of your thoughts in the Notes for Reflection page of your Workbook as you do this. Strategies and Resources Cont. (Slide #1.5.2.3) In the development of this learning module and the gathering of opinions from expert CDS prescribers, the following themes emerged: Prescribing CDS can indeed be challenging. Not only do the medications themselves have complex side effect profiles, they also have the potential for abuse and diversion which means the clinical encounter can be different from the usual client encounter. Therefore, when prescribing CDS it always important to: Consider this type of clinical encounter different from the usual client encounter and consistently apply the standards for prescribing CDS in these situations. and Develop on-going relationships with practitioner colleagues experienced in prescribing CDS to access their experience and wisdom. An additional resource to support practice is the Rapid Access for Consultative Expertise or (RACE) Program. This is a resource available to practitioners to access specialist consultation by telephone. The goal of the program is to improve communication and knowledge transfer among primary care providers and specialists. Consultation is available province-wide for a variety of specialists. Access to other specialties varies by health region. Additional information including downloadable apps can be found at the link listed below. Once you have reviewed this resource then return to your Workbook and complete Activity #4 about Michael s story as told by his mother after his death. College of Registered Nurses of British Columbia 16
Pharmacovigilance (Slide #1.5.2.4) As mentioned earlier, practicing pharmacovigilance is a critical strategy in harm prevention. Pharmacovigilance, or PV, is defined by the World Health Organization as, The science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other drug-related problem. The aims of pharmacovigilance are to enhance patient care and patient safety in relation to the use of medicines and to support public health programs by providing reliable, balanced information for the effective assessment of the risk-benefit profile of medicines. If you wish to read more about this concept please refer to the WHO webpage on the link below An important factor that you need to consider within your context of practice is awareness that certain populations are more vulnerable to these prescription drugs than others. Take a moment and go to your Workbook to complete Activity # 5 where you can read the story of misuse of Oxycontin in a remote setting and reflect on the challenges faced by certain communities. Responsibilities as a Self-Regulating Professional Introduction (Slide #1.5.3.1) As a self-regulated professional it is your responsibility to ensure that you practice within the Scope of NP Practice and CRNBC s CDS specific Standards, Limits and Conditions. In order to do so, we have provided you with some key resources throughout this module. Now let s focus on the resources you can use to safely prescribe and build your own professional development plan to ensure ongoing safe practice. First, let s highlight some best practices to ensure clients will receive effective treatment and enable you to be aware and thus prevent the misuse, diversion and illicit use of CDS that causes harm. It is important for you to continually assess your knowledge, skills to ensure you are competent to provide the care required by your patients and remain current on relevant legislation and CRNBC standards and policies. As previously discussed, it is also very beneficial to build your competence through mentorship and collaborative relationships with your colleagues both ones experienced in CDS prescribing and others, like yourself, who might be entering into this process. It is important to recognize that treating chronic non-cancer pain is very different from treating palliative and end-oflife pain and only a minority of patients with CNCP obtain modest pain relief or functional benefit from opioids. As outlined in the NP Scope of Practice and the Standards, Limits and Conditions, NPs prescribing CDS for the management of chronic non-cancer pain will need to complete additional education in prescribing for this context of pain. There are a variety of resources that provide educational programs for specific areas of pain management. For example, The National Pain Centre at McMaster University provides this programming. College of Registered Nurses of British Columbia 17
Relevant Resources (Slide #1.5.3.2) The College of Pharmacists of BC and the College of Physicians and Surgeons of BC have extensive experience with prescribing CDS and the related risks and harm this prescribing may cause. The following information is the combined wisdom from these sources, gained from their experience and pharmacovigilance over time. It is intended to assist you in developing your CDS prescribing practice. Links to a variety of great resources that complement CRNBC s Scope of Practice for Nurse Practitioners are listed below that you may find these helpful when incorporating CDS prescribing into your practice and considering your responsibilities as a self-regulated professional. Best Practices (Slide #1.5.3.3) In addition to having the knowledge, skill and competence and adhering to legislation, policies, guidelines and standards for CDS prescribing, as a self-regulated professional you must always engage in best practices and keep public safety a top priority. Some safety related tips include: Always keeping your CPP forms and regular prescription pads secure to prevent access by others. Ensuring prescriptions are written that meet the requirements outlined by the CPBC as discussed earlier in the module. Adhering to strict refill policies and ensuring prescriptions are written clearly to minimize the risk of forgery. Always base treatment decisions on a comprehensive initial assessment and frequent reassessments using informed consent processes and treatment agreements. Exercise caution with patients who use or request a combination of drugs for enhanced effects. Check on PharmaNet for the patient s drug profile before refilling or adding a new medication including: Quantity, last fill date and day supply, Using pain assessment tools to monitor the effectiveness of pain medication, Ensuring thorough documentation Communicating and collaborating with clients, physicians and pharmacists and using appropriate resources when signs of addictive behavior are observed or to determine the medical necessity of prescriptions. And finally, you should make it routine for all patients on Long Term Opioid Therapy to undergo occasional supervised, random urine drug screens. Where misuse is likely, random urine drug screens should be frequent. Even when risk seems low, occasional screening can reveal misuse. College of Registered Nurses of British Columbia 18
Reflective Activity (Slide #1.5.3.4) Before you continue you might find it useful to take a few moments to check out some excellent resources. Go to the link below for the National Pain Centre website and review the Canadian Guidelines for the Safe and Effective Use of Opioids for Chronic Non-cancer Pain. Then, access the Opioid Tool Kit on the same website. This kit was developed from the Guidelines and contains many of the resources you will need to safely assess, prescribe and treat pain with CDS. The Opioid Manager also compiles all the required documentation on a 2 sided form. Take some time now to study these documents and determine how they might be helpful to you in developing the competencies required for prescribing CDS. Best Practices Cont. (Slide #1.5.3.5) Now let s look at some additional questions and answers that highlight Best Practices when prescribing opioid therapy What should I do before prescribing an opioid? Complete a thorough assessment to understand the pain problem and make an informed decision about opioids as a reasonable treatment choice. Consider screening tools to help identify patients at risk of opioid misuse or addiction. Manage expectations by setting function-improvement and pain- reduction goals with the patient these then become the outcomes for measuring opioid effectiveness. Characterize the opioid prescribing as a trial, and Ensure informed consent by reviewing with the patient the potential benefits, risks, side effects, and complications of opioid therapy. How do I ensure patient safety? Use the function-improvement and pain-reduction goals set with the patient to monitor opioid effectiveness. Using structured assessment tools could also help. Watch for aberrant drug-related behaviours that could signal opioid misuse Assess factors that could impair cognition and psychomotor ability. Learn if your patient drinks, drives, performs safety-sensitive work including caring for children. Use available consultation as needed, for example, if pain condition is unresponsive, opioid misuse or addiction is suspected and with special populations, such as, pregnant, psychiatric co-morbid conditions, elderly, or adolescents. Finally, collaborate with pharmacists to improve patient education and safety. If you would like to extend your knowledge about this you might want to access the link below. The UBC Faculty of Medicine Continuing Professional Education has an on-line program titled Can My College of Registered Nurses of British Columbia 19
Patient Drive Safely on Long Term Opioid Medication? You may want to access this course now or at a later date as it is a valuable tool in assessing your patient s safety to drive. Family and Friends (Slide #1.5.3.6) Practitioners may be asked to provide treatment to individuals they have a personal or nonprofessional relationship with. Prescribing Standards indicates that NPs do not prescribe CDS to family members. The rationale for this is that treating a family member can be problematic because of the difficulty in defining the boundary between a professional and a personal relationship. In the absence of a therapeutic relationship it is difficult to obtain a detailed history, complete sensitive physical examinations or be able to fully explain treatment options. Patients accepting treatment from a practitioner they have a close relationship with may not give an accurate history, seek other treatment or opinions which may result in inappropriate and, in the case of CDS, risky outcomes. Similar issues occur when NPs experience situations where self-treatment may be more convenient than seeking care from another practitioner. In the case of CDS, access to these drugs for selftreatment may lead down a slippery slope to substance abuse/addiction. It may be helpful to review the CRNBC Practice Standards and other resources on Professional Boundaries by clicking on the link below and reflecting on how the information in these documents will impact your practice. Consider your response to a family member s request for you to prescribe an opioid for a minor or chronic pain problem. Applying My Learning (Slide #1.5.3.7) At this point you may choose to continue on to the next section in the module or, if you would like to test your acquired knowledge, you can choose to work through a complex case study presented in your Workbook. This case study, with a focus on non-cancer chronic pain, will help you integrate and apply the understanding you have built throughout this module and an opportunity to use some available tools so also refer to the Resource Section for further references. Once you have done this then return to the module to complete the final components. B U I L D I N G C D S P R E S C R I B I N G C O M P E T E N C E Overview (Slide #1.6.1) Our journey to this point has taken us through an exploration of NP CDS Prescribing practice in BC. After completing the foundational course and this CDS prescribing learning module and, in order to prepare you for active prescribing, take the time now to consider how you will incorporate considerations from CDS national and provincial legislation, regulations and best practices into your CDS prescribing. More specifically, you will consider: College of Registered Nurses of British Columbia 20