The American Psychiatry Association has just released new practice guidelines for the pharmacological treatment of patients with alcohol use disorder. For the full guidelines, click here. In this guideline, the use of these 5 agents have been discussed: naltrexone, acamprosate, disulfiram, topiramate and gabapentin.
There is a lot of money invested to address our current opioid crisis. We discuss an opioid strategy and implement measures at various levels. We distribute naloxone kits through our community pharmacies, we provide support through academic detailing services at physicians’ offices and we increase awareness of the risks and harm with long term opioid use in public education campaigns. On many levels, all these activities are addressing our ongoing opioid crisis. But if we dig further, we are also looking at our mental health crisis that desperately needs more attention too.
Alcoholism is a bigger issue that we like to acknowledge. From the individuals with opioid use disorder to patients with longstanding psychiatric history, their medical issues are often coupled with concerns for chronic alcoholism. There are often limited inpatient detoxification programs available in the community. As such, options for outpatient detox program are more versatile to consider and implement especially for individuals who are in mild withdrawal (e.g. CIWA-AR below 8).
It isn’t uncommon that I see a patient admitted to nursing home with advanced dementia and a very low level of vitamin B12. I always wonder how much of vitamin B12 deficiency may be contributing to the progression of dementia, even though it isn’t the cause. I am not a big fan of any vitamin supplements but Vitamin B12 is one where I would advocate supplementation where indicated.
I am always asked to speak to a patient or a family member about someone’s medication regimen, often with a clear focus or intention. It could be to explain the indication of a medication, describe some common side effects and explain the rationale for the treatment duration. But almost always, the patient is not interested to talk about the medications or there is something else that needs to be addressed.
I often hear nurses advising the physicians to change the PRN order (or “as needed” order) to a scheduled order so that the medication will be administered consistently. However, doing so also defeats the purpose of ordering as PRN. PRN orders (“as needed” or “pro re nata” orders) are not meant to be given routinely but only as needed for the specific reason, symptom or indication. This often applies to analgesics for pain relief and antipsychotics for behavioural and psychological symptoms in dementia. It also applies to other medications meant for symptoms management based on the nursing assessment such as scopolamine for excessive secretions, dimenhydrinate for nausea and vomiting and laxatives for constipation. Continue reading Giving PRNs – More Challenging than You Realize
Medicine can be messy business – that’s because medical knowledge keeps evolving and practice guidelines will change with time based on new evidence. But before we can definitely change practice, there is often a period with no black or white answer but many shades of grey. In addition, medical decisions aren’t so simple when patient factors, risks of treatment and benefits of treatment all need to be considered simultaneously.