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Medicines Optimisation – what does this mean to patients?? (5 minute read)

Medicines Optimisation and shared decision making are frequently used buzzwords – what do these terms mean in practice?? – here’s some patient stories to reflect on:

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These stories are fictitious but based on real events:

Ben’s holiday – (finding out what a medicine does by accident) :

Ben is a 16 year old boy who has been prescribed a drug for a behavioural condition, it’s a powerful drug (called an antipsychotic) which he has taken for over a year. His parents think it helps. Ben hasn’t said what he really thinks, but accepts the tablet.

A few years ago the family went on holiday to Bulgaria. During the holiday there was an air traffic controller’s strike. The family were stuck in Bulgaria waiting for the strike to end. They ran out of Ben’s medicine and were unable to obtain any or anything similar. As a result, out of desperation, they gave Ben a saccharin tablet instead, and hoped for the best. He was fine. Over the next few weeks they even noticed an improvement in his mood and behaviour. He seemed to be enjoying life more. When the family returned to the UK they stopped giving him the ‘placebo’ tablets, and he has not needed to take medicines since.

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Ian’s secret: (in jargon this is ‘intentional non-adherence’)

Ian is a 35 year old man diagnosed with bipolar disorder. When Ian moved to another part of the country he was allocated a new community psychiatric nurse [CPN] and, as he was unwell at the time, was re-started on medication. Over the next 18 months Ian’s condition improved so his CPN reported a ‘good response to the medication’. It was only after 2 years of knowing him that Ian confided in his CPN that he didn’t take the medication consistently, and never had.

The medicine was lithium, which requires regular blood tests. This is because too much of it is toxic and too little has no effect. Ian revealed that he had only taken it before his blood test days, then always stopped taking it in between.

Ian’s medical notes had stated that he always ‘responded well to lithium’!

As a result of Ian being able to trust his CPN, and let on that he wasn’t taking it, his medical records were corrected to say that he did not want to be prescribed lithium, confirming that other options worked much better. These options include some medicines which he had previously ‘borrowed’ from someone else, or bought on the internet. Of course he didn’t tell medical staff about this at the time.

So his choice is now clearly written up, should he become unwell again.

…and now the ‘science bit’. If you want them I can provide references for medicines geeks like me! steve@carerightnow.co.uk

Medicines Optimisation is a powerful term because it brings in the:

  •    Patient’s views and their decision

Clinical people may think they ‘know best’, but in the end it is  the patients (you and I) who will decide whether or not we take the medicine, and we will not always tell the doctor or nurse if we don’t feel we can trust them. Statistically around 50% of people, (all ages all types of people), don’t take their medicines as prescribed.

  • The ‘human factors’ and health beliefs related to having to take medicines

Medicines aren’t always the answer. We may have strong beliefs in favour or against them; these beliefs are hard to change and need to be respected. Basically we usually know what’s right for us.

  • The ‘evidence base’, which means is it known to work?

People who prescribe medicines (usually doctors, pharmacists or nurses who have the qualification) need to offer the medicines which are proven to be most effective. And there is often a choice.

Repeatedly studies have shown that clinicians have a list of medicines they prescribe for various illnesses in their minds, and this list may bear little or no relation to the evidence available on what works best.

Medicines optimisation is not simply another term for ‘medicines management’, which is generally used to refer to the mechanics of the medicines process. This leads us to consider not just the process of selecting, prescribing; ordering; supplying; administering and monitoring, but also whether the person has the capacity and enough knowledge to decide to take a medicine; if they actually take the medicine and indeed whether the medicine is needed in the first place.

Sometimes people need multiple medicines (referred to as polypharmacy) because of the complexity of their illnesses. This can be inappropriate if, for example, a medicine is simply added to counteract the side-effects of another medicine.

I will be speaking on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference


Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and fromer NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @MedicineGovSte 

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Version 1   Added 12/02/2018 Amended 15/11/2019

 

Nurse & former patient teaching together as equals

Shared decision making in mental health.

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‘Such a great lecture one of the best since I’ve started Uni’

A workshop session delivered jointly by a facilitator and a user of mental health services

Comments from our students (2017):

‘Thank you. It is always much more real and interesting when taught by someone with real experience, as opposed to theories. Really useful’.

‘It was great to hear Sam’s personal experiences and hear how Steve related them to practice.

In these sessions you can ask us both anything.

Our first video! More to come.

 

Aim of the session:

To discuss adherence to medicines and treatments; relate this to practice through group work and discuss this with a user of mental health services


Example learning outcomes (can be tailored to individual needs):

• To be able to relate theory to practice and give examples of techniques to achieve adherence

• To be able to describe the key issues around adherence and shared decision making

• To be able to define compliance; concordance and adherence and why these are helpful terms

• To have the opportunity to ask questions directly to a user of services and a front line clinician


Comments from attendees include:

• Real life experience better learning environment

• Fascinating and very brave to explain one’s highs and lows to strangers. Thank you x

• Great hearing first-hand experience

• Good balance of theory and practice

• Sam’s talk was brilliant and really helpful

• Brilliant having opportunity to speak to someone who has been through it

• Found the opportunity to question a service user very beneficial. To hear first-hand what he found good and bad during his experience in the mental health system

• The user of services sharing their views on meds, treatment and compliance, concordance and adherence

• Shared info. from a person with own experience & what he identified are characteristics that made a good nurse & the honesty of his own concordance with meds.

• (appreciated) Your honesty

• Providing insight into personal experiences and services

• Nice to hear someone speak honestly about concordance from a service user’s perspective, especially from not taking meds.

• Learning in-depth about adherence, concordance and compliance

• The way our guest was talking about his experience was great, very interesting; honest …just real

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Steve will be speaking on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference 


Feedback and views welcome, send them to info@carerightnow.co.uk


Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @MedicineGovSte   hashtag #MedLearn

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Click on the image to find out more about @MedicineGov & #MedLearn


Author: Steve Turner

Added: 30/01/2018

Psychotropic medicines in people with learning disabilities

Psychotropic medicines in people with learning disabilities who show symptoms of distress*

( #jargonbuster – psychotropic medicines = The phrase “psychotropic drugs” is a technical term for psychiatric medicines that alter chemical levels in the brain which impact mood and behaviour.)

p7amgebk.jpg large                                                            #Oliverscampaign

In my tweets & posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed.

But what about vulnerable groups who may depend on decisions being made for them, and in their best interests?

Key points:

Facts:

  • Most of the prescribing in this area is ‘off label’ ( #jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine ).
  • This prescribing can include multiple anti-psychotic medicines, often medicines in the same class. There is a limited evidence base for this type of prescribing.
  • Psychotropic medicines in people with learning disabilities who show symptoms of distress* are not always prescribed by a specialist in this area.
  • Diagnostic overshadowing may lead to inappropriate prescribing. This is the attribution of a person’s symptoms to their mental condition, when such symptoms actually suggest a comorbid condition.

Actions to take:

  • A Holistic assessment including taking all measures possible to understand why the person may be distressed, a taking actions to alleviate this, based around the person.*

Before prescribing it’s important to understand all triggers and environmental factors. Reasons for behaviour now and what has happened in the past, including what works well and what acts as triggers*.

After exploring ALL options, if medicine is thought to be the answer:

  • Ask about allergies, sensitivities and adverse reactions to medication. Check the documentation on this and ensure it’s recorded accurately (e.g. if the person has reacted to a drug is the nature of the reaction recorded in full, and has it been shared with all involved in the person’s care).
  • Take into account views of family and carers.
  • Take into account any advance decisions and support plans.
  • Take care to avoid diagnostic overshadowing.
  • Ensure there is Specialist initiation and review of prescribing.
  • Ensure Multi-Disciplinary team involvement & inter-organisational involvement.
  • Act in accordance with the Mental Capacity Act [MCA] , where capacity to make a specific decision is lacking. (NB: Capacity assessments must be time and decision specific).
  • Best interests decisions must involve all parties, be fully documented & regularly reviewed.
  • Where appropriate, a tiered approach to prescribing – ‘start low, go slow’.
  • Ensure involvement of Second Opinion Appointed Doctors (SOADs#) to provide a statutory safeguard where consent is an issue.

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Link to above page (section 4 of the MCA on best interests)

#‘SOADs visit the person and explore the current and proposed treatment, certifying what is considered to be appropriate and reasonable in circumstances where the person cannot or does not consent to it, discussing it with team members and the person before reaching their conclusions.’

  • Clear documentation is vital:
    • Of the holistic assessment
    • Of the condition that’s being treated by the medicines
    • Of possible precipitating factors and measures that help the person*
    • Of patient involvement
    • Of carer and family involvement
    • Of multi-disciplinary team involvement
    • Of the decision making process and rationale for any best interests decision(s).
    • Of the rationale for prescribing / not prescribing
    • Including review dates and evidence of reviews
    • Monitoring of the effect of the medicine(s) that includes as required ‘prn’ medicines (Charts can be useful)
    • Documenting evidence of changes in response to the medicine(s) not being as expected, including if the medicines has no effect, and the actions taken on this.

The #Oliverscampaign web site illustrates why this is so important. Click  here for the web site

 


My presentation on Olivers’ story, given to the NICE Medicines & Prescribing Associates on 1st May 2019. (14 minutes).

 


Information sources and links:

Learning from Deaths Review reports

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Click here for the 2018 Report (pdf format).

 

NHS Constitution

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Competency Framework for all Prescribers

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Feedback from teaching sessions (14/01/2018).

Taken from group work with  pre and post registration nursing students and senior nurse managers. N=210:

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#Oliverscampaign

#STOMP

Stopping over medication of people with a learning disability, autism or both (STOMP)

and

#STOMPSTAMP

Supporting Treatment and Appropriate Medication in Paediatrics (STAMP)

and

#ASKLISTENDO

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Click on the image for more.

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NHSEngland STOMP Document

NICE Pathway – ‘Challenging behaviour and learning disabilities overview’

#STOMPLD a NICE Key Therapeutic Topic click here to link directly to it

NHS England Leaflet

Video courtesy of Cheswold Park Hospital 🔽


Feedback and views welcome, send them to info@carerightnow.co.uk


Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and a former NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @MedicineGovSte   hashtag #MedLearn

cropped-mlku-ky6-large.jpg

Click on the image to find out more about @MedicineGov and #MedLearn


Version 5          dated: 20/04/2018

Revision history:

03/05/18

*Following feedback from parents & carers I’ve changed some wording and added some additional wording which puts the patient first. Thank you for the feedback.

08/10/18

Added the video from Paula McGowan telling Oliver’s’ story at a STOMPLD event.

12/12/2018

Updated with link to the RPS Competency Framework for all Prescribers, following feedback from readers.

09/01/2019

Updated to include reference to diagnostic oversahdowing.

14/01/2019

Updated to include allergies, sensitivities adverse reactions and feedback from teaching sessions.

15/01/2018

Updated to include specific mention the Mental Capacity Act.

04/02/2019

Updated to include the #Oliverscampaign web site

16/02/2019

Updated to include the training consultation and STOMPSTAMP link.

26/02/2019

NHS Constitution link and image added.

20/04/2019

Notes that medicines related option should only be considered if non-medical options have not worked. Minor amendments to text.

21/05/2019

Updated to include a presentation to the NICE Medicines & Prescribing Associates Team.

22/05/2019

Updated to include the 2019 Learning From Deaths Review Report

21/08/2019 Updated following feedback re: evidence base on prescribing combined antipsychotics. Point revised, new sentence and link added, ‘There is a limited evidence base for this type of prescribing.’