Welcome to the MUS Webinar on:

Supporting pharmacy staff in acute care to manage patients with mental health and/or substance misuse issues

• The webinar itself will start at 1pm.

• Shortly before 1pm Nina Barnett will be doing sound checks and you may hear this more than once!

• To join the audio call 0203 478 5289 access code 958 833 956

• The webinar will be recorded and both recording and slide set will be available on the SPS website – under Networks (you need to be logged onto the SPS site to access the recording)

• If you want to make a comment or ask a question – please use the “chat” function (you need to choose to direct your question to “All Participants” from the drop down box)

• The speakers will answer questions at the end of the presentation

MEDICINES USE AND

SAFETY WEBINAR

https://www.sps.nhs.uk/meetings/using-cases-to-describe-a-patient-centred-and-outcome-focused-approach-to-optimising-medicines-use-for-older-people-living-with-frailty/

Webinars:

• 9th May - De-prescribing in acute care – Emily Ward

• 13th June – Administering medicines to patients with swallowing difficulties – Paresh Parmar

• 11th July – Pain management, focus on current opioid-related issues – Emma Davies

Face to face events:

• 7th June – CHS Learning Event in London

• 12th July - MUSN Learning Event in London Details on SPS website, see also latest Medicines Use and Safety Update - link

Contact LNWH-tr.MUS-SpecialistPharmacyServices@nhs.net to join networks and receive mailings

Upcoming MUS Events

https://www.sps.nhs.uk/articles/medicines-use-and-safety-updates/mailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.net

Why have the top tips been developed?

Ray Lyon, Chief Pharmacist - Strategy

Sussex Partnership NHS Foundation Trust

Mental Health in General Hospitals - ‘Treat

as One’ – January 2017

• A national confidential enquiry into patient

outcomes and deaths (NCEPOD) report

• Example of findings:

– During the initial assessment mental health medications were prescribed in 311/431 (72.2%).

– 58% of healthcare staff had no training in psychiatric medicine.

What happened next in Sussex?

• Reports key findings around medicines shared with acute trust chief pharmacists in Sussex.

• Training requested initially by one trust.

• Initially 10 key issues identified to base training on.

What happened next nationally?

• Report discussed at the All England Chief Pharmacists’ Meeting.

• Agreed to share top 10 tips nationally.

• Now top 13 tips and SMS version developed.

• Attitude paper developed by Peter Pratt’s Group to address stigma issues.

Issues acute trust pharmacists should consider when dealing with patients

with a mental health diagnosis

Ashleigh Bradley

Lead pharmacist for the community mental health teams.

Nana Tomova

Specialist mental health pharmacist - community teams Brighton and Hove locality.

Stigma • People with severe mental illness are still

people.

• You can talk to them in the same way you would talk to any other patients – don’t be afraid to talk about suicide.

• They are often vulnerable people e.g. exploitation, abuse, homelessness

• Sometimes mistrustful of healthcare – use the opportunity to check how they are physically and mentally.

Identifying Patient of MH drugs

• People with a long term diagnosis are likely to be on long term medicines

• These could be antipsychotics, mood stabilisers, antidepressants or anxiolytics

• Sometimes these do not appear on SCRs

• May result in missed doses, and re-emergence of symptoms

Dementia

Behavioural symptoms often particularly challenging

Before medications are prescribed: • Check that the patient isn’t in pain, suffering from an

infection, delirious, has glasses on, hearing aids in, speak to their carer about how they are usually and what is used at home to soothe them, e.g. music, singing, drawing, talking to them and reassuring them they are safe, etc.

Acetylcholine is neurotransmitter involved in memory and cognitive function - Medications that block acetylcholine can worsen dementia symptoms.

Dementia Anticholinergic drugs cause cognitive impairment Anticholinergics Procyclidine Orphenadrine Trihexyphenidyl(Benzhexol) Atropine Antipsychotics Olanzapine Risperidone Quetiapine Haloperidol Aripiprazole Antihistamines Promethazine Hydroxyzine Chlorphenamine Cinnarizine Tricyclic Antidepressants Amitriptyline Dosulepin Clomipramine Nortriptyline Urinary Incontinence Oxybutynin Tolterodine Solifenacin Propantheline Sedating drugs can cause cognitive impairment Benzodiazepines Diazepam Lorazepam Oxazepam Temazepam Clonazepam Opioid Analgesics Codeine Fentanyl Morphine Oxycodone Tramadol Antidepressants Mirtazapine Trazodone Hypnotics Zopiclone Zolpidem Anticonvulsants Carbamazepine Valproate Levetiracetam Pregabalin Gabapentin

Clozapine

• An antipsychotic used in treatment resistant schizophrenia – unresponsive to other treatment

• Short half life – OD / BD dosing

• Missed doses > 48 hours require re-titration

• Clozapine requires FBC monitoring whilst the patient is on the treatment

Clozapine

• Interactions

• Smoking

• Cardiac side effects

• Constipation

High dose antipsychotic treatment (HDAT) and rapid tranquilisation (RT)

• Always ask about antipsychotics and why they are prescribed.

• Check that the dose is within range – some patients are prescribed above the max but this is rare and requires 3 monthly monitoring of ECG, FBC, LFT’s and U&E’s.

• If high doses are prescribed check that the patient is being monitored and make a note of their last investigations and results.

• Speak with the local mental health team if you are unsure about combinations of antipsychotics or high doses.

Emotional Intensity • Intense emotions that last from a few hours to a

few days and can change quickly • No strong sense of who you are, and it can

change significantly depending on who you're with.

• Hard to make and keep stable relationships. • Act impulsively and cause harm e.g. using drugs

or driving dangerously. • Often self-harm or have suicidal feelings. • Intense feelings of anger

Prescribing in emotional intensity

• Medicines are not licensed for treatment of PD.

• During periods of crisis when these individuals emotions become unbearable medications are prescribed to help manage this.

• Medicines used are antipsychotics, mood stabilisers and sometimes benzodiazepines.

• There should always be a plan for reducing meds again once the crisis period has resolved

Delirium

Characterised by global impairment of consciousness resulting in reduced:

• Alertness

• Attention

• Perception of the environment

Occurs in 15-40% of patients on medical or surgical wards

More common in the elderly and those with pre-exisiting dementia.

Delirium

• Rapid onset and can be caused by medications, medical conditions, electrolyte imbalance, deficiency, dehydration, constipation, or neurological conditions e.g. epilepsy or encephalitis.

• Medical emergency – underlying cause must be identified.

• Non – drug approaches include reassurance, nursing in a side-room, no unnecessary changes to staff.

• Medicines may be needed for agitation, or insomnia – Haloperidol 0.75mg – 1.5mg TDS.

Risk of Overdose • Some people may be at a high risk of overdose

• Find out what the risk is ask them/their carers/their MH team

• Consider the history of overdose, the frequency of overdose

• The severity of OD with the drugs they are prescribed

• If limited quantity supplied - arrangements in community after D/C

Long Acting Injections • Slow acting antipsychotics given I/M

• They have a long half life and take a long time to start working, and have a long washout period

• This is not an urgent medication - may be given a few days earlier/later

• All LAIs have different pharmacokinetics

• All require deep IM administration and have different licensed inj. sites

• Written confirmation of drug and dose

Raising awareness of the local pharmacy mental health teams

• Local mental health Trusts will have pharmacists working within them.

• Build links with these pharmacists – they often know the patients very well and can access their electronic notes.

• Invite them over for training session on psychotropic meds – they are the experts.

• Return the favour – they will always want to expand their knowledge of acute topics.

Communication with Teams • Community MH teams are not often aware that

their clients have been admitted to an acute ward

• They can give you vital information about their care, risks and medication

• Each client will have a dedicated lead practitioner who will meet with them regularly and often know them better than their GP

• Any changes should be communicated with CMHTs directly before discharge – joined up care

Patient Choice and Involvement

“ It’s not about how the pills made me feel. It’s

about how the idea of taking the pills made me feel

about myself”

- John. Filmmaker of “Medicating me”, ex-service user

Patient Choice and Involvement

• Through the construct of meaning, medication encompasses a larger dimension in the individual’s life, it entails implications for their feelings and interactions, requires definitions, choices, attitudes, re-evaluations and redefinition of subsequent actions (Vedana and Miasso, 2014).

• 50 to 80% of people on long term treatment discontinue their medication after 2 years.

How you can support them - Engage people to talk about medication

- Hear, Listen, Understand

- Provide information

- Joint problem solving

- Empathy

- Empower the patient & Encourage hope

Webinar SMS top tips 2018

Soyar Sherkat, Advanced Specialist Pharmacist Addictions, CNWL

Anshu Rayan, Associate chief pharmacist, CNWL

Case 1 Eric has been admitted to your ward with suspected tuberculosis. He has a history of injecting street heroin but has been in treatment with a substance misuse clinic for the past 3 months and has been stable on 120mg of methadone oral solution for the last 2 months. A culture from a sputum sample has confirmed the presence of TB and he has been started on rifampicin, isoniazid, pyrazinamide and ethambutol. He is also prescribed pyridoxine tablets. 5 days after starting these medications, Eric started to feel sick, irritable, sweating and not being able to sleep at night.

– What do you do before prescribing Methadone ?

– Why is Eric experiencing these symptoms?

– What do you advise the medical team?

– What tests should be carried out before starting TB medication?

– How long does Eric need to be prescribed TB Medication?

– What precautions need to be taken with regard Eric’s methadone treatment once his course of TB medication is finished?

Case 2 Anna is a 54 year old woman admitted to your ward via A&E

following a fall. She says she is prescribed methadone 100mg once

daily from her GP. When admitted she smells strongly of alcohol

and when questioned admits to drinking a bottle of wine and 2-3

cans of strong lager per day on a regular basis.

Anna’s blood results from yesterday are as follows:

Test Result Normal range

Sodium 134 mmol/L 135-145 mmol/L

Potassium 3.7 mmol/L 3.5-5.5 mmol/L

Chloride 95 mmol/L 95-108 mmol/L

Urea 3.7 mmol/L 2.5-7.0 mmol/L

Creatinine 70 µmol/L 60-110 µmol/L

Alanine transaminase (ALT) 24 IU/L 0-31 IU/L

Alkaline Phosphatase (ALP) 185 IU/L 30-130 IU/L

Aspartate Transaminase (AST) 47 IU/L 0-31 IU/L

Albumin 41 g/L 33-47 g/L

Globulin 53 g/L 19-35 g/L

Gamma GT 582 IU/L 2-30 IU/L

Platelets 136 x109/L 120-400 x109/L

WBC 3.5 x109/L 4.0-11.0 x109/L

RBC 4.23 x1012/L 3.74-4.99 x1012/L

Case 2 contd. Comment on the following given the blood results above:

- Renal function

- Liver function

Since being admitted the medical team have prescribed the following:

- Methadone Oral Solution (Sugar-Free) 1mg in 1ml 100mg o.d.

- Chlordiazepoxide Capsules 20mg q.d.s. on day 1, reducing

10mg per day until zero for alcohol detoxification

- Ensure Plus drinks 1 bd

• What action would you take regarding the methadone prescription?

• What are the signs of opiate toxicity and why might this occur in

this patient?

• Is chlordiazepoxide the best choice of medication for alcohol detox

in this patient?

Case 3

Mary is brought in to A&E from a nightclub. It is snowing

outside, she is wearing thin clubbing clothes.

She is confused, disorientated and anxious. She is

extremely hot, tachycardic and showing some signs of

myoclonus.

Blood chemistry revealed hypoglycaemia, hypocalcaemia

and hyperkalaemia. Shortly after admission she developed

bradycardia with continuous seizures and asystole.

• What do you think is going on?

You ask her what she has taken – she says Ecstasy

• What course of action do you take?

Case 4 Clara is a 33 year old woman admitted to your ward via A&E. She has

been diagnosed with cellulitis and a broken leg. She has a history of

injecting street heroin and has recently started injecting into her left

hand as she can no longer find a vein in her left arm. Clara says she is

usually prescribed oral buprenorphine 24mg daily, diazepam 24mg

daily and clonazepam 4mg tds. She is also complaining of pain and is

asking for something to be prescribed to treat it.

The day after she is admitted she has been prescribed the

buprenorphine, diazepam, and clonazepam as above, however the

medical team are reluctant to prescribe any analgesics as they feel the

methadone she is receiving should control this.

• What is your advice regarding her current prescription?

• What action should you take regarding pain control?

Following a pregnancy test, you find out that she is 15 weeks pregnant. What

precautions do you take as a result of her pregnancy regarding her:

a) buprenorphine prescription?

b) diazepam prescription?

Back to Ray...

• Summary

• Key points

Questions?

Poll Question Number 1

Overall I found the webinar content useful to me:

• Agree strongly

• Agree

• Disagree

• Disagree strongly

Poll Question Number 2

I would recommend this learning event to others:

• Agree strongly

• Agree

• Disagree

• Disagree strongly

Webinars:

• 9th May - De-prescribing in acute care – Emily Ward

• 13th June – Administering medicines to patients with swallowing difficulties – Paresh Parmar

• 11th July – Pain management, focus on current opioid-related issues – Emma Davies

Face to face events:

• 7th June – CHS Learning Event in London

• 12th July - MUSN Learning Event in London Details on SPS website, see also latest Medicines Use and Safety Update - link

Contact LNWH-tr.MUS-SpecialistPharmacyServices@nhs.net to join networks and receive mailings

Upcoming MUS Events

https://www.sps.nhs.uk/articles/medicines-use-and-safety-updates/mailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.netmailto:LNWH-tr.MUS-SpecialistPharmacyServices@nhs.net

Thank you