This presentation by Linda Renfrew looks at evidence for non medical prescribing among allied health professionals, and how prescribing can be integrated into MS physiotherapy practice.
It was presented at the MS Trust Annual Conference in November 2014.
2. Fit with current policy
Evidence for non medical prescribing
Prescribing options for AHPs
My prescribing journey
Integrating prescribing into MS physiotherapy
practice
Case Studies
Impact on patient care, clinical practice and
service development
Thinking about prescribing: things to consider
3. Key health care policy drivers call for:
a shift from acute, hospital-driven services to
community - treating people faster and closer to
home
meeting the needs of the ageing population and
rising incidence of long-term conditions
encouraging health improvement and
“wellness” by supporting people with long-term
conditions to self manage their condition
developing services that are proactive, modern,
and safe
4. Non medical prescribing is about
enabling quick, safe and equitable access to
medicines for patients.
increasing the kinds of services accessible health
professionals (NMAHPs) can deliver.
improving quality-of-care, reducing health
inequalities and opening access to services for all.
improving patients’ experiences of services and
contributing to better outcomes.
A safe prescription (Scottish Government, 2009)
5. Efficiency
Improved speed & convenience of treatment (Ball, 2009;
Drennan et al, 2009, jones et al, 2010; Oldknow et al, 2010).
Reduced waiting times & increased efficiency of
appointments (Courtenay et al, 2011; 2010; Page et al, 2008).
Doctors make better use of their time to treat more complex
patients (Carey et al, 2010b; Daughtry and Hayter, 2010).
Patient Experience
Patients were highly satisfied with, and confident in, NMP’s
abilities (Courtenay et al, 2011; 2010 Jones et al, 2010;
Watterson et al, 2009).
6. Safety
Patient safety improved (Carey et al, 2009a;
Courtenay et al, 2009a).
Medication errors were significantly reduced in
diabetic management with a nurse prescriber (Carey
et al, 2008; Courtenay et al, 2007).
Nurse prescribers were cautious in prescribing &
recognised budgetary restraints ( Watterson et al
2009).
Only 1 adverse incident reported since 2006
No evidence specifically on AHP prescribing
7. No prescription required
Patient Specific Direction(PSD)
Patient Group Direction (PGD)
Prescription required
Supplementary Prescribing
Independent prescribing
8. “physiotherapists who have not passed an
approved prescribing course must not advise
patients to take or stop taking medication, or
change their dose or type of painkillers, even
paracetamol” (CSP 2006)
Legally we need to demonstrate our
competency to give advice about
medications and that we are working within
scope of practice.
9. Scope of practice
No automatic transfer to new role
Scope of profession
Working within clinical governance framework of employer
Professionally responsible for own actions
Accountable to employers and regulatory bodies for actions
Easy access to primary patient record, timely communication
with GP
Informed consent
No unlicensed medicine, limited prescribing of CD’s
“Off license/off label” or mixing of medicines undertaken with
strong justification /evidence given
Within own caseload
10. Using a medicine outside its licensed
indications/UK marketing authorisation
Only prescribe ‘off-label’ where it is accepted
clinical practice.
Local policies for the use of off-label
medicines should be approved
Many drugs used in MS are used off label
e.g Gabapentin, Amitriptyline, Amantadine etc.
11. No other licensed medicine will meet the
patient’s need
If a licensed medicine is not available
There is sufficient evidence to demonstrate
safety and efficacy
Take full responsibility for prescribing, follow
up and monitoring (or ensure GP does).
Patient informed re the unlicensed aspect of
medicine
12. HCPC registered, minimum of 3 years, identified need & support
from employer
Non-medical prescribing programme
Joint NMAHP course
40 credits @ level 9 ( 6 months), 20 credits @ level 11( 5
months)
Funded by Scottish Government
26 theory days or 10 days blended learning(+ 10 study days)
78 hours of supervised practice
Exam, examination of practice & portfolio of competencies
NMC/HCPC register annotated
Added to local health board register
Part of PDP supported by audit of practice
13. 1986 - BSC physiotherapy
1995 - 2005 Senior Neurological out- patient
physiotherapist
2001 - 2005 MPhil in MS
2006 – 3 year ESP post in MS ( part funded
MS soc). Drive to demonstrate added value &
improve patient pathways - NMP
2007/8 – NMP(supplementary prescribing)
2009 – secured permanent post – consultant
physiotherapist in MS
SP integral to role
Physio led MS review clinics
AHP rep on NMP group NHS A&A
2014 – SP/IP conversion course
2014 – consultant in rehabilitation medicine
retired ( currently unable to recruit to post)
14. First AHP prescriber in NHS Ayrshire & Arran.
? other AHP prescribers in MS nationally
No national or local AHP prescribing a guidelines
Discussions with prescribing leads re prescribing
pathway
demonstrate how patient care is enhanced
alleviate concerns re prompt communication with GP
alleviate concerns re inappropriate prescribing
Liaised with other AHP prescribers re pathways
Undertook audit of prescribing practice
15. Types of medications
Numbers of patients -
where, how often
Details
Costs
16. 50
45
40
35
30
25
20
15
10
5
0
MS clinic Physio Dom visit Total
Total SP
5
4
3
2
1
0
Numbers of
patients
Muscle
relaxants
NSAID
Neuro pain
AB
Bowel med
17. Patient Details of prescription Cost ( 4 weeks) (based on BNF March
2007 prices)
1 7 day course of trimethoprin £1.35
2 Increase Tizanadine from 18mg – 36mg Approx x100tabs extra £40.00
3 Increase Baclofen from 10mg to 15mg Approx 14 extra tabs £1.80
4 Increase Lactulose from 30 ml to 75ml Additional 1260ml £10.50
5 Increase gabapentin from 2.1g to 2.7g Additional 56(300mg) tabs £4.00
6 Start gabapentin 300mg day 1, 600mg day
2, 900mg day 3.
81 (300mg) tabs £5.40
7 Start ibuprofen 400mg x 3 daily 84(400mg) tabs £6.85
8 Start diclofenac 25mg x 3 daily 84(25mg) tabs £2.42
9 Start clonazepam 1mg increasing to 4mg at
night
56 (2mg) tabs £2.93
10 Start Baclofen 30mg daily 84 (10mg) tabs £2.55
Total £77.80
18. How?
Agreement re prescribing pathway (Nov 2008)
Mirrors traditional out-patient prescribing arrangements in
secondary care. Specialist makes recommendations to the GP
Assess, determine need, advise to GP using out-patient notice ( &
follow up letter). Personalised stamp
GP writes prescription
Initially as SP within limits of a CMP guiding prescribing
Autonomous prescribing decisions now as an IP
Agreed date for review (in person or phone) and further
amendments communicated to the GP
19. Pt attendsP pth aytsteion,d ass psehsysseiod & & n neeeeddss t oto s statarrt ts sppaasstctiictyit ym meeddiciacatiotionn
Appointment with consultant at clinic
Pt sees consultant & letter sent to GP re medication
Pt makes an appointment with GP & prescription issued
Pt starts medication
Pt reviewed by physio & requires an dose
DELAY 2-6wk
DELAY 2-4wk
DELAY1-3 wk
DELAY
20. Pt attends physio prescriber , assessed & needs to start spasticity medication
OP advice note issued to GP
GP initiates prescription - pt starts medication
Pt reviewed by physio within agreed timeframe
and dose altered
Final dose of medication notified to GP
21. Where & when?
Physiotherapy new and
review clinics
FES clinic
Domiciliary visits
MS review clinic
Over the phone
▪ where initial assessment
has been undertaken
▪ for symptoms such as pain
and fatigue
22. What?
Symptomatic treatment
Pain (musculoskeletal and neuropathic)
▪ paracetamol, NSAID’s, opiates, compound preparations( co-codamol),
amitryptaline, duloxatine, gabapentin, pregabalin
etc
Spasticity( inc management of constipation acting as a trigger
factor)
▪ baclofen, tizanadine, dantrolene, gabapentin, clonazepam,
sativex (??), movicol, fibrogel, lactulose, anti-biotics
Fatigue and management of secondary factors impacting on
fatigue
▪ amantadine
More unusual symptoms
▪ tremor
▪ hypersalivation
23. Evidence, local & national guidelines
Licencing and legal considerations
Local governance and policy arrangements
Risks and benefits
Medical History
Drug interactions and side effects
Compliance & concordance
▪ Informed consent
▪ Titration & dosing regimes
▪ Impact of psychosocial factors, values & beliefs
▪ Cognition
24. NICE 2014 – MS pharmacological management
Fatigue
Amantadine recommended
8 studies ( 6 Amantadine, aspirin, paroxetine) low to moderate
evidence
Spasticity
Ist line baclofen or gabapentin or combine
2nd line tizanadine or dantrolene
Benzodiazepines ( nocturnal spasms)
Sativex not recommended
33 studies low quality evidence
Tremor
4 studies ( ioniazide, baclofen, botox) evidence inconclusive
No recommendations made
25. NICE 2013 Neuropathic pain
1st line consider amitriptyline, duloxetine,
gabapentin ( al off label) or pregabalin
2nd line tramadol for acute rescue therapy
3rd line Capsaicin cream for localised neuropathic
pain
Trigeminal Neuralgia
▪ Carbomazapene of phenatoyin
26. Amantadine Hydrochloride
licensed for: Parkinson's disease, antiviral
off label for fatigue in MS
Gabapentin
licensed for: monotherapy & adjunct treatment for
focal seizures, peripheral neuropathic pain
off label prescribing for central neuropathic pain and
spasticity
Amitriptyline Hydrochloride
licensed for: depression
off label for neuropathic pain
27. Governance
Systems in place to report and respond to "near misses", errors
and adverse drug reactions ( local & national)
Rapid access to medical history, current medication and
kidney/liver function to prescribe effectively and safely.
Appropriate mentoring, supervision and line management
Effective scrutiny of prescribing practice ( audit & quality
monitoring)
Strong leadership of non medical prescribing at board level
Policy
Local medicines management policy includes NMAHP prescribing
NMAHP prescribing policy developed by a multi-disciplinary group
and reviewed regularly
28. 48 year old lady diagnosed
with RRMS 10 years ago.
Attending FES review clinic.
Is currently taking
copaxone, amantadine
(100mg) and co-codamol (
minimal effect on pain).
Ongoing problems with
fatigue worse over past 4
months and increased lower
limb neuropathic pain
affecting sleep. Her mood is
low.
Previously tried
amytriptyline (25mg) with
no effect.
PMH: mild heart arrhythmia
29. Assessment : lower limb & spinal examination, VAS for pain,
FIS & HAD
Diagnosis : neuropathic pain and low mood impacting on
sleep contributing to increased fatigue
Considerations: PMH, drug interactions, off label
prescribing, concordance
Possible options:
increase dose of amantadine ( from 100mg to 100mg bd)
restart amitriptyline and titrate dose from 25mg up to
75mg (depending on response). Caution due to heart
arrhythmia.
trial gabapentin if no/partial response to amitriptyline .
Titrate dose slowly and monitor response
Discuss mood with GP/refer to MS psychologist
discuss fatigue management strategies
30. 46 year old man with MS and
spinal problems. Wheelchair user
but usually independent.
Long history of neuropathic pain
and lower limb spasticity( 20 years)
Referred to physiotherapy because
his legs feel stiffer,he is falling to
the right and forward and now
unable to self propel or feed self.
Current medication:60mg
baclofen, 36mg tizanadine, 150mg
dantrolene and 1800mg
gabapentin for past 4 years. GP
recently stopped Acupan for pain
and started dihydrocodine.
PMH: ↑BP- minoxidil
31. Assessment: lower limb spasticity ( Ashworth 1/2), L/L ROM -
reduced muscle length hamstrings and gastrocnemius. Poor posture,
reduced trunk tone and poor control in sitting. U/L tone low with
muscle weakness
Diagnosis: anti spasticity medication is causing additional muscle
weakness in upper limbs and trunk
Considerations: PMH, drug interactions, avoid abrupt withdrawal
Options
gradually reduce & stop one of her AS meds & review impact on
L/L spasticity and trunk stability
refer to physio to address trunk stability and reduced muscle
length
refer to bioengineering clinic for review of wheelchair
refer to OT to review U/L function and additional aids to assist with
eating
32. 38 year old man with
advanced MS. Poor
cognition, wheelchair
bound, poor swallow,PEG
fed, marked upper limb and
trunk tremor, requiring 24
hour care.
Attended the MS review
clinic with mum and carers-main
issue is excessive
drooling causing him to
choke on saliva.
Medication –hyoscine
hydrobromide patches
changed every 3 days and
propranolol (60mg)
33. Diagnosis: progression of condition requiring management of excessive salivary secretions
Considerations: capacity and compliance, drug interactions, scope of practice, withdrawal
of meds
Options:
increased frequency of change of patches
amitriptyline
glycopyrrolate– required further information from MIU on unlicensed application for
use via enteral feeding
botox into salivary gland
Outcome
no additional benefits noted changing patches daily & significant respiratory side
effects noted.
following reaction it was decided not to start glycopyrrolate due to possibility of similar
serious side effects.
amitriptyline started (25mg) – no response therefore gradual titration to 75mg.
Increased drowsiness and negative affect on transfers noted. Titrated down and
stopped.
referral to head and neck surgeon made for consideration of Botox injection
CMP set, close liaison with consultant , GP and mum/carers
34. Improved patient pathway
avoiding multiple appointments with consultant and GP
avoiding delays in starting and titrating medication
Optimal symptomatic management
optimising combined use of medication and physical
treatments
limiting use of medication where not necessary
Seeing the right person with the right skills at the right
time
The MS physiotherapist has expert knowledge and skills to
assess and prescribe for pain and spasticity and to evaluate the
impact of treatment
Improved concordance
Physiotherapists spend more time with the patient allowing
opportunities for discussion, improving adherence and patient
safety, reducing waste and improving outcomes (NICE 2009)
35. AHP led MS review clinic
rehab consultant only sees pts requiring medical
review
freeing up time for rehab consultant to focus on
other areas of service development
longer appointment slots for review
appointments
patients as satisfied/more satisfied with new clinic
targets for annual review now being met
36. Comprehensive initial assessment
Consider impact of prescribing decisions &
accountability
Independent & joint decision making
Extending treatment options & refinement of
treatment combinations
Insight into professional strengths of other
disciplines ( nursing, pharmacy 7 medicine)
Understanding the bigger picture
37. Symptom management clinics
spasticity ( combine with botox)
Pain
Relapse management
Medicines management at ward review
Clinical lead role?
38. Would prescribing enhance patient care?
Within a service
▪ what, how often and where would prescribing be done?
▪ Are there other professions within the team who would/could take this role on?
As an individual
▪ what is your role & function within the service/team?
▪ is there a need for you to initiate new medications, titrate & alter medications?
Where is your service based and is this likely to change ?
Primary or secondary care
Cost codes linked to prescriptions
Communication with GP & access to up to date prescribing summary essential
What is the impact of IP training on service delivery and how would thi be managed within
the service
What are your clinical governance structures to support prescribing?
39. A safe prescription ( Scotland) (2009)
http://www.scotland.gov.uk/Resource/Doc/286359/0087194.pdf
National Prescribing Centre: A single competency framework for all
prescribers (2012)
http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single
_comp_framework_v2.pdf
HCPC Standards for prescribing ( 2013)
http://www.hpc-uk.org/assets/documents/10004160Standardsforprescribing.pdf
Practice Guidance for Physiotherapist Supplementary and/or Independent
Prescribers in the safe use of medicines (CSP, 2013)