Electronic supplementary material
Impacts on practice
Nurse prescribers and doctors in a specialist addiction service differ in the types of medications they review but appear to be working within their competency.
Decreasing medical expertise in addictions may pose a threat to quality decision-making by nurse prescribers.
The decreasing availability of medical expertise in addiction services presents a challenge to the management of complex service users by GPs.
There is a need to provide training and support to nurse prescribers and GPs on prescribing for people with substance misuse problems, so that they can provide optimal care to specialist addiction service users.
Study design and setting
Review of medications
The remaining prescribers consisting of other doctors and nurse prescribers described a more limited remit. These doctors considered their scope of practice to encompass medications for mental health illnesses, addictions and sometimes opioids for pain relief while nurse prescribers described a focus on medications used for treating addiction problems. This quote captures a nurse prescriber’s view:So I’d look at the list of drugs prescribed and see how they matched up to what I thought the person was showing in terms of addiction illness, physical illness and mental illness [P3, consultant].
Nurse prescribers further described involving doctors at the specialist addiction service or service users’ general practitioners (hereafter GPs) if they had particular concerns about medications. There was an underlying feeling of cautiousness characterised by their perceptions of their competency. This was captured by the quote below:So I don’t really see, with psychiatric medication, that that would be within my remit really. If somebody came and they were prescribed 100 mgs of methadone and they couldn’t even open their eyes then, I would be assessing the appropriateness of the dosage and making necessary adjustments to things like that [P10, NP].
Doctors at the specialist addiction service were a valuable source of support to nurse prescribers in prescribing-related issues. There was also particular reliance on the expertise of consultant addiction psychiatrists by both nurse prescribers and doctors who were not consultants. A doctor described contacting a GP concerning an inappropriate medication and the support of her consultant in providing expert advice when needed:As I say, if I was particularly concerned about someone’s mood or I have particular concerns about the medication I would defer to a medic. You know, it’s not an area I feel strongly confident on [P6, NP].
It appears that prescribers at this specialist addiction service provided a ‘safety net’ function to other prescribers such as GPs:For the example I started with [ patient with schizophrenia on supra-BNF dose of olanzapine], I wrote to the GP saying, you know, Mr So-and-So is stable and is relatively symptom free on this but I’m worried about this monitoring [ olanzapine monitoring] but generally if I think something’s really inappropriate and I’m in a position to contact the original prescriber I’ll try to do that, but I’d always discuss a case with my consultant and make a decision about whether or not I need to do something imminently [P12, SHO].
If I find something that’s maybe been overlooked or prescribed wrongly, then I will let the GP know about it [P5, Locum].
Specialist addiction service prescribers further described GPs’ varying responses to the need for review of service users’ medications:I’d probably look at it [ medication appropriateness] at the initial assessment and if there’s anything that comes up or that was sort of glaringly obvious I’d refer to the GP and ask the GP to review, if they’re prescribing [P11, NP].
They also described sometimes taking over prescribing of psychiatric medications from GPs:Yeah. that has happened on a couple of times where I’ve written to the GP to ask them to review… there have been a couple of scenarios where I’ve written and the GP hasn’t responded or the GP has written back saying, I don’t feel I’m the best person to do this, would you refer to a specialist service or would you basically will you deal with it [P12, SHO].
But in general I’d like to take over all of the psychoactive drugs that somebody gets, at least until the point that we’re sure that the drugs are appropriate and we’ve got some sort of stable situation [P3, Consultant].
One prescriber described a service user who she felt had an inappropriate and high risk prescription of olanzapine (an antipsychotic). The service user was an elderly man who was being prescribed olanzapine (25 mg) at a dose higher than that stated in the British National Formulary (BNF) without monitoring by a psychiatrist:Well if it’s going to do, first of all, less harm than the actual substance, not more harm, so the actual prescription can be worse than doing nothing [P5, locum doctor].
The SHO described contacting the service user’s GP concerning the antipsychotic medication. His GP refused to alter it due to the service user’s stability on the dose for a prolonged period. The GP and SHO differed in their views concerning the antipsychotic. There was no change made to the antipsychotic.I have a patient who has a very old diagnosis of paranoid schizophrenia dating from his late teens, and for this he’s prescribed a very high dose of medication called olanzapine and he’s prescribed over the limit in the BNF and he’s not under the supervision of a specialist. So I would label that as an inappropriate prescription because (a) he’s elderly, which means that he’s more prone to cardiac disease, and the drug can cause diabetes which can lead to heart disease. It can cause arrhythmias, he’s not being monitored regularly with regards to that, and he’s not being monitored with regards to his clinical symptoms, which, are actually, from a psychosis point of view, negligible [P12, SHO].
Guideline adherence versus successful prescription
A consultant addiction psychiatrist also expressed similar views and contrasted guideline adherence with successful prescribing:And I think any comment about any prescribing should only be made when you know about the circumstances in which the decision was made. For example, we prescribe very high doses of some drugs, now some people say that you shouldn’t prescribe at those levels, but they are appropriate if you know about the circumstances [P1, NP].
Prescribing is something of an art as well as a science, so prescribers will sometimes prescribe things that they know are not really indicated but with the aim of achieving a particular goal [P3, Consultant].
Despite prescribers routinely obtaining a medical/medication history from service users, most reiterated that it was not within their remit to explore the appropriateness of all prescribed medications:Looking at the history of their substance use, history of any physical health problems, mental health history, and current mental state as well so I’d get the full history and I think then you can kind of gauge whether something might be inappropriately prescribed [P11, NP].
All prescribers further described some challenges with self-report when obtaining service users’ histories. These include problems with the reliability of information provided by service users as some of them may withhold information. This may lead to prescribing of unnecessary medications. Prescribers also described service users who do not know details of their medications such as the name and reason for medication use. Some may be cognitively impaired by substances and therefore unable to provide necessary information. Prescribers may have to contact GPs concerning needed information. There was however an acknowledgment that contacting GPs for information was not always routine practice as prescribers tended to rely on information obtained from service users.…I would, in as much as part of the assessment, I would ask the service user …are they on any medications. If they are, what it is, what dose, what’s it prescribed for and are they taking it. That would be the total sum of my assessment. I wouldn’t move to beyond exploring that condition or whether that was appropriate, I don’t think that’s my place [P6, NP].
Involvement of service users
Prescribers also highlighted the fact that lack of engagement by service users may affect prescribing decisions. For instance, service users’ medications may need to be stopped due to repeated non-attendance of clinic appointments.Well, firstly I discuss with the patient to see what the patient’s view is, and explain what I think, which are the reasons for this inappropriateness [P13, SpR].