Discharging Patient With Opioid in Hand?

[ceegee69]

Hello,

Wondering what everyone's thoughts are re: this scenario...patient is being discharged, physician writes an order for patient to be discharged with a dose of whatever opioid they were on (p.o.)--for example, "discharge patient with 1800 dose of 30mg p.o. morphine".

I refuse to do this, as if that opioid gets into the wrong hands, or is taken a different route, for example (I could think of many possible scenarios), isn't my license on the line?

Thoughts?

[Cara_SN]

Unless there was a pt Hx logged or there was a need for suspicion, I would do the same! Too many people are judgemental. We are here to help and not judge.

[DisneyNurseGal, BSN, RN]

No way. If the patient wants their next dose of morphine before going home, they can hang out until 1800 and be discharged when it's swallowed.

With all due respect, I have to disagree with some of this.

I agree that this dose should not be given for the patient to walk out with.

With that being said, nurses are responsible for assessing the reaction to any narcotic given, usually by a NAMDU score or other facility protocol. I would compromise with the patent. I would agree to give the medication 30 minutes early (my hospital allows this), but they must stay the 45 minutes for the assessment. No way do they get a dose to leave with.

[CharleeFoxtrot, BSN, RN]

Given the mixed response, what do you all think of this...one of our local hospitals has a "first fill" program which means at discharge the pharmacy sends over a few days worth of any new medication, including pain management so that the patients don't need to worry about getting scripts filled for a few days.

[wondern, ASN]

The 'first fill' pharmacy sounds like a great idea to me anyhow. That way the pharmacy is dispensing. A lot of people probably never even need to get more pain med after the first few days. It could prevent a bunch of opioids sitting around unused in households waiting to be discovered by someone addicted.

Sending someone home with a dose of morphine~no way. Their toddler could get a hold of it while they're busy unpacking or something. Who knows? A million things could go wrong.

[CharleeFoxtrot, BSN, RN]

Sending someone home with a dose of morphine~no way. Their toddler could get a hold of it while they're busy unpacking or something. Who knows? A million things could go wrong.

But people get pain medications (and other medications) filled at the pharmacy in far greater quantities than one morphine pill and bring it home without anyone panicking. A toddler that gulps down a handful of Mom's glimperide or metoprolol-or OTC tylenol for that matter- is in mortal danger as well. How is handing a patient one morphine pill at DC any different than handing them a script for one pill?

The emotional sticking point here IMO is the fact that it is morphine which is a scary drug for lots of people. But most any drug in excess or the wrong hands is dangerous. Heck, I just had a post surgical patient discharge that I went over where there was enough Tylenol in the percocet and the norco combined that if the patient took both drugs at the max PRN by the label they would have ingested 6gms in 24 hours. Yeah some intern greenlighted that one.

[kbrn2002, ADN, RN]

I guess LTC really is a different beast. It's not at all uncommon for us to send meds, even controlled meds home with a resident. We will send meds out with a resident during a therapeutic LOA if they are going "home" with family for a few days, there is even a separate category in our Pyxis type machine for dispensing LOA meds.

On rare occasions we have discharged a resident with controlled meds. This is dependent on their payer source, for example if the meds are covered by insurance and recently filled their payer source may not cover another refill after discharge. In that case the meds are sent home with the discharging resident. If they are responsible for themselves they sign that they accepted the meds upon discharge, if they have a POA that person signs that they accepted the meds.

[JKL33]

The 'first fill' pharmacy sounds like a great idea to me anyhow. That way the pharmacy is dispensing. A lot of people probably never even need to get more pain med after the first few days. It could prevent a bunch of opioids sitting around unused in households waiting to be discovered by someone addicted.

Sending someone home with a dose of morphine~no way. Their toddler could get a hold of it while they're busy unpacking or something. Who knows? A million things could go wrong.

The morphine is going home with them whether the hospital pharmacy dispenses it or the nurse dispenses it. The toddler could get ahold of it in either scenario, as well as a scenario where the Rx is filled at a community pharmacy.

The issue here is one of dispensing, not what happens after a medication is properly dispensed.

I don't see a lot of problems with a 'first fill' program as long as there is vetted policy in place about the nurse's role (if any) and how the transfer of medication into the patients' keeping is to be documented.

[Alex_RN, BSN]

I have never done this with opioids but have given the patient things that would be tossed, like Dakins or hemorrhoid cream. However, if someone is discharging with pain med prescriptions and they have an urgent need, I encourage them to get on the phone and get that squared away before they leave. We are near many pharmacies but sometimes you have to call around to find out who can fill your MS Contin or Norco right away. A lot of regular pharmacies, even national chains, do not keep it in stock.

[dream'n, BSN, RN]

It'll take just one pharmacy employee getting their panties in a wad about this and all heck will break loose on nursing. Some people can get very protective when they think nursing is stepping over into their space.

[Susie2310]

But people get pain medications (and other medications) filled at the pharmacy in far greater quantities than one morphine pill and bring it home without anyone panicking. A toddler that gulps down a handful of Mom's glimperide or metoprolol-or OTC tylenol for that matter- is in mortal danger as well. How is handing a patient one morphine pill at DC any different than handing them a script for one pill?

That one pill that the pharmacy dispenses is given to the customer in a child-resistant container with a top that often requires effort for an adult to intentionally remove.

[RainMom]

We do it all the time in the ER with full knowledge of the pharmacy. They get enough to make it through til their script can be filled.

We do it when we discharge a pt home from PACU after hrs as well. We do not have any 24 hr pharmacies in my rural area, most close by 8. Our own pharmacy closes at 10, 9 on the weekend. Our pharmacy will provide a labeled package of the meds to dispense, just enough for the pt to make it until morning when the Rx can be filled. The written Rx reflects that # of pills dispensed at the hospital.

In the event of a late night discharge from surgery, we have a label that we fill out & the MD signs indicating what is being dispensed to the pt. The Rx shows that x# of pills were given so the pt's pharmacy will deduct that from the total filled for the pt. The pills are dispensed from pyxis & a copy of the label & Rx is faxed to our pharmacy to see when they reopen.

[MunoRN, RN]

I guess LTC really is a different beast. It's not at all uncommon for us to send meds, even controlled meds home with a resident. We will send meds out with a resident during a therapeutic LOA if they are going "home" with family for a few days, there is even a separate category in our Pyxis type machine for dispensing LOA meds.

On rare occasions we have discharged a resident with controlled meds. This is dependent on their payer source, for example if the meds are covered by insurance and recently filled their payer source may not cover another refill after discharge. In that case the meds are sent home with the discharging resident. If they are responsible for themselves they sign that they accepted the meds upon discharge, if they have a POA that person signs that they accepted the meds.

The difference there is that meds given in an LTC have often already been dispensed for that specific patient by a pharmacy, the LTC is then giving the patient meds from the patient's stock of meds, not the facility's stock of meds, this is technically assisting with self administration rather than administering. There's no problem sending these meds home with a patient because they were dispensed for the patient from the beginning.