DNP/700 Week 4: Initial Practice Problem and Significance, sample paper

Long-Term Opioids and No Naloxone in the House: An Initial Practice Problem Statement for a Safety-Net Primary Care Clinic, With Its Local Data, National Significance and Evidence That Co-Prescribing Helps

[Student Name]

University of Phoenix

DNP/700: DNP Expectations Seminar

Week 4 Assignment

[Instructor Name]

[Date]

The author is a composite doctoral student written for a model paper.

I work as a nurse practitioner in a federally qualified health center serving about 12,000 adults in a mid-sized Midwestern city. Last spring, one of our patients on long-term opioids for back pain died of an overdose at home. His wife told me afterward that she had not known there was a medication that could have reversed it. That conversation led me to ask how many of our patients on long-term opioids have naloxone. This paper presents that practice problem, its local and national significance and the early evidence that a solution exists.

The Local Problem

Our electronic health record identified 214 adult patients receiving opioids for 90 days or more in the past year. Of these, 19, or 9%, had a naloxone prescription on file. Of the 61 patients on 50 or more morphine milligram equivalents per day, 8 had naloxone. Twelve of the 214 patients were also prescribed a benzodiazepine, and 2 of them had naloxone. Our clinic has no standing process for offering naloxone; it depends on individual prescribers remembering.

Why Dose Matters

Dunn et al. (2010) followed nearly 10,000 patients receiving opioids for chronic noncancer pain and found that, compared with patients on 1 to 20 mg per day, those on 50 to 99 mg per day had a 3.7-fold increase in overdose risk and those on 100 mg per day or more had an 8.9-fold increase, with an annual overdose rate of 1.8% at the highest dose. Many of our patients are in the higher-risk dose ranges.

What the Guideline Recommends

In the 2022 federal opioid prescribing guideline, Dowell et al. (2022) recommend that clinicians evaluate risk for opioid-related harms and offer naloxone when risk factors for overdose are present, including higher opioid dosages, concurrent benzodiazepine use and a history of overdose. Our clinic's rate falls far short of this recommendation.

One widow's question, "Why didn't anyone tell us?", became the practice problem; the data showed she was not alone.

Evidence That Co-Prescribing Helps

Coffin et al. (2016) studied naloxone co-prescription for 1,985 patients receiving long-term opioid therapy in safety-net primary care clinics in San Francisco. About 38% received naloxone, and those who did had 47% fewer opioid-related emergency department visits per month in the six months after the prescription and 63% fewer after a year, compared with patients who did not. Opioid doses did not change. Although observational, the study took place in a setting like mine and suggests that co-prescribing is feasible and associated with fewer harms.

Significance for Patients

For patients and families, naloxone in the home is the difference between a reversible overdose and a death. Overdose on prescribed opioids can happen to patients who take their medication as directed, especially with changes in health, other sedating medications or alcohol.

A Gap in Current Practice

Our prescribers are skilled and caring. The gap is not knowledge but system design: no prompt, no standing order and no shared expectation. Problems of this kind respond well to process changes rather than education alone.

Significance for the Clinic and System

Opioid-related emergency visits and hospitalizations are costly. Our clinic is also measured on quality indicators related to opioid safety. A systematic process for co-prescribing naloxone would improve safety, align with the national guideline and reduce reliance on individual memory.

Why It Persists

Early conversations with colleagues suggest several reasons: prescribers worry that offering naloxone implies a patient is misusing opioids, there is no reminder in the health record, some patients decline because of stigma, and prescribers are unsure whether naloxone is covered by insurance. Understanding these reasons will shape my intervention.

Narrowing the Problem

A DNP project must be feasible for one student in about a year. My initial problem statement is: Among adult patients receiving long-term opioid therapy at our clinic, only 9% have a naloxone prescription, despite a national recommendation to offer naloxone to patients at increased overdose risk. A focused scope would target patients on 50 or more morphine milligram equivalents per day or on a concurrent benzodiazepine, the highest-risk groups identified in the guideline and in dose-risk data.

Why Now

The recent death in our patient population, a new state program that supplies free naloxone to clinics and our upcoming quality review make this the right time. Clinic leadership is receptive, and a DNP project can provide the structure and evaluation that past informal efforts lacked.

Possible Interventions

Early options include a health record alert when a qualifying opioid is prescribed, a standing order allowing nurses to offer naloxone, a brief patient education script that frames naloxone as a safety tool like a fire extinguisher and pharmacy partnership to confirm coverage. I will appraise the evidence for each in later courses.

Equity Considerations

Our clinic serves many uninsured and Medicaid-insured patients, and about a third speak Spanish as their primary language. A naloxone process must include Spanish-language education, confirmation of coverage or a free supply through the state's distribution program and attention to stigma in communities where opioid use is heavily judged. Otherwise, the patients at highest risk may be the least likely to benefit.

Family and Household Members

Naloxone is used by someone else, not by the person who has overdosed. Education must therefore reach household members. The widow's comment that she had not known naloxone existed shows that a prescription alone is not enough; the person likely to find the patient must know where it is and how to use it.

Stakeholders

My medical director, the clinic's pharmacist, nursing staff, the quality director and the IT team will need to be involved. Patient input will help shape the education script. I plan to ask two patients on long-term opioids, and the widow who first raised the question, to review a draft and tell me what language feels respectful rather than accusatory.

Early Feasibility

My medical director supports the idea, and our pharmacist has confirmed that naloxone nasal spray is covered by most of our patients' plans. The IT team can build an alert within existing tools. These early signals suggest the project is feasible within our resources.

Measures

The main outcome would be the percentage of eligible patients with a naloxone prescription. Process measures might include the proportion of alerts accepted and patient acceptance rates. A balancing measure, such as visit length, would show whether the new step burdens clinicians.

Conclusion

Only 9% of our patients on long-term opioids have naloxone. Overdose risk rises with opioid dose (Dunn et al., 2010), a national guideline recommends offering naloxone to patients at increased risk (Dowell et al., 2022), and evidence from safety-net primary care suggests co-prescribing is feasible and associated with fewer opioid-related emergency visits (Coffin et al., 2016). This problem is significant, supported by local data and narrow enough to address as a DNP project.

References

Coffin, P. O., Behar, E., Rowe, C., Santos, G.-M., Coffa, D., Bald, M., & Vittinghoff, E. (2016). Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Annals of Internal Medicine, 165(4), 245-252. https://doi.org/10.7326/M15-2771

Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain: United States, 2022. MMWR Recommendations and Reports, 71(3), 1-95. https://doi.org/10.15585/mmwr.rr7103a1

Dunn, K. M., Saunders, K. W., Rutter, C. M., Banta-Green, C. J., Merrill, J. O., Sullivan, M. D., Weisner, C. M., Silverberg, M. J., Campbell, C. I., Psaty, B. M., & Von Korff, M. (2010). Opioid prescriptions for chronic pain and overdose: A cohort study. Annals of Internal Medicine, 152(2), 85-92. https://doi.org/10.7326/0003-4819-152-2-201001190-00006