PS516 Unit 10 Interdisciplinary Case Plan Example

One Client, Five Medicines, Four Professionals: A PS516 Unit 10 Interdisciplinary Case Plan for Opioid Use Disorder and Depression

[Student Name]

Purdue University Global

PS516: Psychopharmacology

Unit 10 Interdisciplinary Case Plan

[Instructor Name]

[Date]

The client, the clinic, the team members and every detail of the case are composite and illustrative; the sources cited are real.

The Client

Daniel is 39 and maintains irrigation systems for vineyards around Walla Walla. Three years ago, after a crush injury to his foot, he developed opioid use disorder that progressed from prescribed oxycodone to heroin. He has been taking buprenorphine-naloxone from our clinic's nurse practitioner for eighteen months and has had no opioid use for the past year. He also has major depression, treated with sertraline, high blood pressure treated by his primary care doctor and mild asthma. Last month a sleep clinic in Kennewick prescribed zolpidem for insomnia. Daniel's PHQ-9 score has stayed between 13 and 15 for four months.

The case raises three medication questions and one coordination problem: whether the sleep aid is safe with buprenorphine, why depression has not improved, how to manage foot pain without opioids and how to keep four prescribers informed.

The Team Model

Our clinic uses collaborative care. Archer et al. (2012) pooled the controlled trials of this team model and found patients with depression or anxiety did better than with ordinary care, at early follow-ups and later ones. In this model, a care manager tracks symptoms with measurement tools and supports the client, a prescriber in primary care manages medication and a consulting psychiatrist reviews cases that are not improving. The model depends on shared information and regular review.

On Daniel's team, I am the care manager. Our psychiatric nurse practitioner prescribes buprenorphine and sertraline. A consulting psychiatrist reviews our caseload weekly by video. Daniel's primary care doctor manages his blood pressure and asthma. The sleep clinic is outside our system.

Question 1: The Sleep Aid

Buprenorphine only partly switches on the opioid receptor it occupies, and Walsh et al. (1994) found that its effects on breathing level off at higher doses, which makes it safer alone than full agonists. That ceiling does not protect against other sedatives. Zolpidem acts on the same GABA system as benzodiazepines, and combining it with an opioid adds sedation and can slow breathing, especially with Daniel's asthma.

Action: I report the new prescription to the nurse practitioner the same day. The nurse practitioner contacts the sleep clinic, with Daniel's consent, to discuss alternatives, such as a structured insomnia treatment, which our clinic can provide through counseling sessions. Daniel keeps naloxone at home and at work.

Buprenorphine's ceiling protects Daniel from his own medicine, not from the one another clinic just added.

Question 2: Depression That Has Not Improved

A PHQ-9 that stays above 10 for four months on an adequate dose of an antidepressant is the kind of case collaborative care is designed to catch. I bring Daniel to the psychiatric consultant's weekly review with his score trend, his adherence, his sleep problems and his report that he still feels like "a burden" to his family.

The consultant's recommendations go to the nurse practitioner, who decides on the change with Daniel. Options include a dose increase, a switch to another antidepressant or the addition of psychotherapy targeting depression, which Daniel has not yet had. Because poor sleep and chronic pain both worsen depression, the consultant also recommends addressing both directly.

Question 3: Pain Without Opioids

Daniel's foot pain flares after long days walking vineyard rows. Mattick et al. (2014) showed buprenorphine holding people in care and cutting their use of street opioids, gains that untreated pain can erode. The primary care doctor and nurse practitioner agree on a plan: a referral to physical therapy, an orthotic insert, scheduled acetaminophen and a temporary split of Daniel's buprenorphine dose into two daily doses, which some prescribers use to extend its pain relief. Ibuprofen is avoided because of his blood pressure.

Coordination Plan

With Daniel's written consent, which meets federal rules for substance use treatment records, the clinic shares a single medication list with the primary care doctor and the sleep clinic. I review that list with Daniel at every monthly check-in, asking about any new prescription or over-the-counter medicine. Each month, I update his PHQ-9, sleep log and pain rating in the shared registry so the team can see trends.

Roles Summary

The nurse practitioner prescribes and adjusts buprenorphine and the antidepressant and contacts the sleep clinic. The consulting psychiatrist reviews the case and advises on the antidepressant. The primary care doctor manages blood pressure, asthma and pain referrals. I track symptoms, review medicines with Daniel, deliver insomnia and behavioral activation sessions, coordinate consent and bring the case back for review if scores do not improve within eight weeks.

Goals

Within one week, the zolpidem question is resolved with the prescribers. Within eight weeks, Daniel's PHQ-9 falls below 10 or the case returns to the consultant. Within three months, Daniel reports pain manageable enough to work full days and has completed six insomnia sessions. Opioid abstinence is confirmed by monthly urine tests throughout.

Conclusion

Daniel's case shows why medication care for complex clients needs a team. Archer and colleagues' review supports collaborative care as the structure, Mattick and colleagues support keeping Daniel on buprenorphine and Walsh and colleagues explain why its safety does not extend to added sedatives. The care manager's role is to see the whole list, track the numbers and make sure each question reaches the person who can answer it.

References

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 2012(10), Article CD006525. https://doi.org/10.1002/14651858.CD006525.pub2

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2), Article CD002207. https://doi.org/10.1002/14651858.CD002207.pub4

Walsh, S. L., Preston, K. L., Stitzer, M. L., Cone, E. J., & Bigelow, G. E. (1994). Clinical pharmacology of buprenorphine: Ceiling effects at high doses. Clinical Pharmacology and Therapeutics, 55(5), 569-580. https://doi.org/10.1038/clpt.1994.71