Date of Award

Spring 5-25-2024

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Katie Lais, DNP, PMHNP-BC

Second Advisor

Alex Sietsma, DNP, PMHNP-BC

Third Advisor

Crystal Ross, MSN, PMHNP-BC

Abstract

Introduction: The purpose of this evidence-based practice (EBP) Doctor of Nursing Practice (DNP) project was to evaluate the clinical applicability of Controlled Substance Agreements (CSAs) in the adult outpatient psychiatric clinical setting. The first goal was to determine the frequency of Controlled Substance Agreement (CSA) utilization. The second goal was to identify potential outcomes associated with the implementation of CSAs, such as improved monitoring practices. Finally, this project aimed to evaluate provider perception of the efficacy of CSAs.
Background: The misuse and diversion of prescribed controlled substances contribute significantly to addiction and fatalities nationwide. Prescription psychotropics are the second most misused illicit substance in the United States. A CSA constitutes a formal established contract between the patient and provider outlining the clinic’s policies and protocols governing the prescription of controlled substances; including, monitoring practices, such as urine drug screens and in-person appointments.
Methods: NP Trainees were instructed on the planned quality improvement intervention of CSAs implementation into clinical practice without supplemental supportive education. Research articles and supportive evidence were compiled to provide the NP Trainees with a 15 minute educational session, which included the background, use, and evidence supporting the implementation of CSAs into clinical practice.
Results: During this EBP project, 130 patient charts were reviewed in total. Sixty Seven charts were reviewed, during the 30 day period post-initial CSA implementation without provider education, and 63 charts were reviewed during the 30 day period post provider attendance to a supplemental educational session supporting the clinical use of CSAs. The number of complete CSAs for patients prescribed a controlled substance by a provider in the NP Training Clinic increased from 7% to 27%. The data collected from the implementation of CSAs with provider education showed a positive correlation with the monitoring practice of urine drug screens. The utilization of urine drug screens increased from 21% to 32%. Unexpectedly, the number of in-person appointments decreased from 71% to 59%; however, this was likely attributed to the notion that a large percentage of psychiatric intake appointments occur during the beginning of the year and are required to be in-person. Of the 5 NP Trainees who attended the educational session, 4 chose to participate in the voluntary survey evaluating provider perception of CSAs. Survey findings indicated that all NP Trainees perceive CSAs as a valuable intervention to incorporate in psychiatric care, fostering the therapeutic relationship, promoting monitoring practices, and intending to integrate CSAs into their future practice as psychiatric providers. However, only 75% of NP Trainees concurred that CSAs are an effective mitigation strategy.
Conclusion: The outcomes of this EBP project revealed an overall increase in the utilization of CSAs, alongside an increase in the concurrent monitoring practice of urine drug screens. The implementation of CSAs is considered best practice when prescribing a controlled substance to a patient receiving outpatient psychiatric care. It is advisable for all psychiatric providers to re-evaluate their existing methods and consider the establishment of standardized policies and protocols when prescribing a controlled substance. Additional research is needed to expand the awareness of effective strategies for monitoring and preventing the misuse of prescription controlled psychotropic medication.

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