Howard is a 24 year-old male who presents to the clinic his wife for what he states is severe lower back pain. He states the pain is so bad that he rates it as a “50 out of 10.” He also tells you that due to a past medical history of an ulcer, he cannot take any medications “like Motrin.” He states that the pain is from a car accident in 2012, and that it flairs up and he needs pain medications. He also tells you that he has a high pain tolerance, and that when he gets pain meds he requires the higher doses.
Discussion 1
- What would you do first prior to prescribing any medication?
- What are the various schedules of medications for controlled substances?
- Would you prescribe a long or short acting narcotic? Why or why not?
Discussion 2
- What other non narcotic medication options can you offer to this patient?
- What patient education is needed with them?
- What would you do if the patient and his wife tell you that none of them work for him?
Discussion 3
You are concerned that this patient may have a substance abuse problem.
- What screening testing is available for you to use that is reliable and valid?
- What strategies would you suggest for this patient if he was found to have a problem?
- What type of referrals would you make?
Discussion 4
After some investigating, you find that Howard actually is seeing a pain specialist who has given him epidural injections, and prescribes medication for him.
- How does that impact any intervention that you may consider?
- What other pharmacological options could you offer him?
- What nonpharmacological options could you suggest?
Discussion 5
After seeing Howard and performing the appropriate screening tools, and a urine drug screen, he admits to you that he does have a problem with opioids due to his back injury. He states he has been admitted to an inpatient detox and twenty-eight day rehabilitation unit previously and was able to quit using for 3 months, but relapsed due to his pain. He states for the last 6 months he has been unable to get opioids from physicians since there is a record of him being prescribed a large amount over a short period of time. Due to this, he has started buying heroin from an acquaintance who he went to high school with. His wife is very tearful and states she is concerned that eventually Howard will end up killing himself.
- What type of substance abuse programs would be most appropriate for him?
- What requirements are there for a nurse practitioner to prescribe a medication to treat opioid addiction?
- What are the requirements for a patient who is enrolled in a medication assisted opioid treatment program?
Expert Solution Preview
Introduction:
This scenario involves a 24-year-old male who presents with severe lower back pain and a past medical history of an ulcer. He is unable to take medications like Motrin and requires pain medication due to a car accident in 2012. As a medical professor, I will address several discussions, including prescribing medication, non-pharmacological options, substance abuse screening, intervention options, and requirements for prescribing medication for opioid addiction.
Discussion 1:
Prior to prescribing any medication, I would conduct a thorough physical examination, including a complete medical history, to identify potential contraindications, side effects, or risks associated with the prescribed medication. I would request to see the patient’s medical records from the pain specialist to confirm the prescriptions and dosages of medications he is currently taking.
The various schedules of medications for controlled substances have five classifications that range from Schedule I to V. Schedule I medications are illegal, while other schedules represent addictive medications that have different degrees of risk for dependency. Healthcare providers must follow specific guidelines for prescribing these medications and track the number of prescribed medications on a prescription drug-monitoring program to prevent the misuse of these medications.
Depending on the severity of pain, I would prescribe a long or short-acting narcotic. Long-acting narcotics are typically reserved for moderate-severe pain, while short-acting narcotics are appropriate for treating acute pain. Nonetheless, I would prescribe a narcotic only after considering non-pharmaceutical options, and following the appropriate guidelines to prevent dependency and addiction.
Discussion 2:
Non-narcotic medication options could include nonsteroidal anti-inflammatory drugs (NSAIDs), neuropathic pain medications like gabapentin, or muscle relaxants like cyclobenzaprine. I would provide patient education on the potential benefits and side effects of these medications. Also, I would emphasize the importance of following the recommended dosages and not exceeding them to avoid adverse side effects.
If the patient and his wife state that none of the medications are working, we would assess their adherence to the treatment and the severity and response to the pain medications. Additionally, we could consider a referral to a pain management specialist or physical therapy if appropriate for further evaluation.
Discussion 3:
There are several screening tools for substance abuse that healthcare providers can use to identify substance abuse problems. One commonly used tool is the CAGE questionnaire, which asks four questions related to alcohol abuse, although it can be extended to drug use as well. Other tools include the Alcohol Use Disorders Identification Test (AUDIT), Substance Use Brief Screen (SUBS), and the Drug Abuse Screening Test (DAST).
If the patient was found to have a substance abuse problem, I would suggest prescribing medication-assisted treatment (MAT) with behavioral therapy to help manage the dependence on opioids and reduce the potential for relapse. Referrals to support groups, inpatient rehabilitation centers, or outpatient day programs would also be appropriate.
Discussion 4:
The pain specialist’s intervention and prescriptions would impact the options that I may consider. As such, it is imperative to review the patient’s medical records and request to communicate with the pain specialist to ensure our prescriptions and dosages do not interfere or exacerbate the risk of dependency.
Other pharmacological options that we could offer the patient include alternate oral or transdermal medications, spinal cord stimulation, or radiofrequency ablation of nerve endings. Non-pharmacological alternatives include physical therapy, acupuncture, or nerve blocks.
Discussion 5:
For patients who have a substance abuse problem, specialized substance abuse programs designed to meet the individual’s needs and level of dependency may be the most appropriate. These programs may include MAT, behavioral therapy, or inpatient rehabilitation programs. We may also consider providing information on a holistic approach to managing pain that involves healthy lifestyle changes, such as diet and exercise, to enhance pain management strategies.
To prescribe medication for opioid addiction, a nurse practitioner (NP) must have a DEA certification and comply with state regulations that apply to prescribing controlled substances. Additionally, an NP must obtain specific training through a waiver program to prescribe buprenorphine, methadone, or other medication-assisted treatments in a clinical setting.
Patients enrolled in a medication-assisted opioid treatment program must comply with the program’s regulations, including urine drug screenings, regular clinic visits, and participation in behavioral therapy or counseling. Patients who participate in these programs are expected to remain adherent to the treatment plan and follow the physician’s prescribed dosages to avoid relapse and dependence.
