A 49-year-old woman comes to the urgent care clinic due to flu-like symptoms. For the last 3 days, the patient has had nasal congestion, coughing, and a low-grade fever. Medical history is negative for underlying cardiopulmonary disease, but she has a history of chronic back pain due to a work-related injury 5 years ago. Her only medication is hydrocodone-acetaminophen, which she takes on a regular schedule 3 times daily. The patient does not use tobacco, alcohol, or recreational drugs. Temperature is 37.2 C (99 F); vital signs are otherwise normal. Examination shows boggy, erythematous nasal mucosae. Lung examination is normal. Moderately exaggerated lumbar lordosis is present with bilateral lumbar paraspinal tenderness. The patient ambulates with the assistance of a walker, but lower extremity motor strength, sensation, and reflexes are normal. Straight-leg raising test is negative. Bedside influenza screening is negative, and she is counseled in over-the-counter medications for her acute illness. Prior to release from the clinic, the patient reports that she has a regularly scheduled pain management follow-up appointment the next day but says, "I'm worried that I might miss my appointment because I'm sick. As long as I'm here, can you give me my hydrocodone prescription?" Which of the following is the most appropriate response to the patient's request?

Question

A 49-year-old woman comes to the urgent care clinic due to flu-like symptoms.  For the last 3 days, the patient has had nasal congestion, coughing, and a low-grade fever.  Medical history is negative for underlying cardiopulmonary disease, but she has a history of chronic back pain due to a work-related injury 5 years ago.  Her only medication is hydrocodone-acetaminophen, which she takes on a regular schedule 3 times daily.  The patient does not use tobacco, alcohol, or recreational drugs.  Temperature is 37.2 C (99 F); vital signs are otherwise normal.  Examination shows boggy, erythematous nasal mucosae.  Lung examination is normal.  Moderately exaggerated lumbar lordosis is present with bilateral lumbar paraspinal tenderness.  The patient ambulates with the assistance of a walker, but lower extremity motor strength, sensation, and reflexes are normal.  Straight-leg raising test is negative.  Bedside influenza screening is negative, and she is counseled in over-the-counter medications for her acute illness.  Prior to release from the clinic, the patient reports that she has a regularly scheduled pain management follow-up appointment the next day but says, "I'm worried that I might miss my appointment because I'm sick.  As long as I'm here, can you give me my hydrocodone prescription?"  Which of the following is the most appropriate response to the patient's request?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1d9_0b8a_8f63_97c63167274e_MD0005_00 Use of opioid analgesics for chronic pain can be complicated by toxicity, dependence, misuse, and diversion. Therefore, physicians who prescribe chronic opioid therapy are responsible for providing appropriate oversight of the treatment plan. Because patients may, knowingly or unknowingly, take multiple opioid formulations or concurrent medications that can amplify opioid toxicity (eg, benzodiazepines), all opioid prescriptions should be provided by a single physician who is primarily responsible for the patient's pain management. This provider should regularly review the medication plan with periodic office visits, searches of the state prescription drug monitoring program database, and intermittent urine drug tests. In addition, patients should ideally fill all prescriptions at a single pharmacy, which can serve as an additional safety check on inappropriate prescriptions and drug interactions. This patient has chronic, noncancer pain and is requesting a refill on opioid pain medications from a physician other than her regular pain management provider during an appointment for an unrelated issue. Because the urgent care physician does not oversee the patient's pain management care plan, the patient should be redirected to the primary pain management office. The provider responsible for prescribing opioids can then discuss with the patient the best course of action for renewing the prescription (Choices B and C). (Choice D) Random urine drug testing is a required part of a chronic opioid care plan. However, the drug test (and any follow-up opioid prescriptions) should be ordered by the physician responsible for the patient's pain management. Even if the test is appropriately positive (showing no evidence of diversion), it would still not identify dependence or excessive use. (Choice E) Nonpharmacologic and nonopioid pharmacologic interventions are preferred over opioids for chronic pain. Because of the risk for uncomfortable withdrawal symptoms, opioid therapy should not be discontinued in nonemergencies without consultation with the physician who provides the patient's primary pain management. Educational objective: In management of chronic pain, all opioid prescriptions should be provided by a single physician who is responsible for the patient's pain management. The treatment plan must include periodic office visits, searches of the state prescription drug monitoring program database, and intermittent urine drug tests. In addition, patients should fill all prescriptions through a single pharmacy. References: CDC guideline for prescribing opioids for chronic pain-United States, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/26977696)

A 49-Year-Old Woman Comes to the Urgent Care Clinic Due