A 27-year-old man comes to the office for follow-up regarding a herniated disc. He first injured the disc 3 months ago while at work. Nonsurgical treatment options, including physical therapy and as-needed NSAIDs and tramadol, were recommended. The patient has completed physical therapy, and follow-up MRI indicates that the herniated disc has regressed. He reports a significant amount of ongoing pain and asks for a dose increase and refill of his pain medication. In the past month, the patient has been to the emergency department on 2 occasions to request pain medication due to running out before his next scheduled refill. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following statements by the physician would be most appropriate at this time?

Question

A 27-year-old man comes to the office for follow-up regarding a herniated disc.  He first injured the disc 3 months ago while at work.  Nonsurgical treatment options, including physical therapy and as-needed NSAIDs and tramadol, were recommended.  The patient has completed physical therapy, and follow-up MRI indicates that the herniated disc has regressed.  He reports a significant amount of ongoing pain and asks for a dose increase and refill of his pain medication.  In the past month, the patient has been to the emergency department on 2 occasions to request pain medication due to running out before his next scheduled refill.  Vital signs are within normal limits, and physical examination is unremarkable.  Which of the following statements by the physician would be most appropriate at this time?

Quizplus · Accepted Answer

Pain is subjective, and physicians must use clinical judgment to balance effective pain management with prevention of drug overuse and misuse. Prescription opioid misuse has become an increasing occurrence in recent years. Signs of misuse include not taking medication as prescribed, requesting early refills, accessing drugs from multiple physicians or illicit sources, requesting higher doses, and refusing alternate pain-management strategies. This patient is showing signs suggestive of opioid use disorder: running out of medication early; obtaining prescriptions in emergency departments rather than from the primary prescriber; tolerance (ie, requiring higher doses to attain the same effect); and dependence. However, confronting the patient about misuse at this point is unlikely to be helpful. The most appropriate initial action is a patient-centered approach: validating the patient's concern about pain control; engaging the patient in a nonjudgmental, collaborative discussion of how he is using the medication; and exploring reasons for the escalating use. (Choice A) This statement may be interpreted as confrontational and put the patient on the defensive. It fails to validate the patient's subjective experience of pain and instead focuses on the physician's concerns about dependence. (Choices B and E) These statements reject the patient's request for more medication without discussion and prematurely shut down the conversation. This approach is likely to frustrate the patient, making it less likely that he will be receptive to alternate approaches to pain management. (Choice C) This response prematurely switches the focus of the conversation to mood, ignoring the patient's concerns. Raising the possibility of self-medication of mood symptoms would be more appropriate once the patient has already engaged in a collaborative discussion of how he is using the medication. Educational objective: When misuse of prescription opioids is suspected, physicians should first engage patients in a nonjudgmental, collaborative discussion to understand the reasons for the misuse. __________ References: Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse: part 1. (http://www.ncbi.nlm.nih.gov/pubmed/28226333) Prescription opioid misuse, abuse, and treatment in the United States: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26337039)

A 27-Year-Old Man Comes to the Office for Follow-Up Regarding