A 34-year-old man comes to the office to establish care and receive an opioid prescription. His medical concerns include a history of disc atrophy with likely thecal sac entrapment at C2, C3, and C4 that is associated with severe shooting pain with neck extension. He also has a large skin graft on his left upper thigh from a water heater burn. The patient, a general contractor, recently moved to the area and has not yet established a relationship with a new primary care physician. He reports "my previous physician put me on high-dose oxycodone that enabled me to continue working." Physical examination reveals numbness and weakness of both arms, which the patient reports has been getting worse for some time. The physician recommends surgical consultation to discuss surgical options. The patient is reluctant to consider surgery and requests a refill of his opioid pain medication. He explains, "Without the medication, I am unable to work. My family is relying on me. I only have a 1-week supply left." Which of the following is the most appropriate course of action?

Question

A 34-year-old man comes to the office to establish care and receive an opioid prescription.  His medical concerns include a history of disc atrophy with likely thecal sac entrapment at C2, C3, and C4 that is associated with severe shooting pain with neck extension.  He also has a large skin graft on his left upper thigh from a water heater burn.  The patient, a general contractor, recently moved to the area and has not yet established a relationship with a new primary care physician.  He reports "my previous physician put me on high-dose oxycodone that enabled me to continue working."  Physical examination reveals numbness and weakness of both arms, which the patient reports has been getting worse for some time.  The physician recommends surgical consultation to discuss surgical options.  The patient is reluctant to consider surgery and requests a refill of his opioid pain medication.  He explains, "Without the medication, I am unable to work.  My family is relying on me.  I only have a 1-week supply left."  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: Managing patients who request opioid medication is frequently challenging because it may be difficult to differentiate inadequate pain management from drug-seeking behavior. Prescription opioid misuse and dependence have escalated rapidly, requiring increasing oversight and monitoring. Prior to prescribing opioids, the best approach is to confirm the patient's medical history and prescription use by contacting the patient's previous physician. State-based prescription drug monitoring programs should also be checked to identify undisclosed prescriptions, clarify prescription patterns, and determine whether the patient has obtained prescriptions from multiple prescribers. By identifying potential opioid misuse, physicians can make more informed decisions regarding opioid prescriptions. Risk factors for opioid misuse include a personal or family history of substance use and psychiatric disorders. Features concerning for drug-seeking behavior include requesting high doses or a specific medication by name, running out of medication before the refill is due, reporting lost or stolen medication, and pain out of proportion to the physical examination. (Choice A) Although a pain contract may be useful in documenting shared decision-making and a monitoring plan, the first step is to confirm the patient's history with outside sources. The efficacy of pain contracts has not been established. (Choice B) Referring the patient to a pain management specialist may be helpful, but it does not address his acute condition because he has a possible legitimate need for the opioid pain medication. Abrupt discontinuation may precipitate a severe uncomfortable withdrawal syndrome and risk of suicide. (Choice C) Although the risks of prescription opioids should be reviewed, this patient reports needing high doses and is unlikely to be receptive to a nonopioid analgesic. In addition, abruptly stopping an opioid medication could lead to withdrawal symptoms. Patients who are on long-term, high-dose opioid therapy need a careful balance of deescalation of dosing while preventing withdrawal symptoms. (Choice E) It would be inappropriate to prescribe high-dose opioid medication without verifying the prescription. Educational objective: Physicians should assess patients for prescription drug misuse prior to initiating opioid therapy. This includes verifying medication history by contacting the patient's previous physician and by using prescription drug monitoring programs. References: Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: evidence from the National Survey of Drug Use and Health. (http://www.ncbi.nlm.nih.gov/pubmed/28152391) CDC guideline for prescribing opioids for chronic pain-United States, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/26977696) Breaking the pain contract: a better controlled-substance agreement for patients on chronic opioid therapy. (http://www.ncbi.nlm.nih.gov/pubmed/27824537)

A 34-Year-Old Man Comes to the Office to Establish Care