What other non-narcotic medication options can you offer to this patient?
Discussion #1
What other non-narcotic medication options can you offer to this patient?
The goal of treatment for all pain is elimination. In cases of chronic pain, this is less likely to occur, and a more realistic goal might be to reduce the pain to a tolerable level to maximize function and quality of life. As with acute pain management, it is desirable to meet treatment goals with minimum side effects (Woo & Robinson, 2016).
I would prescribe for this patient an NSAID like Ibuprofen 800 mg 1 tab orally every 6 hours as needed for pain. I would add Omeprazole 20 mg 1 tab orally daily before breakfast to minimize GI discomfort.
What patient education is needed with them?
The most common side effects of Ibuprofen are dizziness, epigastric pain, heartburn, constipation, nausea, rash, edema, fluid retention, headache, and vomiting. Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of serious cardiovascular thrombotic events, myocardial infarction (MI), and stroke. NSAIDs increase the risk of serious GI adverse events, including bleeding, ulceration, and gastric or intestinal perforation, that can be fatal (Advil, Motrin, 2019).
What would you do if the patient and his wife tell you that none of them work for him?
I would recommend lifestyle modifications like weight loss, exercises, healthy diet. He could benefit from physical therapy, massage, acupuncture, and relaxation techniques like deep breathing and meditation.
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?
Comprehensive urine drug testing is performed when the drug abuse habit of the patient is unknown but suspected.
Naloxone challenge test: This test is performed to assess physical dependence. An intramuscular injection or IV, 0.2-0.8 mg of naloxone is administered. A positive test is indicative of physical dependence and consists of typical withdrawal symptoms and signs. These symptoms and signs usually last for 30-60 minutes. This test is found to be very helpful before starting opiate antagonists for maintenance therapy. Starting opioid antagonists, such as naltrexone, soon after detoxification may cause withdrawal symptoms and discourage patients from further treatment (Dixon, 2018).
What strategies would you suggest for this patient if he was found to have a problem?
Current guidelines recommend comprehensive treatment with pharmacological agents such as methadone, buprenorphine, or buprenorphine combined with naloxone as well as psychosocial therapy. Acute opioid-related disorders that require medical management include opioid intoxication, opioid overdose, and opioid withdrawal. Treatment of chronic opioid abuse includes opioid agonist therapy (OAT), psychotherapy, and treatment of acute pain in patients already on maintenance therapy (Dixon, 2018).
What type of referrals would you make?
Patients who need pain management beyond the acute phase should be referred to another provider with this expertise. We must document the referral in the patient’s health record. We should consider referral also for patients who seek opioids beyond when they are likely to be needed (The role of the Nurse in preventing opioid abuse, 2017).
Discussion #2
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?
There are two appropriate screening tests for this patient to determine if he has a substance abuse problem:
CAGE-AID questionnaire; an addiction risk tool, used to determine whether a patient may be suffering from addiction. The questions are focused on past drug and/or alcohol abuse (Woo & Wynne, 2012).
DAST-20 screening tool; uses a similar set of questions to assess for chemical dependency. The questions admittedly seem to assume drug abuse and are probably not as appropriate as the CAGE-AIDquestionnaire for patients in whom chemical dependency is more possible than probable (Woo & Wynne, 2012).
What strategies would you suggest for this patient if he was found to have a problem?
According to Woo & Wynne (2012) Although opiates carry a high risk for physical tolerance, as well as having “street value,” they are still appropriate for the treatment of severe pain. If the patient is found to have a chemical dependency problem, initiating a pain contract may be appropriate. Obtaining informed consent should be done as well prior to the start opiate therapy and documented in the patient’s medical record. Not using partial agonists or mixed-agonists for patients who have a history of chemical dependency or who may be currently using opiate derivatives, is another useful strategy (Woo & Wynne, 2012).
What type of referrals would you make?
Referrals that may be beneficial for this patient include a Physical Therapy consultation, to aid in increasing his activity level and possibly developing an exercise routine. Also, an evaluation by a Clinical Psychologist, to further evaluate and monitor his cognitive-behavioral status (Woo & Wynne, 2012).
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?
A statewide prescription drug-monitoring program would assist in evaluating whether the patient is obtaining prescriptions from other prescribers, in addition to the pain specialist. This vital information would validate the decision to decrease and/or adjust my prescribing of all medications for this patient, including controlled substances. For monitoring of prescriptions, the patient would be instructed to bring all medication vials to each scheduled appointment. To identify the patient’s illicit and prescribed drug use, routine urine drug screening will also be performed at each appointment (Woo & Wynne, 2012).
What other pharmacological options could you offer him?
Woo & Wynne (2012) A pharmacological option recommended for this patient is the pure opioid agonist Methadone (Dolophine); Usual starting dose for moderate to severe pain in opioid-naïve patients, 2.5 mg orally Q8-12 hrs. for adults and children greater than or equal to 50 kg. Larger doses may be required for analgesia during chronic therapy (Vallerand & Sanoski, 2019).
What nonpharmacological options could you suggest?
Suggestive nonpharmacological options include weight loss (if indicated), increased activity which may include an exercise routine, setting personal goals and identifying effective coping mechanisms to assist with stress management (Woo & Wynne, 2012).