DQ reply 9 634

Question 1

A 53-year-old male is presenting to you with a 4-week history of low back pain. He does not have an identified traumatic event. He is requesting something for pain. He has history of alcohol abuse but has abstained for 5 years. He has a 25-pack year smoking history and is a current smoker. He takes fluoxetine 20 mg po daily for depression. How would you use the Opioid Risk Tool resource to determine his risk for opioid abuse? How would you counsel him regarding treating his pain?

Question 2

Imagine a patient comes into your office with above condition . What elements in the patient history and physical exam would indicate the patient has the selected condition or disorder? Select two differential diagnoses that could be applied to this patient. How did you arrive at the two differential diagnoses? Include history and physical examination findings that would support each of the two alternative diagnoses.

DQ-1

Acute and chronic pain affects millions of Americans and has been estimated to cost up to $635 billion annually in medical and economic costs (Jones et al., 2019). Medications remain the most commonly used treatment modality and this has contributed to the widespread use of opioids in patients, opening the door for misuse and abuse (Jones et al., 2019).

The Opioid Risk Tool (ORT) was developed using the best known risk factors for abuse in order to aid clinicians in evaluating the probability that a patient would abuse opioids during treatment (Vargas-Schaffer & Cogan, 2018). The ORT categorizes the population into three groups depending on their scores: low risk (0-3), moderate risk (5-7), and high risk (more than 8). It was designed to predict the probability of patients displaying aberrant drug behavior when opioids are prescribed for chronic pain and is the recommended tool nationally for safe and effective use of opioids for noncancer pain (Vargas-Schaffer & Cogan, 2018).

When this patient presents to me with a complaint of a 4-week history of low back pain without a traumatic event, I would utilize the ORT and obtain a thorough history. Obtaining the patient’s history would include assessing any family history of substance abuse, including alcohol, illegal drugs, and prescription drugs. According to the ORT, the patient would score points due to his alcohol use history, current use of prescription drugs, and depression. Without even having obtained the patient’s family history, the patient scores a 9, which according to the scale, indicates a high risk for opioid abuse.

Before starting and periodically during opioid therapy, I would discuss with the patient known risks and realistic benefits of opioid therapy and discuss patient and clinician responsibilities for managing therapy. I would discuss with the patient that opioids are not first-line or routine therapy for acute or chronic pain and present different options available, including nonpharmacologic therapies (CDC, 2020). I would establish treatment goals for pain including realistic goals for pain and function with the patient and the importance of following the prescription instructions. I would also consider with the patient, how opioid therapy will be discontinued if benefits do not outweigh risks. I would counsel the patient on opioid misuse, risks and side effects. Counseling would also include effective follow-up visits, that can help improve functioning and quality of life (CDC, 2020). I would counsel the patient on potentially fatal respiratory depression from opioids alone or in combination with other agents, and the potential development of lifelong opioid use disorder (Jones et al., 2019).

Patient education can decrease fears and concerns about pain, leading to better overall health. Engaging patients to be active members of the team helps promote adherence, compliance and acceptance of treatment plan.

  

References 

Centers for Disease Control (CDC). (2020). Guideline for prescribing opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/prescribing/Guidelines_Factsheet-a.pdf

Jones, L. K., Lussier, M. E., Brar, J., Byrne, M. C., Durham, M., Kiokemeister, F., Kjaer, K., Le, H., Magee, C., McKnight, E., Mehta, N., Papp, J., Pastwa, E., Radovich, P., Ravin, K., Ruther, M., Woodie, G., Wrona, S., Yousefvand, G., & Greskovic, G. (2019). Current interventions to promote safe and appropriate pain management. American Journal of Health-System Pharmacy, 76(11), 829–834. https://doi-org.lopes.idm.oclc.org/10.1093/ajhp/zxz063

Vargas-Schaffer, G., & Cogan, J. (2018). Attitudes Toward Opioids and Risk of Misuse/Abuse in Patients with Chronic Noncancer Pain Receiving Long-term Opioid Therapy. Pain Medicine, 19(2), 319.

DQ-2

If a patient presented to me with low back pain, I will like to first rule out some possible causes before treating the patient. The first step on ruling out is asking the patient about events leading to his back pain. It is important to figure out if the patient pain is either a strain or a problem with the spinal cord. Often the patient will explain about a certain repetitive motion that either required heavy back lifting or twisting that possibly caused the pain. First, I will order a back Xray and a urinalysis. Patients with back pain may have a urinary tract infection that may be causing the pain. Differential diagnosis are back pain, herniated intervertebral disc, pyelonephritis. The first line of treatment for back pain based on our readings is Nsaids and acetaminophen. The second line treatment is a short-term use of opioid analgesics. Using the opiod risk tool I scored this patient a number 4 and determined that the patient is a moderate risk for opioid abuse. I will counsel him on opioid risk of abuse and recommend that we stay away from opiod administration medication until further testing. The patient may need an MRI in order to rule out disc herniation. I will inform the patient that NSAIDs are effective medications to reduce pain and inflammation (Schellack,Masuku, Mogale,Mokwele, Skosana, 2018). I will prescribe ibuprofen 600mg po bid prn pain. The patient is high risk of stomach acid disturbances because of smoking so I will have the patient take famotidine 20mg po bid prn for abdominal discomfort. If pain is unrelieved, I will have the patient take acetaminophen 325mg po bid prn pain together with ibuprofen. I will inform the patient that ibuprofen and acetaminophen taken together can relieve back pain better than ibuprofen alone and may be effective as some low opiods medications (Pallin, 2017).

 

 

Pallin, D. J. (2017). Acetaminophen plus Ibuprofen Is Noninferior to Low-Dose Oral Opioids for Acute Extremity Pain. Journal Watch General Medicine, 37(24), 193.

 

 

Schellack, N., Masuku, P., Mogale, K., Mokwele, N., & Skosana, P. (2018). Hands on management of muscle pain and injuries. South African Pharmaceutical Journal, 85(6), 27.

DQ-3

If I had diagnosed this patient with a lower lumbar strain, additional information that I would need to collect prior to counseling him regarding treatment would include what he has tried for pain relief, and what he expects from pain management. Because he has a history of alcoholism, I would need to find out whether he is currently involved in any recovery-oriented practices such as a 12 step program and what kind of social support he has available. This patient’s five years of sobriety is an important achievement and I would want to address any concerns he may have about his pain affecting his sobriety. He would be reassured that there are numerous treatment options that we could explore, and that acute pain is treated in a similar fashion for all patients regardless of addiction history. I would inform him that we would be working closely together to figure out what treatment works best for him. I would also clarify that a complete absence of pain is generally not a realistic goal and that a decrease in pain to facilitate increased functioning would be more attainable (Passik & Kirsh, 2011).

 According to the Opioid Risk tool resource, this patient would be at moderate risk for future opioid-related aberrant behaviors, which was determined based on his history of alcoholism, his depression, and having a male gender. Opioids would only be considered if the other options, such as weight loss, physical therapy, and non-opioid analgesics like NSAIDS have failed (Qaseem, Wilt, McLean, & Forciea, 2017). Chen and Mao (2014) explain that patients who have risk factors in their history for opioid abuse or addiction can benefit from “out of the box prescribing.” For instance, buprenorphine/naloxone has been shown to provide pain relief in chronic pain patients with a history of addiction.

 

 

Chen, L., & Mao, J. (2014). Buprenorphine-naloxone therapy in pain management. Anesthesiology, 120(5), 1262–1274. https://doi.org/10.1097/ALN.0000000000000170

 Passik, S. D., & Kirsh, K. L. (2011). The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Experimental and Clinical Psychopharmacology, 16(5), 400–404. https://doi-org.lopes.idm.oclc.org/10.1037/a001363

Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367