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Homework answers / question archive / Howard is a 24 year-old male who presents to the clinic with his wife for what he states is severe lower back pain
Howard is a 24 year-old male who presents to the clinic with his wife for what he states is severe lower back pain. He states the pain is so bad that he rates it as a “50 out of 10.” He also tells you that due to a past medical history of an ulcer, he cannot take any medications “like Motrin.” He states that the pain is from a car accident in 2012, and that it flairs up and he needs pain medications. He also tells you that he has a high pain tolerance, and that when he gets pain meds he requires the higher doses.
You are concerned that this patient may have a substance abuse problem.
After some investigating, you find that Howard actually is seeing a pain specialist who has given him epidural injections, and prescribes medication for him.
After seeing Howard and performing the appropriate screening tools, and a urine drug screen, he admits to you that he does have a problem with opioids due to his back injury. He states he has been admitted to an inpatient detox and twenty-eight day rehabilitation unit previously and was able to quit using for 3 months, but relapsed due to his pain. He states for the last 6 months he has been unable to get opioids from physicians since there is a record of him being prescribed a large amount over a short period of time. Due to this, he has started buying heroin from an acquaintance who he went to high school with. His wife is very tearful and states she is concerned that eventually Howard will end up killing himself.
“What Would You Do First Prior to Prescribing Any Medication?”
Before giving any drug, I would undertake a comprehensive assessment, including getting precise medication history. Worth noting, this assessment would give insight into medication intolerance, drug interactions, and existing medical conditions. Considering the high likelihood of tolerance, dependency, and abuse, I would also screen the client for drug abuse.
“What Are the Various Schedules of Medications for Controlled Substances?”
The different controlled substances schedules include schedule I, II, III, and IV. Notably, schedule I formulations include opioids with no presently accepted medical use in the US, have a high likelihood of misuse, and lack accepted safety for utilization under medical supervision, for instance, heroin. Schedule II formulations include drugs with a high likelihood for misuse that may result in grievous physical or psychological dependence, such as codeine and fentanyl. Schedule III formulations include drugs with lesser possibility of misuse that may result in low or moderate psychological or physical dependence. Schedule IV formulations include drugs with a lower likelihood of misuse relative to schedule III formulations. Schedule V formulations have the least chance of misuse relative to schedule IV formulations and comprise basically preparations comprising low amounts of certain narcotics.
“Would You Prescribe A Long or Short Acting Narcotic? Why or Why Not?”
Since the patient reports pain of 5 out of 10, and the pain is as a result of an accident, I would prescribe a long-acting narcotic. The rationale would be to ameliorate his functioning, pain management and give relief from connected manifestations.
“What Other Non-Narcotic Medication Options Can You Offer To This Patient?”
If the ulcer does not allow oral pain medication, I would suggest that he utilize a flector. Worth noting, this is a topical anti-inflammatory patch applied to the affected areas. The rationale for this suggestion is that the therapy would not cause gastrointestinal effects (Woo & Robinson, 2020). If the ulcer allows oral medication, I would also suggest that he takes ibuprofen 800 milligrams every six hours with food and fluids. Another non-narcotic formulation I would suggest is Tylenol to manage the body aches.
“What Patient Education Is Needed With Them?”
The patient teaching required would include advising the client to take plenty of water food. I would also educate the client about the breadth of possible side effects, for instance, drowsiness if prescribed with muscle relaxers to enhance compliance.
“What Would You Do If The Patient And His Wife Tell You That None Of Them Work For Him?”
As the care provider, I would consider undertaking tests for drug abuse if the patient reported that none of the treatments work for him. This is because medication misuse can limit the effectiveness of the medication.
Discussion 3
“What Screening Testing Is Available For You To Use That Is Reliable and Valid?”
The valid and reliable office-based screening test for drug misuse available is the “Substance Abuse Subtle Screening Inventory, 3rd Edition” (SASSI-3), which is widely utilized in the US.
“What Strategies Would You Suggest For This Patient If He Was Found To Have A Problem?”
The strategies I would propose for this client who is found to have substance use disorder include medical devices to provide skills training and behavioral counseling.
“What Type Of Referrals Would You Make?”
In this situation, the type of referral I would make is a direct referral comprising of the pertinent clinical data, referral data, and signature. This would enable the client to receive substance abuse management services that he cannot receive from the office.
Discussion 4
“How Does That Impact Any Intervention That You May Consider?”
While epidural injection lowers inflammation and improves relief, it would impact other intercessions that one may examine. The injection impacts any intercession I may consider due to drug interaction. The injection may also increase the client's blood glucose level and may also alter activity. Therefore, the client should be advised not to engage in some activities, including driving and exercise for the day.
“What Other Pharmacological Options Could You Offer Him?”
Besides opioids and corticosteroids, other medication options would include local anesthetics, bisphosphonates, and “nonsteroidal anti-inflammatory drugs” (NSAIDs).
“What Nonpharmacological Options Could You Suggest?”
The non-medication options I could propose include gel packs, physical therapy, acupuncture, relaxation methods, positioning (El Geziry, Toble, Al Kadhi, Pervaiz, & Al Nobani, 2018), and massage therapy.
Discussion 5
“What Type of Substance Abuse Programs Would Be Most Appropriate For Him”
Since the patient has a relapse problem, the suitable substance abuse program is the “Minnesota model of residential chemical dependency treatment” (Lander et al., 2020). This approach would integrate a biopsychosocial illness addiction model that would center on abstinence as the main objective and utilize the twelve-step program for recovery and relapse prevention.
“What Requirements Are There For a Nurse Practitioner (NP) to Prescribe a Medication to Treat Opioid Addiction?”
The NP must be qualified to offer buprenorphine to manage opioid use disorder. To get a waiver, the NP must notify the “Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT), Division of Pharmacologic Therapies (DPT)” of their intention to perform this kind of treatment (Substance Abuse and Mental Health Services Administration, 2021). This should be done prior to the initial prescribing or dispensing of OUD management formulation.
“What Are the Requirements for a Patient Who Is Enrolled In a Medication-Assisted Opioid Treatment Program?”
According to the "Substance Abuse and Mental Health Services Administration” (2021), the federal law provides that MAT clients getting treatment for opioid misuse must get counseling, which may include various forms of behavioral therapies.
