John is a 38-year-old male with chronic back pain due to three herniated discs and spinal stenosis, first diagnosed after a motor vehicle accident three years ago. He currently rates the severity of his back pain as a 9/10 and has been unable to work as a plumber due to his pain. The pain is dull and constant with occasional sharp exacerbation in the lower back, increasing with bending, prolonged standing, and walking. The patient denies any loss or change of bowel/bladder control, history of intravenous drug use, recent infection, progressive neurological complaints, night pain, night sweats, weight loss, or fever. The pain occasionally radiates into the right buttock. The patient can do all his activities of daily living but reports poor sleep at night.
He has a past medical history of hypertension and recently developed stage II chronic kidney disease thought to be secondary to hypertension and excessive use of ibuprofen. His only current medication is lisinopril to control his blood pressure.
He has had multiple treatment modalities, including four rounds of physical therapy, chiropractic treatment, and numerous medications. He tried to control his back pain with acetaminophen, naproxen, ibuprofen, the lidocaine patch, and topical NSAIDs without relief. The patient experienced significant tremors and increased blood pressure while on tramadol. A series of epidural injections did not help. Surgery was discussed, but the patient refused this option.
John is married and has one daughter. He has limited financial means and lives paycheck to paycheck. He has a history of alcohol abuse but has not had a drink in five years and is currently a smoker. He denies any history of prescription substance abuse and has no family history of alcohol or substance abuse.
A physical exam showed a patient with a slow, deliberate gait and a limited range of motion in the spine with no obvious deformity, swelling, or erythema. There is mild tenderness on the right side of the spine from L4 to S1 and tenderness in the right sacroiliac joint. Normal reflexes, sensation, strength, and no atrophy are noted in the lower extremities. The straight leg raise test is normal.
One year ago, an MRI found a herniated disc at the L5/S1 level and mild spinal stenosis.
The Opioid Risk Tool (ORT) was administered, and it was determined that the patient was at moderate risk for opioid abuse. The prescription drug monitoring database was queried and showed that he had not had a controlled substance prescribed in the last two years. He signs a written opioid treatment agreement that outlines the conditions of opioid therapy. His past medical records were verified.
The patient has been prescribed hydrocodone/acetaminophen 5 mg/500 mg, two tablets every six hours as needed (56 tablets) for one week.
Five days later, he calls for an early refill and reports that the medication is not helping his pain, even though he is lying around all day.
He comes back into the office for a re-evaluation. He reports that he needed to take more pain medication than prescribed. His wife confirms that he has been lying around all day, believing it is because he has so much pain. It was reviewed with the patient that he violated the opioid agreement. A urine sample showed no illicit substances or medications that would not be expected in the urine.
While the patient is at moderate risk of abusing the medication, his past medical history was confirmed. He was referred to a psychiatrist and a pain specialist and was agreeable to both. He was able to get into the psychiatrist within one week, but the pain specialist appointment was three weeks out. The patient saw the psychiatrist, who diagnosed him with depression and prescribed him sertraline, but the patient refused to take the medication due to side effects. The psychiatrist was unable to make an assessment related to opioid abuse.
With the help of the pain specialist, oxymorphone extended release of 5 mg was ordered every 12 hours. The patient was told to follow up in one week to assess effectiveness. After one week, the patient reports being more functional but in much pain. The dose of oxymorphone extended release was increased to 10 mg every 12 hours. After one more week, he was given oxymorphone immediate release 5 mg to be used one hour before exercise. This change allowed John to function well and participate in an exercise program. He was ordered a bowel stimulant, senna, and a stool softener, docusate sodium, to prevent constipation.
John was prescribed fourteen pills of oxymorphone extended release 10 mg (to be taken twice a day) and seven pills of oxymorphone immediate release 5 mg (to be taken once a day before exercise) per week. Part of the agreement was that the medications were to be given by the patient’s wife to reduce the risk of misuse.
John is given a treatment plan that includes the following:
- A list of goals:
- Improved pain and increased function
- Improved anxiety and depression
- Eventual cessation of opioid therapy
- Regular exercise program
- Lidocaine patches to be used for 12 hours a day and taken off at night
- The use of acetaminophen 1000 mg two times a day
- Evaluation and treatment by a pain psychologist
- Physical therapy
- He is prescribed duloxetine to help treat his depression, which also helps with musculoskeletal pain.
After two weeks, the patient returns to his primary care provider and reports that he has started physical and psychological therapy, is sleeping better, and wants to start to wean the oxymorphone. After four more weeks, he has weaned off the extended-release oxymorphone and is just using oxymorphone immediate release for breakthrough pain. In addition, he reports feeling less anxious and depressed and is sleeping “just fine.” After another four weeks, he says he no longer uses his opioid medication, has secured a part-time job, and regularly exercises.