Sara is a 42-year-old physical therapy assistant with chronic back pain due to a herniated disc and spinal stenosis, first diagnosed after lifting a patient four years ago. She currently rates the severity of her back pain as an 8/10 and has been unable to work due to her pain. The pain is described as dull and constant with occasional sharp exacerbation in the low back, with the pain increasing with bending, prolonged standing and walking. The patient denies any loss or change of bowel/bladder control, history of IV 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 her ADLs but reports poor sleep at night.
She has no significant past medical or surgical history.
She has had multiple rounds of physical therapy, chiropractic treatment and numerous medications. She tried to control the back pain on acetaminophen, naproxen, ibuprofen, the lidocaine patch and topical NSAIDs without relief. The patient experienced a possible seizure while on tramadol. Epidural injections did not help. Surgery was discussed, but the patient refused this option.
Sara is single, and now that she is not working, she has limited financial means. She reports having a problem with drinking in her twenties but has not had a drink in three years. She currently smokes. She denies any history of substance abuse and has no family history of alcohol or substance abuse.
Physical examination 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.
An MRI was done one year ago that was significant for a herniated disc at the L5/S1 level and mild spinal stenosis.
The Opioid Risk Tool was administered and determined that the patient is at low risk for opioid abuse. She signed a written opioid treatment agreement that outlines the conditions of opioid therapy. The state prescription drug monitoring program was queried and showed no suspicious activity.
The patient is prescribed hydrocodone/acetaminophen 5 mg/500 mg; two tablets every six hours as needed (56 tablets) for 1 week.
Five days later, she calls for an early refill and reports that the medication is not helping her pain, and she just lies around all day.
She comes back into the office for re-evaluation and reports she needed to take more pain medication than prescribed. It was reviewed with the patient that she violated the opioid agreement. A urine sample showed no illicit substances or medications that would not be expected in the urine. The prescription drug monitoring program did not show that she got any other prescriptions in the interim.
She was referred to a psychiatrist and a pain specialist. She was agreeable to both. She was able to get into the psychiatrist within one week, but the specialist pain appointment was three weeks out. The patient saw the psychiatrist, and he diagnosed the patient with depression and started her on duloxetine (which may also help with pain). The psychiatrist was unable to make an assessment related to opioid abuse.
With the help of the pain specialist, oxymorphone ER 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 she is more functional but still in a lot of pain. The dose of oxymorphone ER was increased to 10 mg every 12 hours. After one more week, she was given oxymorphone IR 5 mg to be used one hour before exercise. This prescription allowed the patient to function well and participate in an exercise program. The patient was ordered a bowel stimulant (Senna) with a stool softener (Colace) to prevent constipation.
The patient was prescribed fourteen pills of oxymorphone ER 10 mg (to be taken twice a day) and seven pills of oxymorphone IR 5 mg (to be taken once a day before exercise) once a week.