I will use the Institute for Clinical Systems Improvement (ICSI, 2013) assessment protocol to evaluate the patient. I will conduct a history, physical, and assessments of pain and function. I will next ascertain the biological causes of the patient’s back pain, i.e. if the pain is neuropathic, muscle-related, inflammatory or compressive/mechanical (ICSI, 2013). If the pain is chronic, it is necessary to find out if the cause can be corrected which may require referral to a specialist. If not, I will perform assessments of work, disability, psychological and spiritual wellbeing, contributing factors, and barriers to pain management (ICSI, 2013).
Red flags behaviors which may indicate drug abuse include worsening work or social functioning, illegal sourcing or selling of medications, frequent loss of prescriptions, resisting medication change even with adverse effects, non-compliance with drug screening or pill counts, and doctor shopping (NIDA, 2013). Physical warning signs include changes in sleeping habits and appetite, unexplained sudden weight loss or gain, dilated or constricted pupils, bloodshot eyes, deterioration in self-care, frequent runny nose, tremors, impaired coordination, slurred speech, and uncommon body or breath odor (IHS, 2015).
Prescribing narcotics for chronic back pain should be guided by an evaluation of the risks and benefits. While patients have the right to adequate pain relief, improved functional status, and a higher quality of life, prescriptions should be weighed against the risks of overdosing and developing an opioid use disorder which often creates an ethical dilemma especially if used for the long-term (Dowell, Haegerich & Chou, 2016; Fields, 2011). There should be strategies to mitigate the risks such as having treatment agreements and periodic urine drug testing (Dowell, Haegerich & Chou, 2016).
For an adult patient presenting for the first time for chronic periodic, mild-to-moderate, muscle-related back pain, I will prescribe an NSAID as Level I management because of the lower risks of adverse effects and known effectiveness (ICSI, 2013). It will be subject to periodic evaluations of effectiveness. I will also prescribe non-pharmacologic treatment such as exercise therapy which has been shown to minimize pain and enhance functioning (Dowell, Haegerich & Chou, 2016).
References
Dowell, D., Haegerich, T.M., & Chou, R. (2016). CDC guidelines for prescribing opioids for chronic pain – United States, 2016. Retrieved from http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Fields, H. L. (2011). The doctor’s dilemma: Opiate analgesics and chronic pain. Neuron, 69(4), 591–594. http://doi.org/10.1016/j.neuron.2011.02.001
Indian Health Service (IHS) (2015). Warning signs of drug abuse and addiction. Retrieved from https://www.ihs.gov/asap/information/warningsignsdrug/
National Institute on Drug Abuse (NIDA) (2013). Knowing when to say when: Transitioning patients from opioid therapy. Retrieved from https://www.drugabuse.gov/sites/default/files/knowing_when_to_say_when_3-31- 14_ln_sd_508.pdf
