Urine drug test (UDT).
Assess the patient’s history and define precipitating factors that increase and decrease the pain, pain onset, and pain medication that has helped in the past. Determine history of addiction. Obtain a urine drug test (UDT). A negative UDT for a patient-reported to be taking pain medication is suspicious; Negative results do not always indicate diversion. A complicated issue may be present, like misuse and overuse, or social factors such as loss of insurance or medication cost may be high, and the patient may be lacking the money to pay for the medication (Woo, 2019).
- What are the various schedules of medications for controlled substances?
Schedule I
Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule are heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote.
Schedule II
Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are: combination products with less than 15 milligrams of hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin
Schedule III
Schedule III drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Schedule III drug abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. Some examples of Schedule III drugs are: products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone
Schedule IV
Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are: Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol
Schedule V
Schedule V drugs, substances, or chemicals are defined as drugs with a lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes. Some examples of Schedule V drugs are: cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin
- Would you prescribe a long or short-acting narcotic? Why or why not?
Nonopioid therapy is the preferred treatment for pain, but there are times when a patient’s pain is not managed adequately by conservative therapies. At this time in the treatment plan, the provider may consider offering a trial with opioid medications in conjunction with ongoing nonpharmacological and nonopioid therapies if deemed necessary through assessment and patient history. ARNPs in FL per the board of nursing can prescribe controlled substances listed in Schedule II, Schedule III, or Schedule IV as defined in s. 893.03
- What other non-narcotic medication options can you offer to this patient?
The patient already identified a stomach ulcer and that NSAIDs did not work. Would ask the patient if he had tried the Celecoxib (Celebrex, Consensi) cox 2 inhibitor would not act on his stomach. A COX-2 inhibitor blocks only the COX-2 enzyme — the one that’s more likely to cause pain and inflammation such as with his back injury. Would also consider Cyclobenzaprine for short-term management of acute exacerbations of muscle spasms. A non-narcotic option for pain relief is tramadol (Ultram). A nonopioid analgesic that binds to the m receptor and has low opioid and SNRI activity. Because of its opioid-like activity, tramadol should not be used in patients recovering from narcotic addiction (Woo, 2019). This would only be prescribed if he is a recovering narcotic addict. Dosing of tramadol is usually 50 to 100 mg every 4 to 6 hours, not to exceed 400 mg/d.
2. What patient education is needed with them?
Documenting explanations and educational information is a part of the medical record. Records should reflect what was discussed with the patient and that the patient expressed an understanding of the content and medications treatment plan. Protect children from having access to medications, safe storage that is not within easy access of others, use of medication safes, not sharing medications, taking medications for the purpose they were prescribed, do not take medications from another person, do not drink alcohol while taking cyclobenzaprine or crush tramadol, do not stop taking medications without discussing this with the provider, and to notify the provider of any changes in health status or adverse events that are believed to be associated with the medication. Do not operate machinery on cyclobenzaprine and should take it before bed may cause drowsiness.
3. What would you do if the patient and his wife tell you that none of them work for him? Discuss the treatment plan with the patient and develop appropriate treatment options. Discuss if these combinations have been tried together in the past to relieve pain. Would consider the history and treat pain as appropriate. Cox 2 inhibitors, muscle relaxants cyclobenzaprine, and Tylenol should be effective. Could prescribe 3-day supply of short-acting narcotic of Norco 5/325mg q4 prn not to exceed 4g/day and discuss referral to a pain specialist if deemed unsuccessful in non-narcotic treatment options. Or develop a plan with the patient. Discuss Opioid therapy based on the assessment phase data and should only be considered if the anticipated benefits for pain and function outweigh the potential risks (Woo, 2019). Two specific components that need to be in place before initiating the trial of an opioid are the patient-provider agreement (PPA) and the informed consent. The PPA details the expectations of treatment and identifies acceptable behaviors on the part of the patient such as not sharing medications, avoiding misuse, using only one pharmacy, not seeking treatment or prescriptions from other providers, submitting to random UDTs, no early refill requests, and keeping follow-up appointments. The PPA also outlines consequences for noncompliance with the treatment plan which can include the termination of care by the provider. Informed consent is used to document the discussion of the risks and benefits of each medication prescribed. Establishing realistic functional goals with the patient is also necessary and they can be used as a benchmark of progress during treatment. Additionally important is the discussion about the safe handling and storage of opioid prescriptions at home.
References:
Florida Board of nursing » important legislative update regarding HB 423 – licensing, renewals & information. (2016, April 15). Florida Board of Nursing. Retrieved May 26, 2022, from https://floridasnursing.gov/new-legislation-impacting-your-profession/
Woo, T. M. (2019). Pharmacotherapeutics for Advanced Practice Nurse Prescribers with 3-yr access to Davis Edge (5th Edition). F. A. Davis Company. https://digitalbookshelf.southuniversity.edu/books/9781719641531
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