The following case vignette provides key concepts that could be considered when developing a plan of care for a patient who may require a controlled substance to manage their health concerns. As with any clinical situation, there are many patient variables that must be considered, including comorbid conditions, social determinants of health and their personal choices. You may choose to include different or additional health history and physical examination points, diagnostic tests, differential diagnoses and treatments depending on your patient’s context however this case vignette focuses on the aspects relevant to controlled substances.
Jackie is a patient rostered to the FHT where Carolyn is the NP. Carolyn has seen Jackie a few times over the last few years but not on a regular basis. Carolyn is in her clinic in an anteroom with a desktop computer.
Carolyn: Hmmm Jackie’s presenting complaint is painful feet according to the clinic admin staff. I know she has been a Type I diabetic since childhood: I have seen her before because of poor glycemic control but I see she has been doing a lot better in the past few years and her HbA1C is pretty stable. It looks like she was in clinic 4 months ago to see Dr. Mike. His notes include a diagnosis of acute renal failure as her serum creatinine was 148. It looks like he was concerned about her transitioning into chronic renal failure and had asked that she come back in a week for repeat bloodwork. It doesn’t look like that happened. He also notes that she was experiencing some symptoms of peripheral neuropathy but there were no visible signs of circulatory changes.
There is an admission note from 1996 scanned in that reflects a brief hospitalization on the acute mental health unit for suicidal ideation and a subsequent note from psychiatry that she was treated successfully for depression at that time.
Carolyn: Hi Jackie – it’s nice to see you.
Jackie: Yeah, it has been a while
Carolyn: So what has been going on with you? The clinic staff tell me you’re having some pain in your feet.
Jackie: I am at my wits end with the pain. Every time I try to walk anywhere or even keep my feet down, they start to burn – it’s like they’re on fire. I can’t do anything. I was working at the gas station but as soon as it started to get cold out, I had to start calling in sick. The cold made my feet hurt even more. Now I am out of a job and it’s taking forever for EI to kick in.
Carolyn: Let’s talk about your feet for a moment. When did this pain start?
Jackie: it started as numbness and tingling in my toes about a month ago and has gotten much worse. Last week I noticed that my toes are cold when I touch them and I think they are whiter than usual. I can’t even keep the sheets on them when I’m in bed…it hurts too much.
Carolyn: OK I’m going to do a complete pain assessment but I have a few related questions to ask you. How much are you smoking right now?
Jackie: I smoke about 25 a day – I get them in bulk from a supplier near my place. Sometimes I confess I also smoke some weed – I’ve been doing this for almost 30 years.
Carolyn: Can you tell me what medications you are taking right now?
Jackie: Well I take my insulin that Dr. Mike ordered just like I am supposed to and I check my blood three times a day. I got scared last time I had a problem so I’ve been really good since. I started to take either 2 or 3 ibuprofen tablets a couple of times a day but they don’t really do anything for the pain.
Can I tell you something confidential? Promise you won’t be mad?
Carolyn: Jackie it’s important you tell me everything about your health so I can do my best to help you.
Jackie: OK. My mom had a big jar of Percocet from when she had her knee surgery a few years ago. I started to take some of those because the pain was just too bad. They worked pretty good.
Carolyn: How were you taking the Percocet? How many and how often?
Jackie: For the last three weeks I have been taking 2 every four hours but I have been out now for a day and I feel awful.
|What is the next step?
|Selection 1 and 3 would provide additional instruction on how these are not the appropriate options. A description of each one is required.
Carolyn [THINKS]: Although it looks like Jackie has had a difficult pain problem, I have some real concerns about her using her mother’s prescription – as far as I know she has not called the clinic up to now.
|What are your main concerns so far?
What risk screening tools are you planning to add to your focused assessment?
Carolyn: OK Jackie, I’m going to ask you some questions about your pain and ask you to answer some questions on paper as well.
Carolyn: Thanks Jackie – it looks like you are using resting and protection of your feet as your most common coping activity and are not really asking for much help – is that accurate?
Jackie: well yes – it’s such a long way to come to the clinic, I’ve been trying to deal with this on my own. I didn’t have the money for a cab and I didn’t want to ask my family either.
Carolyn: Let’s have a look at your feet.
|What assessment tools would you consider using?
Carolyn does a focused exam of Jackie’s lower limbs and feet and includes:
- Examination of her skin
- Sharp/dull discrimination
- Sensation using cotton wisps
- Sensation to light touch from knees to toes
- Evaluation of gait
Carolyn [THINKS]: So my examination of Jackie’s legs and feet was significant for diminished ankle reflexes at 2/5 bilaterally, allodynia on the dorsum of both feet, temperature changes at the forefoot and extending to her toes, and minimal sensation on all toes bilaterally. I note as well that Jackie is quite cachexic – it looks as though she has lost quite a bit of weight. Her Dn4 score is 8 indicating probable neuropathic type pain.
|What other related assessments should you consider at this point?
What are your next steps?
Carolyn: Jackie I am concerned about your use of your mother’s medications and I know you are having pain. At this stage, I would like to try one of the medications that we routinely use for the nerve pain I think you are having. Your body is now used to the medication you have been taking and some of the questions I asked you tell me you’re are experiencing withdrawal from the Percocet because it has been more than 24 hours since your last does.
Jackie: Yes – I agree. I feel like I have the flu and my pain is a lot worse.
Carolyn: We are going to have to reduce the amount of medication you are taking slowly – it is a process called a ‘taper’
Jackie: You mean you’re going to give me a prescription for Percocet?
Carolyn: No, I am going to give you a prescription for a longer acting medication that is similar to Percocet along with a schedule for reducing the dose over the next few weeks.
Sample Taper and Rotation
|What important document must Carolyn put in place before writing any prescriptions for Jackie for opioids?
|Calculate the total daily dose of opioid in oral morphine equivalents that Jackie is taking.
|Correct answer is as follows:
|Convert to oral morphine.
|40 mg x 1.5 = 60 mg.
|What long acting opioid would you use in the taper?
The guidelines recommend considering converting to morphine prior to taper is dependent on oxycodone.
|Write a tapering schedule for a total daily dose of oxyneo 40mg in 2 divided doses.
|What total daily dose of morphine should Carolyn use to begin a taper if decided to convert from oxycodone?
|What rate would you taper for morphine SR with a starting dose of 40 mg in 2 divided doses?
Slow taper to one half or less of the rate once 1/3 of the original dose is reached.
Carolyn: Alright Jackie – let me explain this process to you. (lots of explaining….maybe off line) You and I are going to see each other every week until we have completely reduced this medication.
I have arranged with our social worker to see you to help with affording transportation and other things you may need at home. I have also send a message to the Chronic Pain Self Management program coordinator to call you to set up some times for you to attend this great class.
We can organize it for the days when you see me so you don’t have to travel so much.
Jackie: I hope this works Carolyn – I do appreciate you helping me.
This interactive case study covered the following information:
- Pain assessment
- Substance misuse risk assessment
- Symptom assessment
- Interprofessional collaboration
- Prescribing opioids/ opioid tapering
- Opioid rotation
- Treatment contracts
- Following up/safety monitoring