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.
- Lily James PHCNP (African Ethnicity)
- Caleb Kozinski – Male Patient (Caucasian Ethnicity)
Clinical office – include table, two chairs, examining bed, paper chart or computer, need reflex hammer, BP cuff/machine, stethoscope. NP is wearing a watch – no lab coat, not in a uniform.
Lily James, PHCNP is in her usual clinic for a full day, her next patient is Caleb Kozinski, a 40 year old man from the city.
Lily spends some time reviewing the referral note (see right column for description) as Caleb is a new patient to her clinic. Lily notes that Caleb has recently visited the ER as a result of low back pain with radiation down his right leg.
Reason for referral: Please see this 42 year old male with recent onset back pain with radiation to right ankle. No Primary Care access. In need of work-up and coordination of care. Seen in ER today. No imaging done, no evidence of disc prolapse on exam. Sent home with instructions to follow up with local Family Health Team (called).
Caleb is shown into the clinic room by the clinic nurse – he sits down across from Lily.
Lily: Hi Mr. Kozinski. My name is Lily James and I am a nurse practitioner. Dr. Smith from the ER at XX hospital has asked that I see you urgently as you are experiencing some difficulties.
Caleb: Please call me Caleb. Thank you for seeing me – I haven’t had a family physician or NP since last year and I feel like no-one cares about my problems.
Lily: I am happy to meet you Caleb. I will be your primary care provider here in the clinic. I will book you in to have a full physical exam and an orientation to the community health centre next week. Today, I would like to focus on the reason Dr. Smith sent you to me today.
Caleb Puts hands on lower back and shows where pain moves down right leg to the ankle. Caleb’s non-verbals are consistent with moderate pain.
Caleb: Well, I have this horrible pain in my lower back that has been driving me crazy. Sometimes I feel it right down to my foot.
Lily: How long have you had this pain?
Caleb: For about a month. I was picking up wood in my back yard to bring in for the woodstove and I felt something in my back go pop. Right away I had pain across my back and down my leg.
Lily: What does the pain feel like?
|The questions that Lily is asking Caleb is helping her rule out diagnosis’ like spinal cord compression.
Assessment tools for this kind of pain:
What specialised assessment tools can help you with performing a more comprehensive pain history?
|DN4 – The DN4 (which stands for Douleur Neuropathique 4) is a questionnaire that can be useful in helping to diagnose neuropathic pain. It has components of how the pain feels to the patient but also requires the examining health professional to assess whether there is reduced sensation (hypoaesthesia) to touch or pinprick, and whether light brushing increases or causes pain (allodynia).
BPI-SF – The Brief Pain Inventory – Short Form (BPI-sf) is a 9 item self-administered questionnaire used to evaluate the severity of a patient’s pain and the impact of this pain on the patient’s daily functioning. The patient is asked to rate their worst, least, average, and current pain intensity, list current treatments and their perceived effectiveness, and rate the degree that pain interferes with general activity, mood, walking ability, normal work, relations with other persons, sleep, and enjoyment of life on a 10 point scale.
SF-MPQ – The short-form McGill Pain Questionnaire (SF-MPQ) is a shorter version of the original MPQ and was developed in 1987.
The pain rating index has 2 subscales:
These words or items are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate and 3 = severe. There’s also one item for present pain intensity and one item for a 10 cm visual analogue scale (VAS) for average pain.
Caleb: My back is aching most of the time. It’s worse when I am walking and I can’t lift anything without it hurting. The pain that goes down my leg is burning – like hot knife.
Lily: have you experienced any numbness in your right leg or does it just ‘give out’?
Caleb: No numbness and no my leg hasn’t given out on me.
Lily: What about your bowels and your bladder, have you had any changes in the way you pass urine or have a bowel movement?
Caleb: No thank goodness, I don’t need that too!
Caleb is sitting on the exam bed with the different assessment tools that would be suggested for use. Users click to see the descriptions pop up.
Lily: OK thanks for filling out the pain questions for me. The pain is interfering with your activity to a moderate degree (BPI-SF) and you currently rate the intensity of the pain as 7/10. Is that right?
Caleb: Yeah, that sounds accurate.
Lily: I see that you have had some challenges with substances in the past. Can you tell me about that?
Caleb: Well about 5 years ago, I broke a bunch of teeth in a fight with a guy in a bar. The dentist had to do lots of work to fix my teeth and gave me Percocet afterwards because the pain was so bad. The Percs made me feed so good! Not only did they take away the pain but I also felt like I was superman. After the pills were all gone, I really missed them. I got the chills and I had diarrhea plus I missed how they made me feel. I was going through a really tough time back then. My wife had just left me and I was really broke. I was working as a mechanic but only part time. I asked a friend if he knew where I could get some more and pretty soon I was buying them as often as I could.
Lily is thinking now that she might want to do the PHQ9 assessment. Lily is thinking: I am worried that Caleb has all these stressors – it would be useful to screen him for depression.
These questions that Lily is asking Caleb is helping her to construct a risk assessment for substance misuse.
Lily: How long were you using Percocet for reasons other than for pain?
Caleb: I used for about 4 years on and off. It was bad, I lost my job and had to move in with my mother. At one point I was using 12 percs a day just to get by.
Lily: I see that you are now on methadone for treatment.
Caleb: Yes thankfully about a year ago, my mother stepped in and took me to the local Street Health clinic where I met with the team. I have been on methadone ever since and off the percs. I started off going there every day to get my dose but now I have three ‘carries’ so I only have to go there twice a week.
Lily: OK thanks for being so honest with me. Do you mind if I do an examination of the areas where you have pain and also your legs? If you’re OK with it, I’ll step out and you can put on a gown for me. You may leave your underpants on but please remove your socks.
Caleb: no problem.
Lily leaves the room and Caleb does as she asks. She comes back in
Lily: OK Caleb, let’s begin
At this stage, Lily does the DN4, examines his back and legs, checks reflexes, straight leg raise etc. She test his gait and all other assessments consistent with the CORE back tool. The DN4 score is 2 – not consistent with neuropathic pain. The Clinically Organized Relevant Exam (CORE) Back Tool will guide clinicians to recognize common mechanical back pain syndromes and screen for other conditions where management may include investigations, referrals and specific medications.
Note: The scope of practice between nurse practitioners varies between provinces. For more information consult the appropriate regulatory body.
Lily: Well Caleb, my examination of your back and legs does not make me worried that there is something urgent we need to get addressed but I would like to get Dr. Baker, my physician colleague, to assist me because I would like to get an MRI of your back. That will tell us if there are nerves trapped or if you have some problems with your discs.
Caleb: I’m really worried that if you don’t give me something for the pain while you are getting that organized that I will be tempted to buy something on the street to help. Can you help me?
Lily: Before we make any decisions about what we’re going to do I would like you to answer a few questions for me.
|What tools or guidelines would inform your assessment at this stage?
|The scores that Caleb achieved in the tools were as follows:||
The moderate score for ORT is concerning although his UDS supports that he is only taking methadone.
Lily: Thanks for answering the extra questions for me. One of the tools I asked you to fill out helps me to plan your care. Did you fill out an opioid contract with the clinic that you get your methadone from?
Caleb: Yes I think I did – I’m not sure.
Lily: Would you mind if I worked with your methadone clinic? I can get their clinic charts if you sign this consent form – please sign here. Once I have that information, we can decide what to do. I will call them now…
If the patient has a pre-existing contract then he may not be eligible to be prescribed controlled substances.
The result of the phone call is that he has a contract but the 2 clinicians (Lily and the methadone provider) together decide that if warranted she could start a short term opioid trial with daily dispensing.
|What should Lily do?
User will be able to click on the possible options to see a rationale for each.
Lily calls the methadone provider to discuss and make aware of the situation.
She calls the pharmacist from the pharmacy indicated by the patient on the opioid contract to inform them of the opioid trial and that a prescription is being faxed.
She faxes the prescription to the pharmacy and puts a copy in the patient’s chart along with the completed questionnaires and a copy of the contract. She provides Caleb with a copy of the contract.
Lily: Together we have decided we are going to do a week-long opioid trial using Tramacet for your pain while we wait for news about the MRI. I have spoken to your methadone provider and she is aware and in agreement. We have already discussed the parts of the contract, do you have any questions?
Caleb: No, I understand, I won’t let you down, I promise.
Lily: I have faxed a prescription for tramacet to the pharmacy. Here are some important facts about this medication…. I have booked an appointment for you to come see me again next week. Please call me right away of you have any changes in your symptoms or if this medication is not effective.
Caleb: OK – I will stop at the appointment desk on my way out – thanks!
This interactive case study covered the following information:
- Pain assessment
- Substance misuse risk assessment
- Symptom assessment
- Interprofessional collaboration
- Prescribing opioids/ opioid trial
- Treatment contracts
- Following up/safety monitoring