A 32-year-old woman comes to the emergency department requesting medication for severe back pain. She has tried multiple over-the-counter agents and says that nothing has relieved her pain except oxycodone. The patient was seen in a pain clinic a year ago but cannot recall the name of the physician and says that her prescription has run out. Medical history includes a motor vehicle collision 10 years earlier and obesity. Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, pulse is 76/min, and respirations are 16/min. Physical examination shows no abnormalities. A recent MRI was normal. The patient says that her pain level is 10 on a scale of 0-10 and becomes frustrated when the physician suggests nonprescription pain medication. Which of the following is the most appropriate next step by the physician?
Back pain accompanied by a request for opioid medication is a relatively common occurrence in the emergency department that requires differentiating inadequate pain management from drug-seeking behavior. This patient exhibits many features concerning for drug-seeking behavior, including requesting a specific medication by name, running out of medication, and claiming pain out of proportion to the physical examination. Reporting lost or stolen medication and obtaining multiple opioid prescriptions from different providers are other red flags indicating misuse or diversion.
The best initial approach is to clarify the patient's medication history to determine which drugs have been prescribed, by whom, and at what frequency. State-based, online, prescription drug–monitoring programs are increasingly used in emergency departments to check for undisclosed prescriptions, clarify prescription patterns, and identify patients who obtain prescriptions from multiple providers. By identifying potential opioid misuse, physicians can make more informed decisions regarding pain prescriptions.
(Choice A) It would be inappropriate to challenge the patient prior to clarifying her pattern of medication use.
(Choice C) Repeating an MRI of the spine would not be the next step in a patient with a normal physical examination and recent normal MRI.
(Choices D and F) These are options that can be considered once the patient's history is clarified. If the patient has received opioid prescriptions for a documented diagnosis at appropriately spaced intervals, a limited prescription would be reasonable. If there is evidence of misuse, refusing to prescribe opioid medication would be more appropriate.
(Choice E) This patient does not perceive her opioid use as problematic and would likely be unreceptive to discussing referral to a substance abuse rehabilitation program.
Educational objective:
Physicians have a responsibility to identify signs of potential drug-seeking behavior and prescription drug misuse. This involves being alert to red flags (eg, lost or stolen medication, pain inconsistent with physical examination) and attempting to clarify medication history by using prescription drug–monitoring programs or other information sources.