Making a Treatment Plan for Owen
The following reviews appropriate rehabilitative measures for Owen.
A comprehensive physical therapy approach, targeting multidimensional drivers of pain/disability and promoting increased activity, may reduce dependence on opioids, ETOH, and other substance-related approaches to treatment of pain and other symptoms.
Physical Therapy Focus
The patient has signs and symptoms that change with body positions and movements, suggesting a mechanical component to his pain which should be addressed. The patient's general inactive state likely contributes to his low tolerance for activity and pain. He may think that any movement that increases his symptoms is causing tissue damage (kinesiophobia), and thus may be avoiding movement altogether.
Imaging Prior to Physical Therapy
The patient's history and presentation does not suggest that repeated imaging would be helpful. The initial findings of a posterior disc bulge and facet arthropathy are common findings in someone of his age and BMI, and often are not correlated with symptoms.
Home Strength and Flexibility Program
The patient has low motivation to exercise and likely will not adhere to such an extensive routine. Non-adherence would likely negatively impact his self-esteem.
Focusing on returning to meaningful activities instead of on symptom behavior will help the patient play a more active role in his treatment.
Include Patient's Spouse
It will be important for the patient to have social support and encouragement to increase activity and decrease the focus on symptom behavior.
Instruction for Maintaining Body Alignment While Sleeping
The patient has a history of sleep apnea and mentions that he sleeps in a "rigid" position because of pain. Distrupted sleep is a known cormorbidity that negatively influences LBP outcomes. Use of pillows/supports to properly align the spine and hips may decrease the frequence of sleep disturbances.
The following reviews appropriate pharmacotherapy plans/education for Owen.
Reduce CR Oxycodone to 80mg PO Q12 Hours
Owen is currently at increased risk for opioid overdose given a morphine equivalent daily dose of greater than or equal to 90mg and concurrent alcohol use. Opioid therapy for nonspecific chronic low back pain should be reserved for patients that have failed all other non-pharmacologic and non-opioid analgesic modalities.
A wean trial for Owen may be appropriate, especially if other adjuvant analgesic an non-pharmacologic modalities are to be attempted. Dose reductions of 10% to 20% are generally well tolerated by patients.
Change Escitalopram to Duloxetine 30mg PO QHS
Escitalopram, a selective serotonin reuptake inhibitor, is effective for depressoin and anxiety; however, this medication class is not effective for eitehr acute or chronic musculoskeletal or neuropathic pain syndromes. Additionally, 40mg of escitalopram is higher than maximum recommended daily doses.
Duloxetine, a serotonin-norepinephrine reuptake inhibitor, is effective for depression, anxiety, and several chronic pain syndromes. This medications may be more appropriate for a trial as an adjuvant analgesic than selective serotonin reuptake inhibitors. Reducing the escitalopram to 10mg daily and inititating duloxetine at 30mg with several days of overlap will prevent serotonin withdrawal syndrome.
Change CR Oxycodone to Methadone, Continue Current IR Oxycodone
Methadone, an effective opioid analgesic, would not be recommended for Owen given its difficult titration, unpredictable half-life, and risk of opioid overdose with Owen's current alcohol intake.
Do Not Consume Alcohol while Taking Opioids
Opioids should never be taken concurrently with alcohol due to the additive central nervous system depressant effects. Additionally, alcohol may interfere with the extended-release mechanism of several opioid formulations resulting in dose dumping and potential overdose.
Retrial Gabapentin Starting with Therapeutic Doses of 300mg Q8 Hours
Given Owen's history of opioid overdose, alcohol consumption, and risk factors, increasing the opioid dose at this point in his care would likely not be prudent.
Select the appropriate behavioral therapy plans for Owen.
Postpone Psychological Counseling Until Medication Regimen is Stabilized
Psychological counseling is likely to be instrumental in reducing dependence on opioids, alcohol, and other substance-releated approaches.
Initiate Outpatient Psychological Counseling with Sessions on a Routine Basis
Regular sessions are preferred to need-based (i.e., irregular) sessions because a primary focus is likely to be educational and coaching, approaches that work best if they are not in response to some urgent clinical need.
Include the Patient's Spouse in Part of the Initial Assessment Session
The patient has referenced some marital dysfunction in his interview, and it often is very informative to have the perspective of a significant other when undertaking a behavioral assessment
Focus on Family-of-Origin History to Identify Factors Leading to Substance Misuse
The patient provided little evidence implicating his family of origin as a factor contributing to substance misuse, while he demonstrates substantial indicators of his own history (e.g., his level of daily (ETOH intake) of greater immediate importance).
Provide Educational Materials that Describe Self-Management Approaches to Coping
Much of chronic pain (or any chronic disease) management relies on active patient involvement, and providing educational materials will not only contribute useful content regarding coping skills, but also give an opportunity to examine how the patient is implementing such skills in his daily activities.
Encourage a Leave-of-Absence from Work to Pursue Inpatient Sub Abuse Treatment
Inpatient treatment is not indicated at this time, and it is important to provide counseling that assists a patient to remain as functional as possible as he learns to cope more effectively with pain, without resorting to the use of substances as a primary means of coping.
Provide Instruction in Relaxation Training or Self-Hypnosis
Relaxation training is a useful skill in reducing pain with a myofascial component, and the applied skills can often serve as a behavioral "re-set switch," giving the patient a few moments to assess his status several times a day.
Select the appropriate risk reduction plans for Owen.
Co-prescribe Two Doses of Naloxone
When prescribing or dispensing naloxone, two doses should always be provided. The auto-injector and nasal naloxone product both come with two doses in each box. If providing parenteral single dose naloxone vials, two doses (and two syringes) should always be provided.
Educate Patient to Purchase Lock Box for Opioid Analgesic
Survey data shows that a significant amount of opioid diversion arises from theft of opioids from family or friends. All patients should be educated to store their opioids in a locked box or cabinet.
Admit Owen for Inpatient Opioid Detoxification
While Owen may potentially meet the DSM-V diagnostic criteria for mild opioid use disorder, abrupt inpatient detoxificaton is not warranted. A discussion with the patient regarding provider concerns and possible wean trial would be a reasonable course of action in this particular case.
Review Pain Treatment Agreement and Stress Avoidance of Outside Prescribers
An essential component of risk mitigation, opioid or pain agreements provide an opportunity to spell out clear expectations for both the patient and the provider. Additionally, these documents can be used as an informed consent outlining the harms and benefits of opioid therapy. They should not be used as a punitive tool.
Perform Urine Drug Screening
Random urine drug screening is a vital component of opioid risk mitigation in an effort to recognize potential misuse, abuse, or diversion. Medican decision making following an unexpected urine drug screen result should be reserved until confirmatory testing can be performed.
Begin Wean of Current Opioid Analgesics
Owen's daily dose of extended-release and immediate-release oxycodone places him at an increased risk for opioid-associated sleep disordered breathing as well as overdose. A wean trial would be a reasonable component of Owen's risk reduction plan.
Check State Prescription Drug Monitoring Program
State prescription durg monitoring programs are valuable resources to both identify potential drug seeking behavior and unhealthy relationships with their opioid analgesics. Additionally these programs can provide prescribers and dispensers reassurance that patients with chronic pain are adherent to the medical plan.