SCENARIO 2: Assessing aberrant opioid taking behavior, increasing monitoring
Name: Ms. Mary Tempo
Marital status: Divorced and single
Occupation: Registered Nurse on disability
Pain issue: Chronic low back pain
This is a regularly scheduled follow-up visit. The patient has been seeing this doctor for the past 9 months. She recently had an MRI of her back to evaluate worsening back pain and she is very eager to hear the results.
“ For the past 2 months she has been asking for early refills and non-adherent with monitoring.
The patient has a 10 year history of chronic low back pain. She has been on disability for the past 5 years due to her back pain.
Her back pain started when she slipped on a wet floor. She has had 2 prior back surgeries 10 and 6 years ago which did not help. In fact she thinks the last surgery made her pain worse. Her pain has been treated with ibuprofen, tramadol, gabapentin, tricyclic antidepressants (i.e. Elavil), steroid injections, acupuncture, heat and ice treatments, cognitive behavioral therapy, and physical therapy. She has always been willing to try any treatment recommended to help her pain. Her main focus is on pain relief and not necessarily on getting more opioids. However, opioids, which she has been taking for over 5 years, are the only treatment that consistently helps her pain. She is currently taking sustained-release morphine (MSContin) 15 mg 2 times per day and oxycodone 5 mg every 12 hours (no more than 2 tablets per day) as needed for breakthrough pain. She has been on stable doses of opioids for years, and her pain has been well controlled, ranging from “3-5” out of 10. She spends most of her time at home watching TV and doing crossword puzzles, gardening and has recently started babysitting for her neighbor’s 15 month old son.
The patient is in recovery from benzodiazepine (i.e. Klonopin and Xanax) addiction.
She signed a controlled substances agreement, which outlined the need for adherence around close monitoring, including urine drug tests, pill counts and taking the morphine and oxycodone as prescribed.
For the first 7 months of treatment she has been completely adherent. For the past 2 months she has been asking for early refills and non-adherent with monitoring. The prescription monitoring program shows NO evidence of doctor shopping.
The interview starts with a conversation about her MRI results followed by a discussion of her aberrant opioid-taking behaviors.
Discuss concerns about patient’s aberrant medication taking behaviors
- State your concerns about the aberrant behavior in a non-judgmental way
- Use open-ended questions
Assess the cause of patient’s aberrant medication taking behaviors (early refill requests, non-adherence with monitoring) using a non-judgmental, open-ended, complete differential diagnostic approach
- Inadequate analgesia
- Opioid analgesic tolerance
- Self-medication of psychiatric & physical symptoms other than pain
Discuss strategies for addressing patient’s aberrant behaviors, including a revised treatment plan with intensified monitoring
To continue opioids:
- There must be actual functional benefit
- Benefit must outweigh observed or potential harms
Intensify monitoring “tighten the reins”: increase frequency of urine tests, pill counts, face-to-face meetings
- Discuss with patient that the purpose of increased monitoring is to keep them safe
- Discuss that continued aberrant behavior will make continued opioid prescribing too unsafe to continue