Describe Your Approach With This Patient In Detail

Describe your approach with this patient in detail

You are a Family Nurse Practitioner (FNP) working in a restricted state with DEA license and state furnishing authority for Schedule II-V controlled substances. A complex case presents: a 54-year-old Hispanic female patient, ML, with a history of chronic shoulder and back pain from a boating accident ten years ago. She regularly crosses borders between the US and Mexico but has recently stayed in the US due to COVID, living with her daughter's family. ML has previously undergone rotator cuff surgery and reports persistent shoulder pain, numbness, and tingling, exacerbated by housework and caring for her grandchildren.

Her current medication regimen includes Losartan, Gabapentin, Atorvastatin, Diazepam, and Norco, with her primary concern being the refilling of these medications for six months without frequent office visits. She reports challenges in accessing care, and her social history includes smoking outside the home and weekend alcohol consumption. Her vital signs are stable overall, with notable shoulder pain on ROM but no acute findings. Physical examination is otherwise unremarkable alongside routine back assessment.

The approach to her care begins with a comprehensive evaluation. First, reviewing her medication list and use patterns for potential concerns such as polypharmacy, misuse, or adverse effects. Given her history, I would discuss the risks associated with combining multiple CNS depressants, especially with concurrent alcohol consumption and smoking, which can increase risks of respiratory depression and other side effects. Alternative options include reassessing her need for Diazepam and Norco, considering non-pharmacologic pain management strategies, such as physical therapy, acupuncture, or cognitive-behavioral therapy to reduce her reliance on opioids and benzodiazepines. The use of multimodal pain management aligns with CDC guidelines to minimize opioid overdose risks (Dowell et al., 2016).

Additional screenings include assessing for substance misuse and mental health comorbidities—screening tools like the Opioid Risk Tool (ORT) and PHQ-9 for depression are appropriate. Screening for hepatitis C and HIV is prudent due to her smoking and alcohol use history, along with considering osteoporosis screening given her age and chronic pain (CDC, 2022). Her medication regimen should also be reviewed for drug-drug interactions, especially concerning her combined use of Gabapentin, Diazepam, and Norco.

From an ethical perspective, my standards emphasize respect for patient autonomy balanced against beneficence and non-maleficence—ensuring that her medications are safe, effective, and not contributing to harm. Legally, I would operate within state and federal regulations, including mandated PDMP checks before prescribing controlled substances (California State Law). This ensures safe prescribing by documenting accountability, avoiding prescription overlaps, and preventing diversion (CDC, 2022).

An appropriate pain contract tailored for her should include confidentiality clauses, medication use agreements, safe storage instructions, and clear guidelines on medication sharing or misuse. An example is the Model Pain Contract from the CDC guidelines, which emphasizes patient responsibility and safety measures (CDC, 2022). Ensuring safe prescribing involves searching the California Prescription Drug Monitoring Program (PDMP) registry before each prescribing event to check for previous controlled substance prescriptions from other providers. If in another state, the respective state's PDMP should be checked accordingly.

Regarding her current medications, in California, Schedule II medications such as Norco must be prescribed with an electronic or written prescription; refills for Schedule II drugs are generally not permitted. Schedule III medications, like Diazepam, can be refilled as authorized with a written or electronic prescription. Federal law generally limits Schedule II drugs to a 30-day supply per prescription, with no refills unless authorized under special dispensing procedures (DEA, 2021). California law aligns with this, permitting up to a 30-day supply for Schedule II, with specific exceptions for terminally ill or long-term care patients under a protocol (California Department of Justice, 2023).

Prescriptions must include the patient’s full name, address, provider's DEA number, license number, and the date. For electronic prescriptions, a digital signature that complies with DEA standards suffices; for paper prescriptions, an ink signature is required. The prescription should specify drug name, strength, quantity, directions, and any refills authorized.

After prescribing, I or my staff would log into the California PDMP and report the controlled substance dispensation within 24 hours of writing the prescription, ensuring the data is available to other prescribers and pharmacists for coordinated care (California Department of Justice, 2023). Documentation procedures are crucial for compliance and to support ongoing treatment decisions.

In restricted states, prescribers follow standardized protocols or guidelines when furnishing Schedule II and III controlled substances. These include:

• Performing a thorough assessment of the patient's medical history, substance use, and risk factors;
• Confirming the diagnosis justifying controlled substance therapy;
• Establishing an individual treatment and safety plan, including agreements and ongoing monitoring;
• Using PDMP data prior to issuing prescriptions;
• Documenting all steps and patient communications in the medical record;
• Providing patient education on medication use, risks, and safety measures;
• Scheduling follow-up visits for ongoing evaluation and reassessment.

Adhering to these components supports ethical and legal standards whilst promoting safe and effective pain management strategies for the patient.

References

• Centers for Disease Control and Prevention (CDC). (2022). Guideline for Prescribing Opioids for Pain. https://www.cdc.gov/drugoverdose/prescribing/guideline.html
• Drug Enforcement Administration (DEA). (2021). Drug Schedules. https://www.deadiversion.usdoj.gov/schedules/
• California Department of Justice. (2023). Prescription Drug Monitoring Program. https://oag.ca.gov/pdmp
• Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624-1645.
• American Society of Addiction Medicine. (2019). Medication-Assisted Treatment (MAT) for Opioid Use Disorder. https://www.asam.org/quality-practice/medication-assisted-treatment
• Hoffman, R. M. (2020). Pain management and opioid prescribing: Legal considerations for healthcare providers. Journal of Pain & Palliative Care Pharmacotherapy, 34(4), 219-226.
• Reidenberg, M. M. (2018). Risks of polypharmacy in pain management: Focus on opioids and benzodiazepines. Clinical Pharmacology & Therapeutics, 104(3), 460-464.
• Hoffman, R. S., et al. (2020). Opioid overdose: Pathophysiology, prevention, and treatment. Clinical Toxicology, 58(4), 253-262.
• Schiff, E. P., et al. (2018). Evaluating opioid use patterns with state PDMPs. The Journal of Law, Medicine & Ethics, 46(2), 326-338.
• Fischer, B., et al. (2019). Clinical guidelines for opioid prescribing in chronic non-cancer pain. Canadian Medical Association Journal, 191(20), E552-E558.