You are a new AGACNP at an urban, tertiary referral center working in the emergency department (ED). You are presented with the following case:
Patient is a 45-year-old, Caucasian male, acute care nurse practitioner (ACNP) who comes in with the chief complaint of back pain, acute on chronic. He describes severely compromising, debilitating lumbar spine pain due to a fall from a 20-foot scaffolding several years ago. There is MRI evidence of multilevel degenerative spine disease and bulging discs, with a dx of “failed back surgery.”
In addition to the above, he is nauseated with emesis episodes that are too numerous to count this morning. He also has intractable diffuse abdominal pain, intermittent piloerection, and diaphoresis.
He tells you he is prescribed the following by a local pain clinic: OxyContin 20 mg BID, with oxycodone 5 mg q. 3 hours breakthrough pain, Lyrica 100 mg at HS, Lexapro 10 mg daily, and Xanax 0.5 mg BID prn anxiety. He reports that he received #60 OxyContin 20 mg and #60 oxycodone 5 mg 2 weeks ago but is saying that he has been out of medication x 2 days. When you inquired about how quickly he has used his pills, he admits to using more pills than prescribed due to increased pain following a recent fall at home. He wants help, admits to opioid addiction, and is accepting of inpatient admission.
He is also requesting methadone to assist with addiction/pain management.
He is receiving outpatient physical therapy as well as intermittent epidural blocks (last one was 2 weeks ago).
Answer all the following questions, in detail. Support your answer with two or three peer-reviewed resources.
What are your initial orders to help control his acute pain?
What is your diagnosis for his GI symptoms?
What is your response to his request for methadone? Can you prescribe methadone for acute/chronic pain or addiction as an AGACNP?
Ethically and professionally, what are your concerns for this patient and his own ACNP practice? What resources are available to you as a prescriber to track this patient’s opioid use/abuse? What referrals do you anticipate making for him while he is in the ED?
What populations of people are at risk for addition, pain medication diversion, and psychological conditions that may cause hyperalgesia or adverse reactions to pain regimens?
What resources are available to a provider of medical care who suffers from addiction?
