CC: "I have a constant pain in my lower back with occasional tingling in my right leg. The hydrocodone/APAP (Norco) is not cutting my pain, even if I take 2 tablets every 6 hours."
PMH: GV is a 55 year old female who has a history of lower back pain since an automobile accident 5 years ago. The patient has had a laminectomy to relieve the pain shortly after the accident, but the patient still complains of chronic pain.
Past Medical History: HTN x 3 years, Insomnia, Depression, Etodolac (Lodine) 600mg BID
Atenolol 50mg QD
Sertraline (Zoloft) 50mg QD
Norco 5/325 ii tablets every 4 to 6 hours as needed for pain
Allergies: sulfa (rash), penicillin (rash), codeine (stomach upset)
Social History: patient is married without any children. She smokes 1 pack of cigarettes per day but denies routine alcohol use.
GEN: well-developed, well-nourished female in no apparent distress
VS: BP 148/90, HR 75, RR 16, T 98.9, Wt 170lb, Ht 5'4"
HEENT: PERRLA, EOMI, TMs intact
THORAX: localized kyphosis with an exaggerated lordosis of the lumbar spine. Tenderness to palpation of the low lumbar region. Flexion of the lumbosacral spine was 60 degrees with 0 degrees of lumbar extension. Lateral bend to the right and left and trunk rotation was limited. ABD: soft, nontender, +BS GU: WNL
RECTAL: guaiac-positive stool
MRI: slight degeneration of disc; no evidence of spinal stenosis or herniated disc.
CASE STUDY (Part Two)
Assume you are seeing the patient listed above on February 20th, who is requesting a refill on her hydrocodone/APAP. Knowing that she is early you question her and she responds that her pain has been much worse over the past month and he has been taking the hydrocodone/APAP 2 tablets (sometimes 3) every 4 hours. When questioned about other medications, she replies that she is only taking the medications prescribed by Dr. Lotsofmeds. Upon reviewing the patient's most recent narcotic history in OARRS, you determine that she has received:
oxycodone 15mg tablets #90 from Dr. Nopain (a physician in a different practice across town) on February 15th from Uptown Pharmacy
alprazolam 2mg tablets #90 from Dr. Nopain on February 15th from Uptown Pharmacy
carisoprodol 350mg tablets #60 from Dr. Nopain on February 15th from Uptown Pharmacy
hydrocodone/APAP 5/325mg tablets #180 (30 day supply) from Dr. Lotsofmeds (a physician in your practice) on February 1st from Value Med Pharmacy
oxycodone 15mg tablets #90 from Dr. Nopain (a physician in a different practice across town) on January 13th from Uptown Pharmacy
alprazolam 2mg tablets #90 from Dr. Nopain on January 13th from Uptown Pharmacy
carisoprodol 350mg tablets #60 from Dr. Nopain on January 13th from Uptown Pharmacy
hydrocodone/APAP 5/325mg tablets #180 (30 day supply) from Dr. Lotsofmeds (a physician in your practice) on January 4th from Value Med Pharmacy
Describe your thoughts about this patient, and explain how you would proceed with the care of this patient. Is the patient displaying signs of pseudoaddiction or addiction? Can you ethically deny this patient his pain medication? How would you balance ethics and pharmacy law? How would you defend your decision (cite law code and or practice guidelines).