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?