Unaccredited Module 2: Managing Pain Patients Who Abuse Prescription Drugs

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The following test-and-teach case is an educational activity modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will see whether you answered correctly and can then read evidence-based information that supports the most appropriate answer choice. Please note that these questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the case, there will be a short posttest assessment based on material covered in the activity.

Case Presentation


Edward, a 52-year-old warehouse employee, injured his back at home getting ready for a move out of state. It is now 2 months later and he is in your office as a new patient. He describes the pain at 7/10, aching in the center of the back without radiation, and no numbness or weakness and no bowel or bladder dysfunction. The pain is worse with bending, cough, or straining with bowel movements.

You have no chart, but the patient describes an initial treatment plan by a prior provider consisting of ibuprofen, tizanidine, ice, heat, stretching, and later physical therapy. He was seen by a physiatrist after a magentic resonance imaging (MRI) showed multilevel disc disease without encroachment. An epidural steroid injection under fluoroscopy did not help to alleviate his pain. Edward is now unemployed and spends much of his day in bed due to continued disabling pain, even though he's on hydrocodone/acetaminophen 10/325 mg 6 pills a day. He currently appears sleepy with diminished affect and is asking for something stronger than the hydrocodone.

The physical exam shows tight muscles in the low back with diffuse tenderness and triggering of the pain down the right leg. His range of motion is restricted by pain, with a negative neurologic exam including a normal straight leg raise. Provocative testing of the sacroiliac joint and piriformis muscle are negative.

What is the most appropriate first step in managing this patient?

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