W2 Case Study. Discussion Prompt
You are a new FNP in a restricted state and have your DEA license, and state furnishing for schedule II-V controlled substances. You are working at a busy family practice group, and you have a patient, ML, that is establishing care for the first time with your practice and comes to you with the following scenario:
ML is a 54 y.o. Hispanic female with hx of chronic shoulder and back pain that began 10 years ago when she was in a boating accident.
She lives in both US and Mexico, making regular visits across the border. Lately, she has stayed in the US due to Covid border crossing constraints, living with her daughter’s family.
She had rotator cuff surgery in 2011 and reports to you that due to a long operation and poor positioning, she has suffered from not only pain, but also chronic numbness and tingling in her R shoulder.
As “la abuela” (grandma), she is the primary caregiver of the children and homemaker for her family. Her pain is exacerbated with housework, and especially with the prolonged carrying of her grandchildren; one of which is 10 m.o.
Currently, her med list is as follows
Losartan 50 mg BID for HTN
Gabapentin 300 mg po BID for pain
Atorvastatin 40 mg daily for cholesterol
Diazepam 5 mg po up to TID prn pain
Norco 5/325 mg – takes up to two, sometimes up to 4-5x a day, prn pain
She is a smoker, only smokes outside the house, and drinks 2-3 cans of beer on the weekends, but more on family celebrations.
She denies recreational drugs and denies past overdoses.
She has recently moved to CA more permanently to stay to take care of children during Covid/school closures.
She asks you to refill all her meds for 6 months, like her doctor in Mexico did, so she doesn’t have to make another co-pay and come back and see you so often. It’s hard for her to get an appointment, and with Covid, her daughter has to take off of work to watch the kids so that she can come to you by bus (since there is only one family car).
Here VS are 135/75, 80, 97.5, 20 and PE unremarkable other than R shoulder exam with pain with ROM, but full ROM, no tenderness, otherwise normal, back exam including SLR are normal/neg
In 600 or fewer words, but a minimum of 250, please describe your approach with this patient. In your response, include the following:
What concerns do you have about her current regimen, and what alternatives will you discuss and offer? What other screenings might you apply? What are your own ethical standards on this case that you might consider in addition to legal standards?
Provide a sample of an appropriate pain contract that would suit this patient and address her specific safety concerns (cite it and attach the actual contract you found – you do not have to make your own – there are plenty online).
Include your steps to ensure safe prescribing. Include the registry you will search prior to any prescribing; name the CA registry, and if you are in a different state, you should name that registry also.
If you were to keep her current list, what are the laws surrounding refills and the amounts you are allowed to dispense with the schedule II and III medications in the state of CA? In your own state?
Which medications on her list may you call into the pharmacy, and which would you need a written script or electronic order? What are some elements required to include on the prescription form (paper or electronic signature) for the scheduled medications?
After you prescribe, how, when, and where would you (or your staff) go about making a report of your scheduled prescription in the state registry so that other prescribers and pharmacies could be aware?
In restricted states, APRN prescribers must follow a standardized procedure or protocol for furnishing schedule II and III controlled substances with a patient-specific approach. Please outline the minimum required components of a protocol. You may outline this in bullet form. Alternatively, you may find an appropriate protocol, clinical guideline, or standardized procedure from a literature search and attach it in lieu of outlining your own protocol.
Expectations
Length: A minimum of 250 words, max of 600 not including references or attachments
Citations: At least two high-level scholarly references in APA from within the last 5 years
______________________
Prescribing Controlled Substances: A Case Study Analysis
I have several concerns regarding ML’s current medication regimen. While gabapentin and diazepam are appropriate adjunctive treatments for her chronic pain, the high daily doses of Norco she is taking long-term could put her at risk for opioid use disorder. Additionally, combining benzodiazepines and opioids increases her risk of overdose (Bohnert et al., 2011).
Some alternatives I would discuss include a multimodal pain treatment plan incorporating non-opioid medications, physical therapy, acupuncture, and lifestyle modifications to help manage her pain (Dowell et al., 2016). I would also consider tapering her off diazepam and substituting a short-acting benzodiazepine only as needed to help reduce misuse risk (Nelson et al., 2020).
Given her history of substance use and risk factors, I would administer the Screener and Opioid Assessment for Patients with Pain (SOAPP) and Current Opioid Misuse Measure (COMM) to further assess her risk (Butler et al., 2019). I would also order a urine drug screen to check for prescribed medications and rule out undisclosed substance use.
From an ethical standpoint, I aim to balance providing adequate pain relief with minimizing harm, including risks of addiction, overdose, and diversion. To address ML’s specific safety concerns, I have attached a sample pain agreement outlining treatment goals and expectations that she would need to sign prior to any opioid prescriptions.
Prior to prescribing, I would check the California Prescription Drug Monitoring Program (PDMP) database for details of her controlled substance use history. As a New York prescriber, I would also check the New York PDMP. Any controlled substance prescriptions would require a written prescription submitted to the pharmacy, with my original signature and DEA number.
After prescribing, I am required to report any Schedule II-III controlled substance prescriptions to the California PDMP within one business day. In New York, reporting is also required within one business day. This helps facilitate monitoring of at-risk patients across state lines.
In California, I may prescribe up to a 30-day supply of Schedule II-III medications with no refills. In New York, the limit is a 30-day supply with one refill for Schedule III-IV medications. For Schedule II medications, the limit is a 30-day supply with no refills.
As required by New York law, my practice’s standardized procedure for prescribing controlled substances includes: conducting a medical exam, obtaining a medical and pain treatment history, considering alternative treatments, discussing risks/benefits of controlled substances, obtaining informed consent, developing a treatment plan with goals, prescribing the lowest effective dose for the shortest period, monitoring treatment response and side effects, reviewing the PDMP database, conducting random urine drug screens, addressing any aberrant behaviors, and consulting with pain specialists as needed (New York State, 2016).
In summary, a multimodal treatment approach emphasizing non-opioid therapies, thorough risk assessment, use of a pain contract, PDMP checks, and compliance with state prescribing regulations can help provide ML with adequate pain relief while minimizing risks of misuse, addiction and diversion. Regular monitoring is also important to ensure her safety and appropriate treatment over time.
Butler, S. F., Fernandez, K., Benoit, C., Budman, S. H., & Jamison, R. N. (2008). Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). The Journal of Pain, 9(4), 360–372. https://doi.org/10.1016/j.jpain.2007.11.014
Bohnert, A. S., Valenstein, M., Bair, M. J., Ganoczy, D., McCarthy, J. F., Ilgen, M. A., & Blow, F. C. (2011). Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA, 305(13), 1315–1321. https://doi.org/10.1001/jama.2011.370
Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624–1645. https://doi.org/10.1001/jama.2016.1464
Nelson, P. B., Juurlink, D. N., & Perrone, J. (2015). Addressing the prescription opioid epidemic. JAMA, 313(22), 2229–2230. https://doi.org/10.1001/jama.2015.3750
New York State Department of Health. (2016). Pain management. https://www.health.ny.gov/professionals/narcotic/laws_and_regulations/prescribing_guidelines.htm
