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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Define the goals for pain management in a patient with chronic nonmalignant pain.

  • Apply the principles and tools discussed when prescribing, assessing, monitoring, and dispensing chronic opioid therapy (COT) in chronic non-cancer pain (CNCP).

  • Assess patients to identify possible presence of risk factors for aberrant behavior surrounding COT for CNCP.

  • Describe strategies to identify and manage medication related aberrant behavior and risks associated with COT, including use of current guidelines for prescribing COT, Prescription Drug Monitoring Programs (PMP), urine drug monitoring (UDM), patient and prescriber agreements (PPAs), and treatment modification.

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PATIENT PRESENTATION

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Chief Complaint

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“Everything hurts. My pain is 10/10, it is always at a 10/10! I have tried the medications that everyone has prescribed me, but they never seem to work and I’m still in pain. I’ve tried PT and it makes my pain worse! I’m told to wear my CPAP mask, that it will help my sleep and help my pain. But every time I wear it, I get claustrophobic and my anxiety increases, so I don’t wear it anymore. I have been in pain for 30 years, and every time I ask for a medication that works, like oxycodone, which I know works, I am told to try another medication I have never tried, and to see PT and the psychologist. Well, I’m sick of trying medications that don’t work, and I’m sick of being told the pain is in my head! The pain isn’t in my head, it’s all over my body! I just want a shot or a pill that will take all my pain away!”

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HPI

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Danica Mole is a 56-year-old female with pain from temporomandibular-joint disorder, fibromyalgia, and ruptured L4-L5. She states that her pain began when she was assaulted by one of her high school students 25 years ago. There was never a report filed of an assault, and she has been on disability since the time of the assault. She has been a patient in this pain clinic for five years during which she has failed multiple medications; every time a new nonopioid medication began to work, she developed adverse reactions to it. Thus, she has been prescribed and using opioid medications to control her pain. While she has never overtly misused her opioid medications, she has been calling and asking for early refills of her opioid medications due to overuse, and lost or stolen prescriptions. She bristles at any suggestion that she may be “chemically coping.” She states proudly that she used to have an alcohol problem, but “took care of herself” and did not need any “12 Step program or rehab hospital.” She has never embraced PT, and states that her pain is made worse by PT. She is antagonistic to behavioral therapy and has been fired as a ...

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