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Initial Case Presentation: 59 year old female diagnosed with lumbar and thoracic degeneration, stenosis, multiple cervical foraminal narrowing, chronic pain in the cervical and lower lumbar regions, bipolar disorder, and history of alcoholism. Opioid Risk Tool score is 12. Medications include: Vicodin, Ibuprofen, Neurontin, Trazadone, Lamictal, Xanax, and Carisoprodol. |
Recommendations from Consultants:
Taper Hydrocodone. Taper Carisoprodel slowly. Taper Alprazolam slowly. Complete PHQ-4 screening tools. Assess Prescription Monitoring Link for Washington State (to determine if patient is obtaining prescriptions from other providers in the state) and obtain urine drug screen to confirm. Recommend to not pursue interventional therapy as unlikely patient will benefit. Behavioral support (MSW or clinical psychologist) for cognitive behavioral approach to help manage symptoms and life. Education on how to use proper body mechanics, i.e., physical therapy, yoga, or tai chi.
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Follow-up Presentation: Patient accepted all of the recommendations provided above.
Hydrocodone taper continues; currently decreased to twice a day dose. Carisprodel taper use has decreased by 50% (15 tablets/month). Alprazolam tapered to 0.25mg/day Lamictal stopped PHQ-4 results is a “4”. Prescription Monitoring Link did not reveal other providers writing opioid prescriptions and urine drug screen is negative. Evaluated by community mental health ARNP and patient is not bipolar; now seeing psychologist for behavioral support.
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Follow-up Recommendations from Consultants:
Continue to taper Hydrocordone, Carisprodel, and Alprazolam. Endorse clinical psychologist efforts underway. Discussion and plan for “flare” self-management including strategies for pain and mood.
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