Narcotics and diagnostics...

Specialties NP

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Okay, I have another question....I have a pt who makes me uncomfortable....He's a 35 y.o. male LPN who works nights and comes in once a month with shift work fatigue, gamers grip, and lower back pain/joint pain.....He comes in for refills of his Adderall XR 20mg BID, Tramadol, and Percocet.....Okay, so I discussed tapering off the Tramadol for the gamer's grip as that was a lot along with the percocet....he was fine with that...and then I discussed that we need to cut his Adderall dose back a bit, which he was fine with...

I don't have a problem filling narcotics for people with chronic pain...the thing is I don't have a problem when there is something to back it up (x-ray, MRI) or a clear diagnosis from a specialist.....BUT, in this case, he describes just feeling like his body is "broken down" from pulling patients up all night, etc and he has pain from it all over....? What kind of diagnostics can I do for this? I figure I could run a sed rate...? I don't know...I'm just uncomfortable refilling and refilling percocet....I'd like to try PT.....any advice? As well as advice in dealing with a pushy patient?? He does pressure me to give his refills, and while I don't ever do anything I'm not comfortable with, I'm just not comfortable with this guy....

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Specializes in Psychiatric Nursing.

One thought: refer to a specialist for a clear diagnosis. There may be better medications than Percocet. Or PT like you said. Also is he taking his Percocet as prescribed? Is Percocet the best choice for his situation? Etc

Also the Adderall--how has this been worked up?

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I basically inherited this pt from a PA who recently moved....I don't think Percocet is the best thing for his situation....it's just this is what the person before me had started and that's what he's been getting, and that's what he wants....The shift work fatigue....well, initially when I had him, his chart said ADHD, and when I questioned him about it, he said he never really had ADHD but he has fatigue related to working nights, and the Adderall helps....? Ugh...I'm telling you, this pt is just a mess, and really I just don't know what to do with him at this point....

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What kind of specialist would you refer to?

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Specializes in Psychiatric Nursing.

Pain specialist.

Or wherever they say the pain is. Maybe an orthopedic specialist

Are there protocols for working up pain?? If it seems like nerve pain. A neurologist

Who would work up rheumatoid arthritis?

Is there a pain clinic you could consult??

Could it be psychosomatic? I think you would first figure out if it is physical and if there is no diagnosis then a psychiatric consult may be in order??

Do all the tests you can first. He may like his Percocet. Percocet and Adderall together is fairly mind altering I would think, and may not really help him.

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Specializes in Psychiatric Nursing.

I am not sure you should be giving Adderall for anything but ADHD.

But start with getting work ups for the pain.

He may need counseling to learn sleep hygiene.

I think modofinal is used for shift work fatigue.

Maybe you can talk to him that as a new patient you need to do a complete evaluation so you know what you are treating.

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Hand repetitive stress injury --> occupational therapy. For real, they're amazing (at least where I work). And more specialized in hands than PT.

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Specializes in ER.

I would get him off all scheduled drugs. Provigil (modenafil) is FDA approved for shift fatigue, Adderall is not. I would also do a urine drug screen on this patient. As an NP, I am very uncomfortable using meds for off label usage, especially a schedule II like Adderall. All it would take is for an MD or DO to look at your prescribing for this patient and they would probably flip out. What state do you work in? I am in Michigan and NP's can only write schedule II's for inpatient care. Do you have a supervising physician? I would run this scenario by them and get their input.

I never have a problem telling a patient that I am uncomfortable prescribing certain medications, or that their issues are outside my scope of practice. I also tell patients I do not treat chronic pain. I would NEVER prescribe Adderall and would only provide refills if it was initially prescribed by a psychiatrist, and the patient was under psychiatric care for their ADHD.

I worry that you may be asking for trouble caring for this patient.

Good luck!

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Specializes in Nephrology, Cardiology, ER, ICU.

Agree with above posters: no go for chronic percocet for some ambiguous pain....nope....pain specialist referral.

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Specializes in Psychiatric Nursing.

I am very glad a primary car np responded to this thread. I get pts like this in outpt psych.

I rarely prescribe adderrall to anyone and have strict guidelines for myself. And of course I never prescribe percoset. (I'm psych only). I had a patient once plead with me for percoset-"it is the only thing that works." He said.

He may or may not be a substance abuser. You need support and a plan for someone like this.

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Specializes in Anesthesia, Pain, Emergency Medicine.

Adderrall: NO

Tramadol: NO

Percocet: HELL NO.

Diagnostics: Low back pain - Straight and cross leg raise positive? Any radicular component?

either refer to neuro/pain or get an mri yourself. Narcotics are not the answer.

You may consider gabapentin or amitryptyline.

This pt. sounds like a drug seeker.

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I am in primary care. Whenever I have "inherited" a patient like this, I say, "The standard of care in pain management is to use long-acting pain medications daily, with short-acting medications like Percocet (or Dilaudid, or whatever) for breakthrough pain only. This may provide significantly better relief than your current medications.Therefore, I am going to refer you to a pain specialist who can evaluate your needs and prescribe the appropriate type of pain medications". The phrase "standard of care" gets me a lot of traction. And if they object to seeing a pain specialist, my favorite comeback line is, "You have a complicated pain syndrome. A pain specialist is the most appropriate person to evaluate and treat your pain. This is no different than when I send someone with kidney problems to a kidney specialist". Most patients "get it" at that point and I never leave them without sufficient pain meds to cover them until they see the specialist. Some are never heard from again. Obviously, this would be a problem in a rural area with little or no pain specialists. I also look up EVERY person presenting for pain management in our state database to see what they have been getting and who has prescribed it. We routinely find patients in our practice that are "doctor shopping" (and not given the meds, needless to say).

I am one of the most sympathetic people when it comes to chronic pain. But I strongly believe that patients with chronic pain should be evaluated and treated by a pain specialist. All the short-term junk pain meds do not help them and can make them worse. Once they have a Dx from a specialist, then if I need to manage their pain medications and they check in with the pain specialist on a regular basis, that's a whole different situation. Like you said, this patient makes you uncomfortable. There is probably a reason for that.

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