Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 1
Mr. Connors, 54, has chronic neck pain for which he is prescribed short-acting 10 mg hydrocodone/ACET to take as-needed up to 4 per day. He does not take this medication daily but only on days when the pain spikes to 7/10 at rest, usually after exertion such as weeding his flower bed or taking a bike ride. He has always had consistent UDTs and PDMP checks, and the hydrocodone prescription helps him meet his goals of an active life. He drinks 2 beers several evenings a week and has no other history of or current substance use. He is treated for depression and has been stable on his escitalopram dose for years. His HCP and he have discussed the wisdom of limiting alcohol use with his current medications, and he has promised to try. While mowing his lawn one weekend, he strains his neck more than usual and is in significant pain that is constant, throbbing, and intense (9/10). He ices the area and takes 800 mg ibuprofen but finds the pain is still so intense he cannot sleep that night. His grown daughter offers him one of her alprazolam 1 mg, and he accepts so that he can sleep.
1. Consider what would be the responsibility of the prescriber of CS in such a scenario. Consider the components of the treatment agreement previously assigned. How would one appropriately counsel and follow-up with the patient?
Figure 2. Trends for Most Commonly Dispensed Categories of Controlled Substances in US Commercially-Insured Adults (January 2004 to June 2019)*
Six most commonly dispensed categories as of January 2019-June 2019 are presented: Depressants (schedule IV) contained benzodiazepines and sleep medications zaleplon, zolpidem, and zopiclone Depressants (Schedule V) contained brivaracetam, ezogabine, lacosamide, and pregabalin Opioids (Schedule III) contained codeine ≤90 mg per dosage, morphine ≤50 mg/100 mL or 100 g, both in a combination with another non-opioid ingredient, and buprenorphine Stimulants (Schedule II) contained amphetamine, methamphetamine, methylphenidate, lisdexamfetamine, and dextroamphetamine *Based on de-identified longitudinal claims data on beneficiaries of a large US employer-sponsored commercial health insurance provider and covers approximately 9 million individuals ages 19 to 64 years in any given month across all 50 states.
The Department of Veterans Affairs/Department of Defense (VA/DoD) practice guideline lists concomitant use of benzodiazepines as a contraindication to initiating a trial of long-term opioid therapy. 33 Benzodiazepines should be stopped gradually and perhaps with the help of a specialist. Abrupt cessation with not only benzodiazepines but also baclofen, carisoprodol, or barbiturates, can cause significant morbidity and even death. 59 Acute withdrawal symptoms with sedative-hypnotics can include anxiety, tremors, tachycardia, fever, hypertension, insomnia, seizure, and delirium. 59-61
Scheduled sleep medications include zaleplon, zolpidem, and zopiclone (Schedule IV), known as “Z-drugs,” and brivaracetam, ezogabine, and lacosamide (Schedule V). Like benzodiazepines, Z-drugs enhance the effect of GABA, the major inhibitory neurotransmitter. Evidence shows they have reinforcing effects and carry risks for abuse potential, tolerance, physical dependence, and subjective effects. 62 While Z-drug addiction is uncommon, the risk increases at higher doses and in patients with an SUD history. 62 Z-drugs can cause withdrawal symptoms if abruptly discontinued after prolonged use.
Side effects include nightmares, agitation, hallucinations, dizziness, daytime drowsiness, headache and gastrointestinal (GI) problems. Barbiturates include amobarbital, pentobarbital, phenobarbital, secobarbital, and tuinal. Some are very short-acting drugs with effects lasting only a few minutes while others may have effects that last up to 2 days. 63 Barbiturates have a history of medical uses as sedative-hypnotics for insomnia and anxiety but also have a history of recreational misuse and a narrow therapeutic index. 64 Current medical indications largely center on preoperative sedation and antiseizure, and misuse has dropped in recent decades as barbiturates have been largely replaced in practice by benzodiazepines. 64
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