Chronic Back Pain With Possible Prescription Opioid Misuse

Abstract

Mr O is a 71-year-old man who had been treated for chronic low back pain since 1981 when he underwent surgery for a herniated lumbar disk. He continued to have pain, which was unsuccessfully managed with acetaminophen and tricyclic antidepressants. Nonsteroidal anti-inflammatory drugs were not used because of a history of gastritis and Barrett esophagus. Steroid injections offered temporary relief. For more than a decade he achieved reasonable pain control by taking oxycodone-acetaminophen 3 times a day as needed (84 tablets every month). He signed a controlled substance agreement. However, urine drug testing (UDT) found no oxycodone on 2 occasions. He explained that he occasionally drinks alcohol and does not take his oxycodone-acetaminophen when doing so. His oxycodone-acetaminophen was discontinued for this violation of his agreement. Since then, he reports that his pain is inadequately controlled and his function has decreased.His medical history is notable for hypertension, hyperlipidemia, chronic obstructive pulmonary disease, dyspepsia, Barrett esophagus, anxiety, and depression. He is under psychiatric care.His medications include atorvastatin, hydrochlorothiazide, bupropion, alprazolam, venlafaxine, esomeprazole, gabapentin, and fluticasone, albuterol, and ipratropium inhalers.Mr O is divorced and lives alone. He receives long-term disability due to chronic back pain. He drinks beer occasionally (remote history of heavy drinking) and smokes 2 to 3 packs of cigarettes a day. There is no history of illicit substance use.

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