TC presents to urgent care with a right-shoulder pain 8/10 due to a work injury. The patient has no ROM in the effected shoulder and reports no neck pain. As a healthcare provider there are several things that need to be asked to understand this patient’s pain and pain management. How the injury occurred, if the pain gets better or worse with anything, how long has this pain been occurring for, and what type of pain is TC experiencing should be asked (Woo & Robinson, 2020). The patient should also be assessed for any depression or anxiety via a mental health screen for a history as well as to see if the pain is causing any changes in affect. A past medical history as well as a full physical exam should also be completed prior to making recommendations for pain management. Asking the patient if he is currently on any medications, specifically pain medications will be a useful tool to help decide what treatment will work best for this patient. In addition, allergies need to be considered.
The goal of pain management is to treat the pain but with the least adverse reactions possible (Woo & Robinson, 2020). The best way to accomplish this is to start with non-pharmaceutical management. Ice would be my first recommendation when the patient arrives. If upon assessment this patient has an injury that is affecting the muscle or tendon as most shoulder pain from work occurs from than ice can be put on the patient (Workers Injury Law and Advocacy Group, 2020). The patient’s pain being an 8 out of a 10 on the 0-10 scale however would alert me to give him at least an anti-inflammatory medication as well if not contradicted by information gathered during the history intake and physical examination. I would give TC 1,000mg of acetaminophen due to his high pain scale every 4 to 6 hours (Harvard Health, 2020). This patient may be asked for a urine sample as well for a tox screen to ensure there will be no medication contradictions as well as to assess if this patient is a drug seeker. If this were not sufficient for pain control and there were no other contradictions noted I would try a low dose of hydrocodone.
Instructions for TC would include to rest the shoulder and to ice the shoulder for 10-15 minutes at a time for the first day or two of the injury (Michigan Medicine, 2018). Instructions for acetaminophen include taking with some food to avoid GI upset as well as to not mix with alcohol or loop diuretics, beta-adrenergic blockers, or zidovudine medications (Woo & Robinson, 2020). If the patient were on one or more of these medications I would consider using a non-steroidal anti-inflammatory (NSAID) medication instead of acetaminophen such as Naprosyn. Also, the patient should not exceed the total daily maximum of 4,000mg per day as acetaminophen poisoning is common and dangerous (Woo & Robinson, 2020). Instructions for hydrocodone include not to take with alcohol or other opioid medication. Hydrocodone can cause respiratory distress, low blood pressure, altered mental status, nausea, vomiting, hallucinations, incoordination, constipation, and lethargy (Woo & Robinson, 2020). TC should be instructed not to drive while taking this medication. All opioid medications can become addictive as well so screening and education on this topic is also vital for TC. Lastly I would inform TC to follow-up with his provider and return to urgent care if symptoms get worse or new ones arise.
The DEA Drug Classification Schedule has five categories. Schedule one includes substances that are not for medical purposes or have not been legally endorsed for medical purposes and are highly abused when used such as heroin (DEA, 2020). Schedule two are also high risk for abuse however are used in a medical setting for example hydromorphone. Schedule three includes medications like Tylenol/Codeine which have a less risk of addictive abuse but still could be abused (DEA, 2020). Schedule four medications have a low risk for abuse and addiction as consequence of consumption and they include medications such as Ambien (DEA, 2020). And lastly, are schedule five drugs which do not contain the same narcotic properties as the other categories of drugs. This would include cough syrup and Lyrica (DEA, 2020).
The treatment plan for pain has been a much-discussed topic with different opinions that may have pharmacological companies and government agencies at odds of how to treat pain in this country. The one thing everyone agrees is that pain is “real” and affects millions of people worldwide with ineffective treatment for different reasons. According to Woo (2020), pain can be defined as the duration of the pain is either acute or chronic and the source of the pain. The attempt by large corporations in the late 1990’s to treat pain resulted in millions of people dying of an overdose or with addiction that has cost millions of dollars in healthcare treatments (CDC, 2020). In this case study, there are a few things to consider.
TC comes to the clinic due to a work-injury with an 8 out of 10 pain and is unable to do ROM to the shoulder. The first action that this clinician would take is to assess the patient’s shoulder, his skin, and also take a detailed history of medications, and allergies. After identifying TC’S home medications, if any, and allergies, this prescriber prescribes a fast-acting opioid medication to help with the pain such as morphine. The next step would be sending TC to do an X-Ray and possible follow-up with orthopedic.
While treating TC for acute pain with opioid morphine is important to understand that this treatment option would be just until his pain is controlled and the necessary X-rays and other tests are obtained. Understanding that the inflammatory process has started the moment the injury occurred as a body’s defense mechanism and healing process (Roma et al., 2020). In this situation, an anti-inflammatory, NSAIDs such as Ibuprofen could be prescribed to control his pain, if there were no fracture noted. The use of an NSAID would decrease the need to use an opioid which is associated with chemical dependency (Woo, 2020). Also, a topical agent could be prescribed in adjunction with the NSAID to help in the treatment of the pain. By prescribing the Lidocaine patch to be applied to the site would help in the control of pain with continuous therapy.
The teaching to TC would include following the instructions from the orthopedics. Take medications as prescribed. When taking NSAIDS make sure to take with food and a full glass of water and stay up for at least 30 minutes to prevent any GI disturbance, do not take any other medication that is not approved by the clinician, and report to the clinician if the pain is at a comfortable level. Educate TC to report to the clinician if the pain is increasing and the injury is not getting any better to contact the clinician and not to initiate any home remedies without first consulting a prescriber.
The classification of medication according to the US Drug Enforcement Administration (DEA) drug classification scheduled is to guide prescribers into prescribing drugs. It is designed to regulate the manufacturing, distribution, and dispensing of medications classified as “controlled” (Woo, 2020). The schedule is bound to follow those rules. It is divided into five categories. Scheduled I is drugs that are not prescribed for medical use and have a high potential for abuse, for example, heroin, LSD, marijuana, ecstasy, methaqualone, and peyote (DEA, 2020). In the scheduled II are drugs with high potential for abuse, and may lead to psychological or physical dependency, some examples are Vicodin, Dilaudid, Demerol, OxyContin, Fentanyl, Dexedrine, Adderall, and Ritalin (DEA, 2020). In the scheduled III comes drugs with moderate potential for abuse which are Tylenol with codeine, ketamine, anabolic steroids, and testosterone (DEA, 2020). In Scheduled IV are drugs with low potential for abuse or dependence, some are Xanax, Soma, Darvon, Darvocet, Valium, Talwin, Ambien, and Tramadol (DEA, 2020). Lastly, comes the schedule V which are drugs with low potential for abuse, and contains preparations with a limited quantity of certain narcotics. It is mostly used as an antidiarrheal, antitussive, and analgesic needs, some examples are Robitussin AC, Lomotil, Motofen, Lyrica, and Parepectolin (DEA, 2020). This classification is an important tool for the prescriber to follow and understand how each medication is used and the level of addiction that it can have in patients.
Respond with a well-developed paragraph (300–350 words to each peer), integrating an evidence-based resource that is different than the one used for the initial post.
Respectfully agree and disagree with your peers’ responses and explain your reasoning by including your rationales in your explanation.