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Case Studies: Principles in Practice: Susan [patient profile]

Susan: Addressing Aberrant Behavior Related to Prescription Opioid Use

A new patient, Susan is a 40-year-old woman who presents with worsening of her chronic pain of fibromyalgia. She reports a 3-year history of widespread pain and a longer history of symptoms consistent with episodic irritable bowel syndrome. She also relates that she lost her job as a receptionist a few weeks ago.

Describing “entire-body” muscle aches, tension, and soreness, Susan voluntarily offers that her pain now is “the worst she can imagine” and “an 11 out of 10.” She indicates that she has been taking a prescribed immediate-release (IR) opioid daily but has just a few pills left.

Susan also reports that she is currently taking a serotonin-norepinephrine reuptake inhibitor (SNRI), as well as an over-the-counter nonsteroidal anti-inflammatory drug “as often as the bottle says I can.”

Susan says she desperately wants something for her pain and requests a specific extended-release (ER) opioid. The physician explains that he generally does not prescribe opioids for the treatment of fibromyalgia, but proceeds with the patient assessment, including confirmation of Susan’s fibromyalgia diagnosis.

Note: Representative case example. This case is not based on an actual patient.

Susan: Addressing Aberrant Behavior Related to Prescription Opioid Use

“I Need More Information Before I Consider an Opioid”


The physician explains that he would like Susan to answer a few questions before he can consider her request for an ER opioid prescription (see video). He administers the Opioid Risk Tool (ORT).

Susan’s answers on the ORT result in a score of 6, suggesting moderate risk for aberrant behavior with prescription opioids (see Glossary). During their discussion of the ORT, Susan indicates that she “used to drink a little too much” but now limits herself to 1 to 2 glasses of wine each evening.

To understand more about Susan’s psychological health, the physician asks her to complete the Patient Health Questionnaire-2, a measure of anxiety and depression. Susan scores a 6, the highest possible score, suggesting the presence of both conditions.

The physician then explains to Susan that he would like her to provide a urine sample. Susan is initially unwilling to provide the sample but the physician indicates that a urine test is an important part of his evaluation if he is going to consider providing her with an ER opioid medication. In-office urine testing results are positive for opiates as well as a cocaine metabolite.

Susan: Addressing Aberrant Behavior Related to Prescription Opioid Use

“I Have Concerns About Prescribing an Opioid for You”


The physician asks Susan about the cocaine findings, and she says the test is wrong; she states that she hasn’t used cocaine “in years” (see video).The physician indicates that he can send the sample out for additional testing to check the result.

He then informs Susan that he has checked the prescription drug monitoring program (PDMP) database and it indicates she has been receiving opioids from multiple doctors and pharmacies. Susan says that she had to switch doctors a few times because of her insurance. She insists that she has never taken more medication than she is supposed to.

The physician tells Susan that he will not prescribe an ER opioid, for multiple reasons. He says that he would like her to consult with an addiction specialist. Susan becomes angry, leaves the exam room, and walks out of the physician’s office. She does not return.