Prescribing narcotics for severe lower back pain

Howard is a 24 year-old male who presents to the clinic his wife for what he states is severe lower back pain. He states the pain is so bad that he rates it as a 50 out of 10. He also tells you that due to a past medical history of an ulcer, he cannot take any medications like Motrin. He states that the pain is from a car accident in 2012, and that it flairs up and he needs pain medications. He also tells you that he has a high pain tolerance, and that when he gets pain meds he requires the higher doses.

Discussion 1

What would you do first prior to prescribing any medication?
What are the various schedules of medications for controlled substances?
Would you prescribe a long or short acting narcotic? Why or why not?

Discussion 2

What other non narcotic medication options can you offer to this patient?
What patient education is needed with them?
What would you do if the patient and his wife tell you that none of them work for him?

Discussion 3

You are concerned that this patient may have a substance abuse problem.

What screening testing is available for you to use that is reliable and valid?
What strategies would you suggest for this patient if he was found to have a problem?
What type of referrals would you make?

Discussion 4

After some investigating, you find that Howard actually is seeing a pain specialist who has given him epidural injections, and prescribes medication for him.

How does that impact any intervention that you may consider?
What other pharmacological options could you offer him?
What nonpharmacological options could you suggest?

Discussion 5

After seeing Howard and performing the appropriate screening tools, and a urine drug screen, he admits to you that he does have a problem with opioids due to his back injury. He states he has been admitted to an inpatient detox and twenty-eight day rehabilitation unit previously and was able to quit using for 3 months, but relapsed due to his pain. He states for the last 6 months he has been unable to get opioids from physicians since there is a record of him being prescribed a large amount over a short period of time. Due to this, he has started buying heroin from an acquaintance who he went to high school with. His wife is very tearful and states she is concerned that eventually Howard will end up killing himself.

What type of substance abuse programs would be most appropriate for him?
What requirements are there for a nurse practitioner to prescribe a medication to treat opioid addiction?
What are the requirements for a patient who is enrolled in a medication assisted opioid treatment program?