What is the best approach to manage a 69-year-old male patient with a history of shoulder tendinitis who is requesting Percocet (oxycodone and acetaminophen) and is suspected of drug-seeking behavior?

Management of Suspected Drug-Seeking Behavior in a Patient with Shoulder Tendinitis

For a 69-year-old male with shoulder tendinitis who appears drug-seeking and is requesting Percocet, non-opioid therapies should be utilized first, with opioids like Percocet avoided as first-line treatment due to their limited benefit and significant risks in chronic musculoskeletal pain.

Assessment of Pain and Drug-Seeking Behavior

When evaluating a patient who appears to be drug-seeking:

• Conduct a thorough objective assessment for evidence of pain, as acute pain with objective findings is less likely to represent manipulative behavior 1
• Look for signs of legitimate pain such as:
  • Facial expressions (grimacing, frowning)
  • Body movements (guarding, restricted movement)
  • Functional limitations in the affected shoulder 1
• Review the patient's medication history, including checking the prescription drug monitoring program
• Assess risk factors for opioid misuse using validated tools

First-Line Treatment Recommendations

1. Acetaminophen and NSAIDs:

   • Begin with acetaminophen (up to 3g daily in divided doses) and/or oral NSAIDs 1
   • A Dutch randomized clinical trial showed acetaminophen is not inferior to NSAIDs or their combination in musculoskeletal trauma 1
   • For shoulder tendinitis specifically, ibuprofen has shown better improvement in pain severity and functional activity compared to acetaminophen 2
   • In elderly patients, use NSAIDs with caution due to risk of kidney injury and GI complications; consider adding a proton pump inhibitor if NSAIDs are used 1

2. Physical Therapy and Exercise:

   • Strongly recommended for all patients with musculoskeletal conditions 1
   • Referral to physical therapy for appropriate exercises and modalities specific to shoulder tendinitis

3. Topical Treatments:

   • Consider topical NSAIDs as they have fewer systemic side effects, especially important in patients ≥75 years 1

4. Intra-articular Injections:

   • Glucocorticoid injections are conditionally recommended for shoulder pain 1
   • Local injection of anti-inflammatory medication has shown efficacy in alleviating pain and improving shoulder mobility 3

Second-Line Options (if first-line treatments fail)

1. Tramadol:

   • Can be considered if the patient has contraindications to NSAIDs or finds other therapies ineffective 1
   • Should be used cautiously in elderly patients due to side effect profile 1
   • Not recommended as first-line for long-term management 1

2. Duloxetine:

   • Conditionally recommended for musculoskeletal pain when first-line treatments are ineffective 1
   • May help address both pain and any associated mood disorders

Addressing the Request for Percocet

Opioids like Percocet (oxycodone/acetaminophen) should not be prescribed as first-line treatment for several reasons:

• For chronic neuropathic pain, opioid analgesics should not be prescribed as first-line agents 1
• Recent evidence shows very modest beneficial effects in long-term management of non-cancer pain with opioids 1
• Elderly patients are particularly vulnerable to opioid use disorders and risks of over-sedation and respiratory depression 1
• The American College of Emergency Medicine recommends against routine use of opioids for musculoskeletal pain 1

Communication Strategy

1. Acknowledge the patient's pain concerns without judgment
2. Explain that best practice guidelines recommend starting with safer alternatives
3. Outline a clear treatment plan using the non-opioid options
4. Set expectations about follow-up and reassessment
5. Consider implementing an opioid treatment agreement if opioids are eventually deemed necessary 1

Monitoring and Follow-up

• Schedule regular follow-up appointments to assess treatment response
• Document all interactions, treatment decisions, and patient responses
• If pain persists despite appropriate non-opioid therapies, consider referral to pain management or orthopedic specialist
• For patients with persistent pain, consider diagnostic imaging to evaluate for structural causes requiring surgical intervention 4

Cautions and Pitfalls

• Avoid dismissing the patient's pain complaints, which can damage the therapeutic relationship
• Be aware that legitimate pain behaviors can be misinterpreted as drug-seeking
• Recognize that patients may exhibit "pseudoaddiction" when pain is undertreated 1
• Document objective findings that support or refute the presence of significant pain
• Remember that telemedicine visits may limit the ability to fully assess pain behaviors and physical findings