Is Percocet (oxycodone and acetaminophen) a suitable option for pain management in a patient with a history of bipolar disorder, BPH, HTN, HLD, and chronic shoulder and neck tendonitis, who has previously tried THC and pain management specialist visits without relief?

Management of Chronic Pain in a 69-Year-Old Male with Bipolar Disorder and Multiple Comorbidities

Percocet (oxycodone/acetaminophen) is not an appropriate first-line option for this patient with chronic shoulder and neck tendonitis, especially given his history of bipolar disorder and apparent medication-seeking behavior. 1

Assessment of Current Situation

This case presents several red flags:

• Patient specifically requesting Percocet
• History of bipolar disorder (increases risk for substance misuse)
• Previous use of THC for pain
• Statement that he is "seeking a provider that will prescribe percocets"
• Multiple comorbidities (BPH, HTN, HLD)
• Previous pain management found to be ineffective

Evidence-Based Approach to Management

Step 1: Prioritize Non-Opioid and Non-Pharmacological Therapies

• Physical therapy focused on shoulder and neck exercises should be the cornerstone of treatment 1
• Weight management if applicable
• Cognitive behavioral therapy to address pain catastrophizing and improve coping strategies 1
• Consider referral to occupational therapy for adaptive techniques

Step 2: First-Line Pharmacological Options

• Acetaminophen on a scheduled basis (up to 3000-4000mg daily) 1
• Topical NSAIDs like diclofenac gel for localized pain, which have better safety profiles in older adults 1
• Consider SNRI antidepressants (duloxetine) which may provide dual benefit for pain and mood stabilization 1

Step 3: Second-Line Options if First-Line Fails

• Trial of oral NSAIDs at lowest effective dose for shortest duration if no contraindications from HTN or other conditions 1
• Consider referral to pain specialist for interventional options (injections, nerve blocks)
• Muscle relaxants for short-term use (caution with sedation in older adults)

Why Percocet is Not Appropriate

1. CDC Guidelines explicitly state: "Opioids should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative, and end-of-life care" 1

2. High-Risk Patient Profile:

   • History of bipolar disorder increases risk of opioid misuse 1
   • Age 69 increases risk of adverse effects 1
   • BPH may worsen with opioids due to anticholinergic effects 1
   • Medication-seeking behavior is a concerning sign 1

3. Limited Evidence for Efficacy:

   • Evidence is limited for improved pain or function with long-term opioid use for musculoskeletal conditions 1
   • Risk of opioid-induced hyperalgesia may actually worsen pain over time 2

If Pain Remains Uncontrolled

If the patient's pain remains severe and disabling despite optimized non-opioid approaches:

1. Comprehensive Risk Assessment:

   • Use validated risk assessment tools
   • Check prescription drug monitoring program (PDMP) data 1
   • Consider urine drug testing 1
   • Evaluate for psychiatric comorbidities

2. Establish Clear Treatment Goals:

   • Focus on functional improvement, not just pain scores
   • Document specific, measurable functional goals 1
   • Implement a treatment agreement

3. Consider Referral:

   • Pain specialist consultation
   • Psychiatric evaluation for bipolar disorder management
   • Addiction medicine if substance use disorder is suspected

Important Caveats

• Patients with legitimate pain may exhibit behaviors that appear to be drug-seeking
• Untreated pain can worsen mental health conditions
• Thorough documentation of clinical decision-making is essential
• Regular reassessment of pain, function, and risk/benefit ratio is required

By following this approach, you can provide evidence-based care that addresses the patient's pain while minimizing risks associated with opioid therapy in a high-risk patient.