What are the risks and management options for a patient with chronic back pain on Norco (hydrocodone) who finishes their 30-day prescription in 18 days and has kidney stones with no medical clearance for surgery?

Managing Opioid Use in a Patient with Kidney Stones and Chronic Back Pain

Patients who finish their 30-day opioid prescription early (in 18 days) should be evaluated for potential opioid misuse, and their pain management plan should be reassessed with consideration of alternative therapies, dose adjustments, and risk mitigation strategies. 1

Risk Assessment and Concerns

When a patient with kidney stones and chronic back pain finishes a 30-day Norco (hydrocodone) prescription in 18 days, several important concerns arise:

• Increased risk of opioid dependence: Taking higher doses than prescribed increases the risk of developing opioid use disorder, even if the patient isn't requesting more medication 1
• Inadequate pain control: The patient may have inadequate pain control, requiring higher doses than prescribed 1
• Medication safety: Higher-than-prescribed doses increase risk of adverse effects, including respiratory depression and overdose 1
• Kidney function impact: Kidney stones may affect renal function, potentially altering opioid metabolism and increasing toxicity risk 1, 2

Management Approach

1. Immediate Assessment

• Evaluate pain control and reasons for increased usage
• Assess for signs of opioid misuse using prescription drug monitoring program (PDMP) data 1
• Consider urine drug testing to confirm appropriate medication use 1
• Evaluate kidney function to determine appropriate medication options 1, 2

2. Pain Management Alternatives

For patients with kidney stones who cannot get surgical clearance:

• First-line non-opioid options:

  • Acetaminophen (preferred in kidney disease) 1, 2
  • Short-term NSAIDs with careful monitoring (if GFR >30 mL/min/1.73m²) 1, 3
  • Topical analgesics (lidocaine, capsaicin) 2

• Safer opioid alternatives for kidney disease:

  • Hydromorphone (start with 25-50% of normal dose) 2, 4
  • Fentanyl (preferred option in kidney impairment) 2, 4
  • Buprenorphine (safer alternative with less respiratory depression) 2, 3, 4

• Avoid these opioids in kidney disease:

  • Morphine (contraindicated due to metabolite accumulation) 2, 4
  • Tramadol (not recommended) 2, 5
  • Codeine (avoid use) 2, 4

3. Risk Mitigation Strategies

• Dose adjustment: Prescribe the lowest effective dose of immediate-release opioids 1
• Monitoring: Evaluate benefits and harms within 1-4 weeks of any dose change 1
• Prescription monitoring: Use PDMP data to track prescriptions 1
• Naloxone: Consider offering naloxone for patients at higher risk of overdose 1
• Treatment agreement: Implement a clear opioid treatment agreement with the patient 1

4. Non-Pharmacological Approaches

• Heat or cold therapy for localized pain 2
• Relaxation techniques 2
• Physical therapy when appropriate 3

Special Considerations for Kidney Stones

• Patients with kidney stones often experience severe, episodic pain that may lead to increased opioid use during acute episodes 6
• For patients awaiting surgical management, temporary dose adjustments during acute pain episodes may be necessary, but should be carefully monitored 1
• Consider consultation with nephrology and pain management specialists for complex cases 2

Follow-up Plan

1. Schedule follow-up within 1-2 weeks to reassess pain control and medication use
2. Monitor kidney function regularly
3. Develop a clear tapering plan if continued opioid use is necessary 1
4. Consider referral to pain management and/or addiction specialist if appropriate 1

Common Pitfalls to Avoid

• Abrupt discontinuation: Never abruptly stop opioids in patients who have been taking them regularly, as this can lead to withdrawal 1
• Ignoring kidney function: Failure to adjust medications based on kidney function can lead to toxicity 1, 2
• Inadequate monitoring: Not using PDMP data or urine drug testing to monitor for potential misuse 1
• Overlooking non-opioid options: Many patients with kidney stones can achieve adequate pain control with non-opioid therapies 1, 3

By implementing these strategies, clinicians can address both the patient's pain needs and the risks associated with early completion of opioid prescriptions, particularly in the context of kidney disease and surgical limitations.