What is the best course of treatment for a 52-year-old male with a history of chronic pain, anxiety, and high risk for opioid abuse, currently taking oxycodone (oxyCODONE HCI) and tizanidine (tiZANidine HCI), with a pain level of 10/10 and significant interference with daily activities?

Management of High-Risk Chronic Pain Patient on Long-Term Opioid Therapy

Immediate Priority: Address Opioid Use Disorder

This patient requires evidence-based treatment for opioid use disorder with buprenorphine or methadone combined with behavioral therapy, not continuation of current oxycodone therapy. 1 The patient is flagged as high-risk for opioid abuse, has a completely negative urine drug screen despite being prescribed oxycodone (suggesting diversion or non-adherence), reports maximum pain scores despite being on 40 MME/day, and has untreated anxiety—all red flags for opioid use disorder rather than undertreated pain. 2, 3

Critical Problems with Current Management

The Negative UDS is a Major Red Flag

• A completely negative UDS in a patient prescribed oxycodone 10mg every 6 hours indicates the patient is not taking the medication as prescribed. 1
• The explanation of "running out early due to being out of state" suggests misuse, overuse, or diversion. 1
• This pattern meets criteria for aberrant drug-related behavior requiring immediate intervention, not continued prescribing. 1, 2

Depression and Anxiety Increase Risk Substantially

• Untreated psychiatric comorbidities, particularly depression and anxiety, double the risk of transitioning to long-term high-dose opioid use and increase risk of opioid use disorder. 2, 3
• Depression increases the risk of prescription opioid abuse and is associated with using opioids to self-treat insomnia and stress rather than pain. 3
• Long-term opioid therapy actually increases the risk of incident, recurrent, and treatment-resistant depression. 3
• The patient's anxiety is reportedly "treated by PCP" but there is no evidence of adequate psychiatric management or integration with pain treatment. 1

Current Opioid Dose and Monitoring Issues

• At 40 MME/day (oxycodone 10mg every 6 hours = 40mg/day), the patient is below the 50 MME threshold requiring extra caution, but the CDC guidelines emphasize careful reassessment when approaching this level. 1
• Monthly follow-up is appropriate for doses over 50 MME, but this patient requires more intensive monitoring given the high-risk profile and aberrant UDS. 1

Recommended Treatment Algorithm

Step 1: Do Not Refill Oxycodone Until Evaluation is Complete

• The negative UDS is an absolute contraindication to refilling controlled substances until the situation is clarified. 1
• Schedule an urgent appointment before the 7/31/22 refill date to address the discrepancy. 1

Step 2: Comprehensive Addiction Assessment

• Conduct a structured assessment for opioid use disorder using DSM-5 criteria, not just the Opioid Risk Tool. 1, 2
• Specifically assess for: taking opioids in larger amounts than prescribed, unsuccessful efforts to cut down, continued use despite physical/psychological problems, and using opioids to treat anxiety or insomnia rather than pain. 2, 3
• Review PDMP data for evidence of doctor shopping or obtaining opioids from multiple sources. 1

Step 3: If Opioid Use Disorder is Confirmed (Likely Scenario)

• Initiate buprenorphine/naloxone (Suboxone) 8/2 mg daily, which treats both opioid use disorder and provides superior analgesia for chronic pain compared to oxycodone in this population. 4, 5
• Buprenorphine has demonstrated 86% of patients achieving moderate to substantial pain relief with improved functioning and mood at doses of 4-16 mg daily. 6
• Continue the patient's usual buprenorphine dose and add short-acting opioids only for acute pain exacerbations if needed, not for chronic baseline pain. 7
• Combine with mandatory behavioral therapy—medication-assisted treatment alone is insufficient. 1

Step 4: Optimize Non-Opioid Therapies

• Nonpharmacologic and nonopioid pharmacologic therapies are preferred for chronic pain and should be the foundation of treatment. 1
• Start duloxetine 30 mg daily for 1 week, then increase to 60 mg daily to address both neuropathic pain components and comorbid anxiety/depression. 6
• Start gabapentin 100-300 mg at bedtime, titrating to 300 mg three times daily over 1 week, then gradually increase by 300 mg every 3-7 days targeting 900-1800 mg/day for neuropathic pain. 6
• Continue tizanidine 4 mg three times daily as needed for muscle spasm. 8
• Refer for physical therapy, cognitive behavioral therapy, and consider interventional pain procedures given prior partial response to injections. 1

Step 5: Integrated Psychiatric Care

• The patient requires formal psychiatric evaluation and treatment, not just PCP management of anxiety. 1, 6
• Screen for depression using PHQ-9; scores ≥10 require psychiatric follow-up (88% sensitivity and specificity for major depression). 6
• Address the two-question depression screen: "During the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless?" and "During the past 2 weeks have you been bothered by little interest or pleasure in doing things?" 6

If Opioids Must Be Continued (Only if OUD is Ruled Out)

Strict Conditions for Continuation

• Opioid therapy should only continue if there is clinically meaningful improvement in pain AND function that outweighs risks to patient safety. 1
• With a PEG score of 8.3/10 (indicating severe interference with enjoyment and activity), current therapy is clearly failing to meet this standard. 1
• The patient reports 10/10 pain despite opioids, suggesting either inadequate dosing, opioid-induced hyperalgesia, or that opioids are not the appropriate treatment. 1

Modified Prescribing Protocol

• Prescribe only a 1-week supply (not monthly) until the UDS discrepancy is resolved and consistent adherence is demonstrated. 1
• Require witnessed UDS at each visit, not just "ordered" tests. 1
• Implement pill counts at random intervals. 5, 9
• Review PDMP data at every encounter, not just monthly. 1
• Provide naloxone and train patient/family on overdose recognition and response (already done, continue). 1

Dose Optimization if Continuing

• If opioids are deemed necessary, use scheduled around-the-clock dosing rather than PRN to prevent pain recurrence and reduce clock-watching behavior. 1, 8
• Consider converting to extended-release formulation only after achieving stable control with immediate-release opioids, though this is contraindicated in high-risk patients. 1, 8
• Avoid increasing above 50 MME/day given the high-risk profile; carefully justify any increase with documented functional improvement. 1

Critical Pitfalls to Avoid

Do Not Confuse Pseudoaddiction with Addiction

• Pseudoaddiction (drug-seeking due to undertreated pain) resolves when adequate analgesia is provided. 5, 9
• True addiction persists despite adequate pain control and is characterized by continued use despite harm. 5, 9
• This patient's negative UDS and maximum pain scores despite opioids suggest true addiction, not pseudoaddiction. 2, 9

Do Not Continue Opioids Without Functional Improvement

• The patient has work restrictions and PEG score of 8.3/10, indicating opioids are not improving function. 1
• Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. 1

Do Not Ignore the Psychiatric Comorbidity

• Patients with untreated depression and anxiety are twice as likely to transition to long-term high-dose opioid use and have higher rates of opioid use disorder. 2, 3
• Integrated psychiatric treatment is not optional—it is essential for successful pain management. 1, 6

Do Not Prescribe Benzodiazepines Concurrently

• Avoid prescribing opioids and benzodiazepines together due to increased overdose risk. 1
• If the patient's anxiety requires benzodiazepines, this is an additional reason to transition to buprenorphine rather than continuing oxycodone. 1

Documentation Requirements

• Document the negative UDS, the patient's explanation, and your clinical reasoning for any prescribing decisions. 1
• Document specific functional goals (return to work without restrictions, PEG score <4) and timeline for reassessment. 1
• Document discussion of risks including addiction, overdose, and the plan for tapering if goals are not met. 1
• Document PDMP review findings at each encounter. 1