In a 78‑year‑old man with chronic right lower‑back radicular pain, hypothyroidism, stage 3b chronic kidney disease (estimated glomerular filtration rate ≈35 mL/min, creatinine 1.94 mg/dL), mildly elevated aspartate aminotransferase, and a positive urine amphetamine screen, should narcotic analgesics be prescribed?

Should Narcotics Be Prescribed in This Case?

No, narcotics should not be prescribed to this patient at this time due to the positive amphetamine screen, which represents a major red flag for substance use disorder and significantly increases the risk of opioid misuse, overdose, and death. 1

Primary Concerns That Preclude Narcotic Prescribing

Substance Use Disorder Risk

• The positive amphetamine screen indicates active substance use, which is an absolute contraindication to initiating opioid therapy in the outpatient setting according to pain management guidelines 1
• Patients with concurrent stimulant use have dramatically elevated risks of opioid-related adverse events, including overdose and death 1
• Guidelines explicitly recommend screening patients for risk of substance use disorders before commencing opioids, and this patient has already failed that screening 2

Severe Renal Impairment Complicates Opioid Selection

• With a GFR of 35 mL/min (Stage 3b CKD) and creatinine of 1.94 mg/dL, this patient has significant renal impairment that makes most commonly prescribed oral opioids dangerous 1, 2
• Morphine, codeine, hydrocodone, oxycodone, and tramadol should all be avoided in this patient due to accumulation of toxic metabolites that cause neurotoxicity, myoclonus, and seizures 1, 2, 3
• The only safe opioid options in this degree of renal impairment are fentanyl (transdermal or IV) and buprenorphine (transdermal), which require specialist consultation and careful monitoring 2, 4, 3

Recommended Management Algorithm

Step 1: Address the Substance Use Issue First

• Confront the positive amphetamine screen directly and document the patient's explanation 1
• Refer to addiction medicine or substance use disorder treatment before any consideration of opioids 1
• Consider urine drug screening for other substances of abuse 1

Step 2: Optimize Non-Opioid Pain Management

• Start scheduled acetaminophen 650-1000 mg three times daily, which has evidence for safely alleviating moderate musculoskeletal pain in elderly patients and is the safest first-line option 1
• Avoid NSAIDs entirely given the CKD (GFR 35), as they will exacerbate kidney disease, potentially cause acute kidney injury, and worsen hypertension 1
• Consider topical diclofenac for localized pain, which has a better safety profile than systemic NSAIDs 1

Step 3: Evaluate and Treat the Radicular Pain Specifically

• For radicular lower back pain, consider adjuvant medications such as gabapentin or pregabalin (with dose adjustment for renal function) or tricyclic antidepressants at low doses 1
• Refer to physical therapy and consider epidural steroid injections if conservative management fails 1
• The principles for managing radiculopathy are similar to nonspecific low back pain, emphasizing non-opioid approaches first 1

Step 4: Address the Hypothyroidism

• Ensure the patient's hypothyroidism is adequately treated, as thyroid dysfunction can worsen kidney function and hypothyroidism is associated with increased serum creatinine 5, 6, 7
• Thyroid hormone replacement therapy has been shown to significantly improve renal function in CKD patients with hypothyroidism 7

Critical Pitfalls to Avoid

• Do not prescribe commonly available oral opioids (hydrocodone, oxycodone, morphine, codeine, tramadol) in this patient—they will accumulate toxic metabolites and cause serious harm given the GFR of 35 1, 2, 3
• Do not ignore the positive amphetamine screen or rationalize it away—this represents active substance use that dramatically increases opioid-related mortality 1
• Do not assume the patient needs opioids for radicular pain—restoration of function can occur even in the presence of pain, and non-opioid approaches should be exhausted first 1
• Do not prescribe opioids without establishing firm, realistic expectations about pain goals and functional improvement, which cannot be done in the context of active substance use 1

If Opioids Were Ever Considered (Only After Substance Use Treatment)

• The only safe opioid options in Stage 3b CKD would be transdermal fentanyl or transdermal buprenorphine, which require initial titration with immediate-release formulations under specialist supervision 2, 4, 3
• Buprenorphine is designated as the single safest opioid for patients with advanced CKD, requiring no dose adjustment even in dialysis 2, 3
• Any opioid prescribing would require a patient-prescriber agreement, regular urine drug screening, and close monitoring for aberrant drug-related behaviors 1

In summary, this patient should receive scheduled acetaminophen, referral to addiction medicine, optimization of hypothyroidism treatment, and consideration of adjuvant medications for neuropathic pain—but absolutely no narcotic analgesics at this time.