The results of the physical examination of the patient suggest that the reason for emergency department presentation is renal/uretric colic, which is “the clinical syndrome of acute flank pain with a cyclical intensity which may radiate to the groin” (Dalziel & Noble 2012, p. 2). Patrick describes his pain as ‘throbbing’ and reports that it radiates to his groin. Moreover, the positive costovertebral angle tenderness (CVAT) test on the right side also confirms the initial diagnosis. Another sign of renal colic is the presence of non-visible haematuria, which is associated with approximately 80 percent of patients who have urinary tract stone formations (Manjunath, Skinner, & Probert, 2013).
The results of imaging allow making a definitive diagnosis—renal colic—that is necessary for the development of management plan. Taking into consideration the fact that the calculus is smooth and round, it is most likely will pass within several days to six weeks (Manjunath et al., 2013). Therefore, instead of prescribing medical expulsive therapy, the patient should be advised to increase the level of their fluid intake, in order to accelerate the process of stone passage (Bultitude & Rees, 2012). Two liters of oral fluid intake will help to ensure sufficient hydration (Bultitude & Rees, 2012).
In terms of analgesia, Patrick should be prescribed nonsteroidal anti-inflammatory drugs (NSAIDs), which are known for a substantial reduction in pain scores, and opiates (Bultitude & Rees, 2012). If after several weeks, the patient continues to come back for a new dose of pain medication, it is necessary to consider whether, he requires medical expulsive therapy or urgent surgical intervention. However, it is also possible that Patrick no longer has an underlying reason for using pain medication, and shows signs of prescription drug abuse or even mild opioid addiction. The patients who receive opioid analgesic pharmacotherapy are likely to develop a dependency on prescription drugs, which is exacerbated by their ready accessibility and euphorigenic effects (Garland, Froeliger, Zeidan, Partin, & Howard, 2013).
The nurse practitioner (NP) should pay close attention to signs of prescription drug abuse. The most common signs include but are not limited to failure to fulfill social, professional, and familial obligations, physical symptoms of dependence such as the development of drug tolerance and signs of withdrawal (Garland et al., 2013).
Moreover, the patient may show “an inability to reduce or stop taking opioids”, a desire to “spend substantial amounts of time using, obtaining, recovering, or thinking about opioids” (Garland et al., 2013, p. 2598), and persistence on using drugs despite interpersonal problems caused by them. Other signs of prescription drug abuse are attempts to sell medication. Addictive tendencies are also revealed by unauthorized dose escalation; however, this sign is not necessarily an indicator of drug abuse and has to be treated judiciously by health care professionals.
According to the CDC guideline for prescribing opioids, 1 out of 5 patients with pain-related diagnoses is prescribed some form of opioid medication (CDC, 2016). CDC recommends that health care providers should establish drug discontinuations goals with patients, in order to avoid addictive tendencies. Another recommendation for dealing with this case is the discussion of risks and realistic benefits of pain medication with patients. CDC also suggests prescribing the lowest effective dosage in order to avoid prescription drug abuse (CDC, 2016). A liberal drug dose escalation strategy might result in tolerance development.
References
Bultitude, M., & Rees, J. (2012). Management of renal colic. British Medical Journal, 345(1), 112-117.
CDC. (2016). CDC guidelines for prescribing opioids for chronic pain—United States, 2016. Web.
Dalziel, J.P., & Noble, V. E. (2012). Bedside ultrasound and the assessment of renal colic: A review. Emergency Medical Journal, 22(1), 2-6.
Garland, E., Froeliger, B., Zeidan, F., Partin, K., & Howard, M. (2013). The downward spiral of chronic pain, prescription opioid misuse, and addiction: Cognitive, affective, and neuropsychopharmacologic pathways. Neuroscience & Biobehavioral Reviews, 37(10), 2597-2607.
Manjunath, A., Skinner, R., Probert, J. (2013). Assessment and management of renal colic. British Medical Journal, 346(1), 985-986.