Discussion Prompt

You are a new FNP in a restricted state and have your DEA license, and state furnishing for schedule II-V controlled substances. You are working at a busy family practice group, and you have a patient, ML, that is establishing care for the first time with your practice and comes to you with the following scenario:

• ML is a 54 y.o. Hispanic female with hx of chronic shoulder and back pain that began 10 years ago when she was in a boating accident.
• She lives in both US and Mexico, making regular visits across the border. Lately, she has stayed in the US due to Covid border crossing constraints, living with her daughter’s family.
• She had rotator cuff surgery in 2011 and reports to you that due to a long operation and poor positioning, she has suffered from not only pain, but also chronic numbness and tingling in her R shoulder.
• As “la abuela” (grandma), she is the primary caregiver of the children and homemaker for her family. Her pain is exacerbated with housework, and especially with the prolonged carrying of her grandchildren; one of which is 10 m.o.
• Currently, her med list is as follows
  • Losartan 50 mg BID for HTN
  • Gabapentin 300 mg po BID for pain
  • Atorvastatin 40 mg daily for cholesterol
  • Diazepam 5 mg po up to TID prn pain
  • Norco 5/325 mg – takes up to two, sometimes up to 4-5x a day, prn pain
• She is a smoker, only smokes outside the house, and drinks 2-3 cans of beer on the weekends, but more on family celebrations.
• She denies recreational drugs and denies past overdoses.
• She has recently moved to CA more permanently to stay to take care of children during Covid/school closures.
• She asks you to refill all her meds for 6 months, like her doctor in Mexico did, so she doesn’t have to make another co-pay and come back and see you so often. It’s hard for her to get an appointment, and with Covid, her daughter has to take off of work to watch the kids so that she can come to you by bus (since there is only one family car).
• Here VS are 135/75, 80, 97.5, 20 and PE unremarkable other than R shoulder exam with pain with ROM, but full ROM, no tenderness, otherwise normal, back exam including SLR are normal/neg 

Describe your approach with this patient. In your response, include the following:

• What concerns do you have about her current regimen, and what alternatives will you discuss and offer? What other screenings might you apply? What are your own ethical standards on this case that you might consider in addition to legal standards?
• Provide a sample of an appropriate pain contract that would suit this patient and address her specific safety concerns (cite it and attach the actual contract you found – you do not have to make your own – there are plenty online).
• Include your steps to ensure safe prescribing. Include the registry you will search prior to any prescribing; name the CA registry, and if you are in a different state, you should name that registry also.
• If you were to keep her current list, what are the laws surrounding refills and the amounts you are allowed to dispense with the schedule II and III medications in the state of CA? In your own state?
• Which medications on her list may you call into the pharmacy, and which would you need a written script or electronic order? What are some elements required to include on the prescription form (paper or electronic signature) for the scheduled medications?
• After you prescribe, how, when, and where would you (or your staff) go about making a report of your scheduled prescription in the state registry so that other prescribers and pharmacies could be aware?
• In restricted states, APRN prescribers must follow a standardized procedure or protocol for furnishing schedule II and III controlled substances with a patient-specific approach. Please outline the minimum required components of a protocol. You may outline this in bullet form. Alternatively, you may find an appropriate protocol, clinical guideline, or standardized procedure from a literature search and attach it in lieu of outlining your own protocol.