A 36-year-old single man who works in an office arrives at your office to establish care. He has a 3-year history of low back pain and is requesting a refill of medications. He had to change health care providers due to a change of job and insurance. The pain started 3 years ago with a motor vehicle accident in which he broke ribs and developed disabling low back pain. The patient has been on naproxen and oxycodone regularly since then. He also takes cyclobenzaprine at night as needed for sleep and muscle relaxation. He brings old medical records, which include a report of magnetic resonance imaging (MRI) of the lumbar spine without noted pathology, a copy of a pain contract, and a problem list that shows a history of tobacco use disorder and a family history of alcohol use disorder. His previous physician had recommended a referral to chronic pain management due to worsening pain and increasing requests for oxycodone. On intake, the patient completed a screening, brief intervention, referral for treatment (SBIRT) evaluation, showing a nine-question Patient Health Questionnaire (PHQ9) score of 15 (indicating moderate-to-severe depression) and ASSIST (Alcohol, Smoking, Substance Involvement Screening Test) score of 32 for use of prescription opiates obtained from friends. He states he finds himself looking forward to taking the oxycodone and doubling his dose more often recently. He admits that he was given the option of leaving or being fired from his previous job due to sleepiness at work and poor performance. The Prescription Monitoring Program showed increasing urgent care visits with prescriptions for opiates in the past year. On reviewing the SBIRT screen results with the patient, he admits that he feels out of control and that he tried to cut back on his oxycodone recently but felt empty, isolated, and unable to sleep without the medication. He would like to stop using the medication but does not know how.
1: How do you address the increasing desire for opioids?
2: How can you address his depression?
3: How can you address his chronic pain?
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