The patient is exhibiting drug-seeking behavior: demanding a specific type of medication, becoming upset when alternatives are suggested, and lastly, a PE that does not match the symptoms. Once the suspicion has been identified, the first thing we have to do is gather as much information/PMHx there is on the patient EMR. which includes a Med Reconciliation.
Obtaining serum toxicology and referring the patient to a drug addiction program is inappropriate because we are assuming they are addicts.
An MRI on the spine without any positives on PE is unjustifiable, so it might not get approved by the patient's insurance; plus we should avoid unnecessary procedures.
Lastly, prescribing a limited course of narcotics is not the first thing we should do, although sometimes it what is ultimately done in these cases. However, you must take necessary precautions like using different color papers, ink, very specific instructions, and using formats that are not easily modifiable by the patient.