Case Studies - Michigan Academy of Physician Assistants

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Opioid Case Studies:
Putting Theory into Practice
David A. Cooke, MD, FACP
University of Michigan Health System
Departments of Internal Medicine and Anesthesia
Dr. Cooke has no financial
interests relevant to this
presentation. He has no
relationships to the makers of any
drugs discussed in his talks.
Many thanks to Dr. Daniel Berland
for his assistance and material
contributed to this presentation
Case 1
45 y/o man new to you, his former doc, Dr.
Feelgood, recently “left practice” and he will
soon need refills. History of fairly good health,
but chronic headaches, neck pain and spasms 5
years after a MVA. No hx surgery or PT.
Pain managed well on meds. He works parttime, smokes cigarettes.
Asking for Soma 350 mg – 1 TID, OxyContin
80 mg BID and Vicodin 5/500 – 2 QID.
Exam – NAD, friendly, non-specific exam.
What would you do for him
at this first visit?
A) Prescribe the medications so that he doesn’t go
through withdrawal.
B) Prescribe the OxyContin, but not Soma.
C) I would tell him “I don’t kiss on the first date.”
D) I would rotate his opioids to methadone.
What would you do for him
at this first visit?
A) Prescribe the medications so that he doesn’t go
through withdrawal.
B) Prescribe the OxyContin, but not Soma.
C) I would tell him “I don’t kiss on the first date.”
D) I would rotate his opioids to methadone.
Before that first kiss:
1)
2)
3)
4)
Check MAPS.
Check urine toxicology.
Check records.
Establish use agreement and
expectations.
Current Regimen:
• Soma 350 mg – 1 TID
• OxyContin 80 mg BID
• Vicodin 5/500 – 2 QID
Which of the following is true?
• A) Soma is functionally a barbiturate, and is
commonly abused.
• B) Soma has been proven effective for
treatment of ACUTE back pain.
• C) Soma has been proven effective for
treatment of CHRONIC back pain.
• D) B and C
Which of the following is true?
• A) Soma is functionally a barbiturate, and is
commonly abused.
• B) Soma has been proven effective for
treatment of ACUTE back pain.
• C) Soma has been proven effective for
treatment of CHRONIC back pain.
• D) B and C
Current Regimen:
• Soma 350 mg – 1 TID
• OxyContin 80 mg BID
• Vicodin 5/500 – 2 QID
Which of the following are true?
• A) Oxycontin provides superior pain
control, relative to other long-acting opiates.
• B) Oxycontin is cost-effective relative to
other long-acting opiates
• C) Oxycontin is a preferred long-acting
opiate per the UM Chronic Pain guideline
• D) B and C
• E) None of the above
Which of the following are true?
• A) Oxycontin provides superior pain
control, relative to other long-acting opiates.
• B) Oxycontin is cost-effective relative to
other long-acting opiates
• C) Oxycontin is a preferred long-acting
opiate per the UM Chronic Pain guideline
• D) B and C
• E) None of the above
Monthly cost of opiates
•
•
•
•
Morphine ER 60 mg BID – $51.83
Fentanyl ER 50 mEq/hr – $295.58
Methadone 5 mg TID – $13.58
Oxycontin 40 mg BID – $501.11
Drug prices 3/2013 at UMMC pharmacies
What is the street value for the monthly
supply of his OC 80 mg #60, Vic 5 #120 ?
A)
B)
C)
D)
$ 240
$ 900
$ 1,800
$ 3,400
What is the street value for the monthly
supply of his OC 80 mg #60, Vic 5 #120 ?
A)
B)
C)
D)
$ 240
$ 900
$ 1,800
$ 3,400
Current Regimen:
• Soma 350 mg – 1 TID
• OxyContin 80 mg BID
• Vicodin 5/500 – 2 QID
“Breakthrough Pain” in Chronic Pain
• A) is common, and patients should have
PRN doses of short-acting opiates
• B) is indicative of medication abuse
• C) may not exist
• D) should not require more than 5-10 PRN
doses per month
• E) C and D
“Breakthrough Pain” in Chronic Pain
• A) is common, and patients should have
PRN doses of short-acting opiates
• B) is indicative of medication abuse
• C) may not exist
• D) should not require more than 5-10 PRN
doses per month
• E) C and D
Before you commit:
•
•
•
•
•
Is he really benefitting from the meds?
Level of function?
Any evidence of medication toxicity?
Why no non-medication therapies?
Psychological issues?
Next Steps?
• Stop Soma
• Consolidate opiates; don’t prescribe
scheduled Oxycontin + Vicodin
• Enroll in PT
• Slow medication taper; MAXIMUM of 120
mg/day morphine equivalent
• Continue to monitor frequently
Case 2
• 44 y/o M with a history of low back pain
radiating to left leg, present since motorbike
injury at age 24.
• On opiates for approximately 20 years; now
taking methadone 60 mg QID.
• PMH significant for depression, anxiety, and
substance abuse; denies current drug use.
• Unemployed, lives with parents. No hobbies,
volunteering, or social activities.
Case 2 Continued
• States at visit, “I feel like my body is falling
apart. I hurt all over.” Pain is 6/10 at best,
10/10 at worse, 8/10 most of the time.
• Exam: Appears tearful and depressed.
Moves slowly. Diffusely tender to
palpation over lower back and left leg.
• MAPS shows no other prescribers
• Urine tox shows prescribed medications
What is the strongest indication to
change his regimen?
A) Total daily methadone dose of 240 mg/day
B) 8/10 pain most of the time
C) Prior history of drug abuse
D) Signs of depression
E) Low level of function
What is the strongest indication to
change his regimen?
A) Total daily methadone dose of 240 mg/day
B) 8/10 pain most of the time
C) Prior history of drug abuse
D) Signs of depression
E) Low level of function
Benefits must outweigh risks!
• Patient is on a massive dose of methadone;
maximum UM recommended dose 40
mg/day!
• Diffuse pain suggests opiate-induced
hyperalgesia
• Despite extraordinary opiate doses, patient
is almost completely nonfunctional.
Ok, but now what?
• Have an honest talk with the patient about
risk and benefits from treatment
• Be clear that intent is not punitive
• Plan a gradual taper, with frequent followup
• Set targets for increasing activities and
socialization.
• Mental health interventions
Case 3
• 48 y/o F with chronic low back pain x 15
years following laminectomy, and
fibromyalgia x 3 years, on methadone 10
mg TID, complains of worsening pain in
back, as well as aching in arms, legs, and all
of her joints. Symptoms worsening
gradually over the past year. No fevers,
sweats, or weight loss.
• Exam shows diffuse lumbar tenderness to
palpation, tenderness of muscles, and
classic fibromyalgia “trigger points”.
Normal strength, no muscle or joint
abnormalities beyond pain, and no objective
arthritis.
• Complete rheumatologic workup including
ANA, RF, ESR, CRP, TSH, and CK are
entirely normal.
At this point, which is most likely to improve
this patient’s pain?
A) Increase methadone dose
B) Decrease methadone dose
C) Start duloxetine
D) Start nortriptyline
E) Start gabapentin
At this point, which is most likely to improve
this patient’s pain?
A) Increase methadone dose
B) Decrease methadone dose
C) Start duloxetine
D) Start nortriptyline
E) Start gabapentin
Opioid-Induced Hyperalgesia (OIH):
• Common and under-recognized long term
complication of opioid use
• Mechanisms unclear
• Risk increases with dose and duration
• May be confused with tolerance
• May be focal, or can resemble fibromyalgia;
ask whether on opioids at time of fibro dx
Suspect OIH if:
• Worsening pain complaints in absence of
change in underlying disease
• Fibromyalgia diagnosis or symptoms that
develop after start of opioid therapy
• High dose opioids
• Long duration of opioid use
• Poor pain control on opioid therapy
• Physical evidence of hyperalgesia
Management:
• Taper or discontinue opioids
• Consider switching to methadone
• Consider switching to buprenorphine
Take Home Points
•
•
•
•
•
•
•
Don’t kiss on the first date
Avoid sedatives in chronic pain
Avoid medication duplication
Learn opioid equivalents
Limit dosages to <120 MED
Assess functional benefits
Recognize when opioids fail
Useful Reading
• UM PAIN / OPIOID GUIDELINE
med.umich.edu > For Health
Professionals > Clinical Guidelines
• WA INTERAGENY GUIDELINE on Opioid
Dosing for Chronic Non-Cancer Pain
http://www.bt.cdc.gov/coca/pdf/OpioidG
dline%5B1%5D.pdf or “Google” it
• A COMPREHENSIVE REVIEW OF
OPIOID-INDUCED HYPERALGESIA. Lee
et al., Pain Physician 14:145-161 (2011).

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