Opioid Case Studies: Putting Theory into Practice

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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. - PowerPoint PPT Presentation

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Opioid Case Studies: Putting Theory into PracticeDavid A. Cooke, MD, FACPUniversity of Michigan Health SystemDepartments of Internal Medicine and AnesthesiaDr. 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 presentationCase 145 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 part-time, 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 doesnt go through withdrawal.B)Prescribe the OxyContin, but not Soma.C)I would tell him I dont 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 doesnt go through withdrawal.B)Prescribe the OxyContin, but not Soma.C)I would tell him I dont kiss on the first date.D)I would rotate his opioids to methadone.Before that first kiss:

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 CWhich 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 CCurrent Regimen:Soma 350 mg 1 TID

OxyContin 80 mg BID

Vicodin 5/500 2 QIDWhich 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 opiatesC) Oxycontin is a preferred long-acting opiate per the UM Chronic Pain guidelineD) B and CE) None of the aboveWhich 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 opiatesC) Oxycontin is a preferred long-acting opiate per the UM Chronic Pain guidelineD) B and CE) None of the aboveMonthly cost of opiatesMorphine ER 60 mg BID $51.83Fentanyl ER 50 mEq/hr $295.58Methadone 5 mg TID $13.58Oxycontin 40 mg BID $501.11

Drug prices 3/2013 at UMMC pharmaciesWhat is the street value for the monthly supply of his OC 80 mg #60, Vic 5 #120 ?A)$ 240B)$ 900C)$ 1,800D) $ 3,400What is the street value for the monthly supply of his OC 80 mg #60, Vic 5 #120 ?A)$ 240B)$ 900C)$ 1,800D) $ 3,400Current Regimen:Soma 350 mg 1 TID

OxyContin 80 mg BID

Vicodin 5/500 2 QIDBreakthrough Pain in Chronic PainA) is common, and patients should have PRN doses of short-acting opiatesB) is indicative of medication abuseC) may not existD) should not require more than 5-10 PRN doses per monthE) C and DBreakthrough Pain in Chronic PainA) is common, and patients should have PRN doses of short-acting opiatesB) is indicative of medication abuseC) may not existD) should not require more than 5-10 PRN doses per monthE) C and DBefore 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 SomaConsolidate opiates; dont prescribe scheduled Oxycontin + VicodinEnroll in PTSlow medication taper; MAXIMUM of 120 mg/day morphine equivalentContinue to monitor frequentlyCase 244 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 ContinuedStates 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 prescribersUrine tox shows prescribed medicationsWhat is the strongest indication to change his regimen?A) Total daily methadone dose of 240 mg/dayB) 8/10 pain most of the timeC) Prior history of drug abuseD) Signs of depressionE) Low level of functionWhat is the strongest indication to change his regimen?A) Total daily methadone dose of 240 mg/dayB) 8/10 pain most of the timeC) Prior history of drug abuseD) Signs of depressionE) Low level of functionBenefits must outweigh risks!Patient is on a massive dose of methadone; maximum UM recommended dose 40 mg/day!Diffuse pain suggests opiate-induced hyperalgesiaDespite extraordinary opiate doses, patient is almost completely nonfunctional.Ok, but now what?Have an honest talk with the patient about risk and benefits from treatmentBe clear that intent is not punitivePlan a gradual taper, with frequent follow-upSet targets for increasing activities and socialization.Mental health interventionsCase 348 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 patients pain?

Increase methadone doseDecrease methadone doseStart duloxetineStart nortriptylineStart gabapentinAt this point, which is most likely to improve this patients pain?

Increase methadone doseDecrease methadone doseStart duloxetineStart nortriptylineStart gabapentinOpioid-Induced Hyperalgesia (OIH):

Common and under-recognized long term complication of opioid useMechanisms unclearRisk increases with dose and durationMay be confused with toleranceMay be focal, or can resemble fibromyalgia; ask whether on opioids at time of fibro dxSuspect OIH if:Worsening pain complaints in absence of change in underlying diseaseFibromyalgia diagnosis or symptoms that develop after start of opioid therapyHigh dose opioidsLong duration of opioid usePoor pain control on opioid therapyPhysical evidence of hyperalgesiaManagement:

Taper or discontinue opioidsConsider switching to methadoneConsider switching to buprenorphine

Take Home PointsDont kiss on the first dateAvoid sedatives in chronic painAvoid medication duplicationLearn opioid equivalentsLimit dosages to For Health Professionals > Clinical Guidelines

WA INTERAGENY GUIDELINE on Opioid Dosing for Chronic Non-Cancer Pain http://www.bt.cdc.gov/coca/pdf/OpioidGdline%5B1%5D.pdf or Google it

A Comprehensive Review of Opioid-Induced Hyperalgesia. Lee et al., Pain Physician 14:145-161 (2011).