Mr. X is a 48-year-old iron worker who was injured in 2002 and has experienced ongoing pain issues since. He takes various medications for pain, mood, sleep and headaches. He has a history of substance use issues including past heavy alcohol use and current problematic use of prescription opioids. His opioid medications have been tapered but he continues to report high levels of pain. His case presents complex challenges around adequately treating his pain while managing his risk of addiction relapse.
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More Related Content
Session 5 rieb challenging cases
1. Challenging Cases:
Treating Pain and Addiction
Launette Rieb, MD, MSc, CCFP, FCFP, dip. ABAM
Clinical Associate Professor, UBC
Director, St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship
FME & CPSBC 27th Annual Pain and Suffering Symposium
March 7-8, 2014, Vancouver, BC, Canada
2. Learning Objectives
Participate in group discussion of cases
Help generate a differential diagnosis
Gain ideas of management strategies for
patients with pain and addiction
Reflect on your own practice and identify
patients that may need a new approach
3. Mr. N.
28 yr old construction worker – work injury
Dx: Complex Regional Pain Syndrome
Right hand – all sign and symptom categories
Verbal and standardized screens negative for
substance use disorders – some low level
alcohol and marijuana use
UDS: Cocaine +, oxycodone + (prescribed)
4. Mr. N, cont’d
Broaching the topic:
“Your urine drug screen has come back.
Do you have any ideas about what it might
have shown?”
Rapport/honesty + things not on the UDS
“It has come back with cocaine. Some
people in pain use cocaine. Do you want to
tell me about your experience?”
5. Mr. N. cont’d
“If you are using cocaine I can help you get
treatment and help you with your pain”
Addiction history came spilling out
Years of struggle with alcohol and cocaine
– predating injury but worsened by it
Totally out of control now, frightened
By the end of the conversation – relieved
6. Mr. N. cont’d
Plan: Residential drug and alcohol Tx 103d
Returned drug and alcohol free, off opioids
Then a multidisciplinary pain management
program could begin
PT, OT, Psych, Kin, med management
Participated well
One binge drinking episode – re-stabilized
Good concurrent 12 step involvement
7. Mr. N. cont’d
Medications blister packed:
Gabapentin 1200 mg q8h
Amitriptyline 125 mg hs – with a plan to taper
Cymbalta 60 mg ii qam
Naproxen 500 q 12 h
Quetiapine 25 mg bid-tid prn
Employer supportive: RTW modified duties
Though in pain he felt he could deal with it
He felt the treatment he received saved his life
8. Mr. N. Reflections
What could have happened if I had not
done a UDS on assessment?
What would you do if he denied cocaine
use even once the sample was confirmed?
What other techniques do you use to
encourage patients to reveal their substance
use histories to you?
What would you offer if his USD was
oxycodone -, opioid+, and cocaine+ ?
9. Mr. D.
47 year old married at home father, degree
is psychology, no family history of SUD
Age 19: L4-5 discectomy for prolapse
Post-op give Tylenol #3
He mixed these with ETOH to get high
10 years later – recurrent disc – surgery
Initially successful then increasing low back
pain over the next year
10. Mr. D, con’t
GP managed
Tried different medications, low dose at 1st
Hydromorphone short acting up to 80 mg/d
Would run out early, would crush and smoke
Prozac 60 mg/d
Ativan 4 mg/d
Pain still unmanageable on above regime
Referred on
11. Mr. D., con’t
Multidisciplinary hospital based pain clinic
Medications altered, various medications combined
Opioids were increased over time to the level below:
Fentanyl Patch 150 mcg/h q2 d (prescribed q3d)
+/- fentanyl solution 100 mcg/2ml vile 3-5/d
Fentanyl film (Onsolis) 600 mcg bid = 1200 mcg/d
Tramadol (Ultram) 50 mg ii bid = 6 tabs/d = 300 mg/d
Methadone tablets 60 mg bid = 120 mg/d
Hydromorphone - short acting 80 mg/d (snorting)
Morphine equivalent dose = 1,830+ mg/d
12. Mr. D., con’t
Other medications
Fluoxetine 80 mg/d (adverse rxn - duloxetine)
Diazepam 2.5 mg bid (+still using lorazepam)
Sudafed 2 tabs/d
Caffeine pills and energy drinks
He still felt pain, otherwise felt “Great!”
Function: ran triathlons, others see sedation
Total cost to wife’s insurance = $3,000/wk
13. Mr. D., con’t
Voluntary admission to a medically
supervised residential treatment facility:
education, 12 step, group, 1:1, CBT, etc.
Methadone and fluoxetine same dose at 1st
Stopped tramadol on admission
Stopped all fentanyl after 2 d taper
Added quetiapine 25 mg q6h
No withdrawal seen
14. Mr. D., con’t
Tapered the methadone over 3 weeks to 5
mg tid
Dose held until in withdrawal
Switched to Butrans patch 10 mcg initially
– not quite enough
Then over to Suboxone titrated to 6 mg/d
where he has maintained for 8 months
15. Mr. D., followup
Now 9 months since admission to recovery
Current meds
Suboxone 6 mg/d
Prozac 60 mg/d and tapering
Seroquel 125 mg/d and tapering
Has attended 12 step daily, has a sponsor
No relapses or slips, despite divorcing
No more pain issues, GAF 95/100
16. Mr. D., Reflections
Primary pain disorder or substance use
disorder?
Opioid induced hyperalgesia?
How can the opioids besides methadone be
stopped abruptly without withdrawal?
How can Suboxone and 12 step combined
control both the pain and addiction issues?
17. Ms. J.
19 year old street entrenched female youth
Pierced, tattooed, black clothes torn
Presents asking for methadone
Past Medical History
Severe ankle sprain a year prior, air cast
Initial x-ray negative
Ongoing pain, ER visits – “drug seeking”
Friends helped out with pills then heroin
No mood issues, sleep broken
18. Ms. J., cont’d
Medications
Ibuprofen 400mg 1-2 prn
Acetaminophen ineffective
Substance Use History
Tobacco started age 12, currently 1ppd
Marijuana started age 13, currently 2-3 jnts/d
Alcohol started age 13, 2 beer/wk, rare binges
Heroin – started 6 months prior with smoked
heroin escalating to ¾ gm/d iv divided tid
19. Ms. J., cont’d
Social history
On the street since age 17
Father alcoholic, violent, she left home
Recent breakup with boyfriend
Has a dog which makes housing a challenge
Exam – bony tenderness right ankle
What are the next steps?
20. Ms. J., cont’d
Management
Converted to methadone 85 mg/d
Referred to community counselor for housing
X-ray, CT, bone scan – occult fracture and
low grade osteomyelitis
Antibiotics
Surgical intervention – internal fixation
Temporary oxycodone for several weeks
following surgery
21. Ms. J., cont’d
Management, cont’d
Physiotherapy
Tapered off methadone
Decreased tobacco and marijuana
Social follow-up
Grade 12 equivalent study and exam
Applied and accepted to be a youth counselor
22. Ms. J., Case Highlights
What can begin as pseudo-addiction
(seeking pain relief but labeled as drug
seeking) can become full blown addiction
People who fall outside the average (due to
class, race, sexual orientation, body
ornamentation, age, lifestyle, etc.) can be
misdiagnosed or not fully seen
Treat the underlying condition
Challenge yourself to see whole the person
23. Ms. J, Reflections
How would your management change if
her investigations had been negative?
What if she was in an abusive relationship
where she was being assaulted?
What if her pain was unbearable even on
methadone?
24. Mr. L.
44 year old man presented in 2004
Heroin 2 – 3 gm/d for many years
Detoxed in the past but craving > relapse
Hepatitis C positive
Mild to moderate OA knees
Converted to methadone 210 mg/d
Stable for 2 years, urine drug screens clear
25. Mr. L., cont’d
2006 he decides to sells condo and travel
Voluntary rapid taper from methadone
Relapses in Europe due to exposure
Returns and re-stabilized on methadone
Another rapid taper (10 mg/d) for travel
Getting some knee pain at end of taper
Declines NSAIDS, acetaminophen
26. Mr. L., cont’d
Oxycodone 5 mg bid controlled pain
Leaves for China
2008 re-appears after hospitalization for
endocarditis secondary to intravenous use
Attending a residential “detox”, given…
Methadone 100 mg/d (daily dispensed)
Oxycodone (IR) 20 mg iii tid = 180 mg/d
Diazepam 10 mg bid - tid prn (weekly disp.)
27. Mr. L., cont’d
Patient reports knee pain very high
He curtails walking, and is not attending
physiotherapy, nor swimming
He looks sedated in the office, but he
claims it is due to poor sleep from pain
What could be going on? Next steps?
28. Mr. L., cont’d
Changed to long acting oxycodone 80mg tid
Patient reports it doesn’t work – wants IR
Tapered off diazepam
Daily dispensed all medication, witnessed 1st
dose, upset at being “treated like a child”
Pain reported to be worse, less function
What next?
29. Mr. L., cont’d
Offered TCAs, NSAIDS, atypical anti-
psychotics, SNRIs, neuromodulators, etc.
All declined for various reasons, including HCV
Physiotherapy prescribed, pool pass, not used
Orthopaedic surgeon reviews – offers bilateral
knee replacements, patient declines
Hepatologist contacted
Ok to take acetaminophen up to 1500 mg/d
Ok to take NSAIDs like ibuprofen full strength
Patient declines
30. Mr. L., cont’d
Patient continues to buy benzodiazepines
off the street or get from other MDs
I write letters to the other MDs
Methadone increased slowly to 200 mg/d
Continued dramatic pain complaints
What next?
31. Mr. L., cont’d
Considering OIPS and OD risk…
Oxycodone tapered to elimination
(involuntary – not happy)
Methadone increased to 260 mg/d
Once completed…
Pt less sedated, reports lower pain, attends
physio with some positive results, goes to
UBC for continuing education classes
32. Mr. L., cont’d
Then he starts to report more pain
Pt has clear UDS so we can split his
methadone dose (q8h), makes no difference
Patient wants oxycodone and diazepam
He gets an advocate to protect his rights
Claims I refuse to treat his pain
What next?
33. Mr. L., cont’d
Pt. says he wants tapered off methadone
December 2009 the pharmacist calls to say
he saw Mr. L. hand his methadone to
another person who drank it.
Mr. L. called in for discussion – and he
says he hasn’t been taking his methadone –
he sometimes “shares” it with a friend.
Admits to selling oxycodone previously.
34. Mr. L., cont’d
All methadone prescribing stops and a
letter is given to him about why
He presents angry, threatening to report me
to CPSBC, shows me a letter to this effect
Care transferred to colleague (same clinic)
Letter written to Mr. L. outlining options
Soon colleague must discharge him too.
Observations or questions?
35. Mr. X
48 y.o. male iron worker
injured 2002
Fall, R knee: torn cartilage,
meniscus, ACL with OR
Knee gives way leading to other falls
Pain with any movement
Wakes at night moaning in pain
Not working, limited household chores
36. Mr. X, cont’d
Past Medical History
Low back injuries ++ ongoing pain, Tyl #4
# elbow, torn rot. cuff, # pelvis, # ribs, #leg
Asthma
Motorcycle accident killing 1st wife
Depressed mood, anxiety, abuse issues
Cluster headaches
38. Mr. X, cont’d
Substance Use History
Caffeine - 1 cup per d
Nicotine - 1ppd since age 15, stopped
along with his spouse 5 yrs ago
Marijuana - None (gets paranoid)
39. Mr. X, cont’d
Social drinking age 22-40s
Escalated at 24 when wife killed
Stopped briefly once spouse returned
Back up to scotch 26 oz per day with
tolerance, loss of control, compulsion,
preoccupation, personality changes, anxiety
only w/d symp. (spouse drinks wine)
Alcohol
40. Mr. X, cont’d
Tyl #4 for 7 yrs for back pain
After knee injury T#4 - 4 q4h
Morphine tablets initially, off now
Meperidine 50 mg “chewing them like candy”
Hiding pills from wife, running out early
One heroin use (guilt, biker stigma)
Opioids
41. Mr. X, cont’d
“Recreational use” from 20s-40s
“Problem” after 1st wife killed after a
divorce and post knee injury
2002-03: cocaine 1-2 gm IV every 1-2 d
Paranoid, $ problems, tolerance, loss of
control, depression, use despite
consequences. Stopped after wife left.
Cocaine
42. M. X, cont’d
Speed (amphetamines)
Used in his 20s to stay alert on long
motorcycle road trips.
Last use 20 yrs ago.
No other street drug or herbal remedy use
43. Mr. X, cont’d
Diagnosis
Chronic knee and low back pain
Substance dependence: alcohol, cocaine,
opioid, nicotine in remission
Depression in partial remission
Recommendations
At home taper and stop ETOH, family MD
informed, if problems then residential detox
In Pain Management Program (PMP) taper
meperidine, codeine and benzodiazepines
44. Mr. X – Follow Up
Self tapered ETOH, diazepam &
meperidine at home prior to PMP
During PMP he fell and # ribs, wrenched
knee again, delays in taper of codeine
Almost off codeine with much better
function and lowered pain by end of PMP
Sharing international award winning poetry
He and spouse happy with achievements
45. Mr. X - Reflections
Opioid induced pain sensitivity?
Primary mood induced pain sensitivity?
Alcohol induced mood changes…?
Or primarily substance use disorder driven
on intake by alcohol dependence, which
once treated regulated all other responses.
Your thoughts?
46. Your Cases
Do you have any examples of a patient
with past dependence that was at high risk
of relapse until the pain got under control?
Other cases from your practice you’d like
the group’s input on?
47. Summary
Develop a differential diagnosis
Special considerations need to be applied to those
with present or past addiction
Analgesic control is needed to prevent relapse to
substance dependence in those with past addiction
Substance dependence can develop when exposed to
severe untreated pain – see the whole person
Active substance dependence needs addressing in order
to then get pain under control
You can be compassionate and set clear
parameters for care to benefit all!
49. Resources
Butler D and Moseley G L. Explain Pain.
Noigroup Publications, Adelaide, Australia
(2003)
Moseley G L. Painful Yarns. Dancing
Giraffe Press (2007)
See references in my plenary talk