Session 5 rieb challenging cases

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

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

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)

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?”

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

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

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

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+ ?

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

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

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

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

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

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

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

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?

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

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

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?

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

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

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

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?

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

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

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.)

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?

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?

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

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?

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

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?

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.

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?

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

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

Mr. X, cont’d
Medications
 Salbutamol 2 puffs prn
 Topiramate 25 mg q6h (for cluster h/a)
 Buproprion 150 mg bid (for mood)
 Diazepam 10 mg 1-2 hs prn (for sleep)
 Meperidine 50 mg 2 q4h (tapered to 1 q6h)
 Tylenol #4 2 q4h prn (tapered to 1 q6h)w/d

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)

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

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

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

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

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

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

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?

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?

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!

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

Session 5 rieb challenging cases

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Session 5 rieb challenging cases