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Challenging Cases: Treating Pain and Addiction
Launette Rieb, MD, MSc, CCFP, FCFP, dip. ABAMClinical Associate Professor, UBCDirector, St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship
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’dSocial 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
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’dPast 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