Case Study 1 Ruben Halperin, MD MPH May 30, 2014

BG 56 year old male Active problem list HIV+ Bacterial pneumonia, twice in last 5 years Neuropathy – HIV? lipodystrophy COPD > 40 pack years of tobacco History of poly-substance abuse, clean since age 42 Orthostatic hypotension Hypogonadism Depression with anxiety and insomnia Hepatitis C Chronic lumbar pain with radiculopathy Arrives by wheelchair, flat affect, on oxygen Doctor appointments are only time he leaves house

Active Medication List - May 2011 ROXICODONE 5 MG TAB (OXYCODONE HCL) 1 -2 po q 4 hrs prn pain increasing by mg q 4 hours until adequate pain control is reached not to exceed 9 tablets daily METHADONE HCL 10 MG TAB (METHADONE HCL) Four tablets by mouth TID NEURONTIN 300 MG CAPS (GABAPENTIN) Three by mouth three times a day REGLAN 10 MG TAB (METOCLOPRAMIDE HCL) 1 tab at meals and bedtime FAMOTIDINE 40 MG TAB (PEPCID ) 1 tablet by mouth every morning ENSURE LIQ (NUTRITIONAL SUPPLEMENTS) 4 cans qd prn ANDRODERM 5 MG/24HR (TESTOSTERONE) Apply 2 patches to skin daily, PAXIL 40 MG TAB (PAROXETINE HCL) One by mouth once a day LORAZEPAM 1 MG TAB (LORAZEPAM) 1-2 tabs by mouth TID prn (Max 6/day) TRAZODONE HCL 100 MG TABS (TRAZODONE HCL) One by mouth qd ASPIRIN 81 MG EC TAB (ASPIRIN) FLOMAX 0.4 MG CP24 (TAMSULOSIN HCL) 1 by mouth daily FLORINEF 0.1 MG TABS (FLUDROCORTISONE ACETATE) PROCHLORPERAZINE MALEATE 10 MG TABS (PROCHLORPERAZINE MALEATE) 1 by mouth three times a day as needed nausea XANAX 1 MG TABS (ALPRAZOLAM) 1/2 - 1 by mouth twice a day as needed IMODIUM A-D 2 MG TABS (LOPERAMIDE HCL) 1 by mouth daily as needed PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE) ADVAIR DISKUS MCG/DOSE MISC (FLUTICASONE-SALMETEROL) * MARIJUANA per OAR (4)(b)

Opioid Risks/side - effects/complications Opioid induced ventilatory impairment Central sleep apnea Opioid endocrinopathy Narcotic bowel syndrome Opioid Induced Hyperalgesia

Step 1: June 2012 Address depression and anxiety –Add bupropion xl 150 mg daily –↓ paroxetine to 30 mg daily 2 weeks later –↑ bupropion xl to 300 mg daily –↓ paroxetine to 20 mg daily –First meeting with behaviorist

Step 2: July 2012 Mood and level of activation improved on bupropion Pain education – 2 classes Physical Therapy Started Pool therapy (patient was afraid of land based therapy By August he was paying for it himself so he could go 3 days/week Starts going to church for first time in 10 years Less social isolation Distraction from pain/suffering

Step 3: September 2012 Methadone ↓ by 5 mg/ week Week 0: 40 mg – 40 mg – 40 mg (120 mg) Week 1: 40 mg – 40 mg – 35 mg Week 2: 40 mg – 35 mg – 35 mg Week 3: 40 mg – 35 mg – 30 mg Week 4: 35 mg – 35 mg – 30 mg (100 mg) Week 5: 35 mg – 30 mg – 30 mg … At 30 mg tid he started feeling mentally clearer, and on his own, started cutting by 10 mg / week Still seeing behaviorist Still doing pool therapy

Step 3.5 September 2012 Lorazepam cut to 1 mg three times daily, then ↓ 0.5 mg every 2 weeks Week 0: 1 mg – 1 mg – 1 mg Week 2: 1 mg – 0.5 mg – 1 mg Week 4: 1 mg – 1 mg Week 6: 1 mg – 0.5 mg Week 8: 1 mg qd prn

Step 4: October 2012 Starts land based therapy, continues pool Still seeing behaviorist Stops Marijuana on his own after a discussion with the pastor at his church For the first time, arrives at appointment walking

Step 5: November/December 2012 Off Methadone Mid November Starts tapering oxycodone on his own, is off by late December Stops Lorazepam by later December Nausea improved so we stop metoclopramide, prochlorperazine, immodium Because BP is up, we stop fludricortisone and bp stays up

Active Medication List - January 2013 NEURONTIN 300 MG CAPS (GABAPENTIN) Three by mouth three times a day ENSURE LIQ (NUTRITIONAL SUPPLEMENTS) 4 cans qd prn ANDRODERM 5 MG/24HR (TESTOSTERONE) Apply 2 patches to dry skin daily, PAXIL 20 MG TAB (PAROXETINE HCL) One by mouth once a day BUPROPION XL 300MG TAB One by mouth once a day TRAZODONE HCL 100 MG TABS (TRAZODONE HCL) One by mouth once a day ASPIRIN 81 MG EC TAB (ASPIRIN) FLOMAX 0.4 MG CP24 (TAMSULOSIN HCL) 1 by mouth daily XANAX 1 MG TABS (ALPRAZOLAM) 1/2 - 1 by mouth twice a day as needed anxiety PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE) ADVAIR DISKUS MCG/DOSE MISC (FLUTICASONE- SALMETEROL)

Function January 2013: able to walk 20 – 30 blocks COPD has improved with increased activity If you ask him about pain, he admits he still has some pain Attending church regularly, they offer him, and he takes, a job doing janitorial work No longer uses wheelchair Loses some of his state benefits because he is making an income

Lessons? 1.High doses of opioids carry risk for adverse effects –often lead to loss of function –Require more medications to mitigate side effects 2.Patients can come off opioids, but there needs to be something else first –Mental health treatment –Pain education –Physical therapy, pacing, address fear of movement 3.Many patients want to come off opioids, but are afraid* of: a)Increased side effects b)Worsening pain c)Declining funtion 4.Set appropriate expectations –Withdrawal can temporarily increase pain