1. Case Presentations

2. Case 1: Lymphoma in remission
23 yo patient with hx of depression, suicide attempts, and T lymphoblastic lymphoma in remission on maintenance treatment.
She developed severe wide-spread joint pain during her treatment and was prescribed up to 10-12mg hydromorphone Q4 H PRN. She has been unable to taper her medication and frequently asks for early refills.
She is also needing stimulant medication to help with profound fatigue.
Her mother and her provider are worried about her.
What do you do?

3. Case 1: Her pain treatment is transferred to Internal Medicine
She is dissatisfied that she is now asked to do the following
Opioid agreement
Urine drug test
28 day refills
After lengthy discussions, she complies with taper and considers buprenorphine as an alternative
She continues to struggle with depression

4. Case 1: Opportunities Emphasize non-opioid pain management
Focus on functional gains/progress
Engage in mental health care
Consider limiting opioid dose*
Establish opioid risk assessment and explain risks
Establish opioid agreements
Carefully monitor prescription use
28 day prescriptions, eRx
Consider urine drug tests
Refer prior to problems developing

5. Use a Risk-Benefit Framework
NOT…
Is the patient good or bad?
Does the patient deserve opioids?
Should this patient be punished or rewarded?
Should I trust the patient?
Do the benefits of opioid treatment outweigh
the untoward effects and risks for this patient (or society)?
RATHER…
In terms of a viable framework, this all makes sense if we always think about issues around opioids as health-related issues. So, it’s not is the patient good or bad, or does the patient deserve to have opioids, whether we should reward them if they behave well and punish them if they might be aiming towards misuse.
We need to frame this instead as a risk/benefit assessment for an individual patient. So, if a patient has a history of substance misuse or mental health disorders that may make them more at risk, we are implementing these strategies in order to keep them safe. And when issues arise, we need to think of what might be driving them in terms of the patient’s health. So, these strategies are for the benefit of the individual patient and for the benefit of society or the public health.
Judge the opioid treatment –
NOT the patient
Nicolaidis C. Pain Med Jun;12(6):890-7.

6. Case
35 yo female with chronic daily migraine and diffuse myofascial pain who has been prescribed opioids for 5 years after the birth of her daughter. The patient has severe depression and anxiety, chronic nausea, history of adverse childhood experience (neglect as a child), and obesity. She is a stay at home mother to her 2 children, but frequently has to put the children in daycare because she can not care for them when she has severe migraines. She is also prescribed chronic high dose benzodiazepines by a psychiatrist.
The patient has a history of losing her opioid prescription, obtaining opioids from another provider, being allergic to most other pain medication options, missing appointments, and frequently asking for opioid dose increases.

7. Case: Thought Questions
Does this patient have pain?
Does this patient have an opioid use disorder?
What factors place this patient at risk for an opioid use disorder?
What can you do to help this patient?

8. DSM-V criteria Unable to fulfill major role obligations
Social or interpersonal problems due to use
Use in hazardous situations
Tolerance*
Withdrawal/physical dependence*
Taken in larger amounts or over longer period than wanted
Unsuccessful efforts to cut down or control use
Great deal of time spent to obtain substance
Important activities given up or reduced
Continued use despite harm (physical and psychological)
Craving
*If opioids are prescribed and taken as prescribed, these criterion do not apply.