1. www.pspbc.ca Clinical Case Studies Developed by Dr. David Hunt

2. 2 Case of Reverend R.G.

3. 3  Have You ever Felt Uncomfortable or Uneasy When a Patient with Severe Chronic Pain Requests Increasingly High Doses of an Opioid?  Yes…  No.. Opiates, Addiction And Chronic Pain

4. 4  Can you explain why you feel uncomfortable?

5. 5 I am uncomfortable because: 1.I am never sure if the patient really has pain as bad as they claim. 2.I have no way of knowing if the opioids are actually relieving the pain…is “taking the edge off” enough to justify the doses? 3.I am worried the patient is abusing or misusing them. 4.I am worried about a College Review. 5.I do not generally worry about any of these potential problems. Opiates, Addiction And Chronic Pain

6. LEARNING OBJECTIVES Using Case Studies Discuss Issues Around Opiates, Addiction, and Chronic Pain When working with CPP, you will be able to:  Describe Opioid misuse/diversion  List assessment tools that may be useful (10 available)  Explain the importance of a opioid management strategy  Develop an Action Plan for treatment

7. 7  48, Married  Failed Back Surgery Syndrome  With Right Sciatica Post- Op. Scarring  Minister ½ Time  Stable Medication Dose  Low ORT Score Case of Reverend R.G.

8. 8 Medications:  HM Contin 9 mgm q8h  HMIR. 2-4mgm q6-8h PRN  ( average 12mgm / 24hrs )  Gabapentin 900mgm q8h  Nortryptaline 40 mgm qhs  Celexa 20 mg O.D. Case of Reverend R.G. cont’d

9. 9  Gentle Exercise Program 20-30mins – 5/7Days  Denies Significant Mood or Sleep Problems  No Nausea, Sedation, Sweating or Constipation  Recent Random Urine Test Negative for Drugs of Abuse Question: Any concerns? Case of Reverend R.G. cont’d

10. 10  Rev.R.G.Stopped all Hydromorphone 3 months Earlier  Continued to Refill Rx – “Just in Case of a Flareup”  Kept Remaining Drug in Bathroom Drawer  14 Year Son,Acting Out,Moody,Suddenly Failling at School,Seemed to have More Money… What would YOU Do? How would YOU Treat? Case of Reverend R.G. cont’d

11. 11  If the Patient is Misusing / Diverting, Don’t Expect to Always Catch on Right Away  No Matter how Smart We Are, We Can and Will be Fooled by a Professional Drug-Seeker  With Careful Observation, Careful Prescribing Practices and Careful Documentation Over Time, all Drug Misusers Will Eventually Slip Up Drug Misuse / Diversion