1.  A patient admitted to your ward is on methadone maintenance 120mg daily and had his normal dose earlier today  He was admitted after he stopped taking antibiotics to treat a wound and leg fracture caused by a car accident two weeks ago  He now has osteomyletis requiring IV antibiotics  He is in pain and keeps asking for the s/c morphine that he is ordered prn Pain management Case Study (1) Outline

2. 1.Does he require regular pain relief if he is on methadone? 2.If he was on buprenorphine (subutex/suboxone) maintenance would the pain management be the same, if not why? 3.You find he also drinks alcohol 15 standard drinks daily, will the morphine for pain relief cover any alcohol withdrawal, if not what is the management? Pain management Case Study (2) Questions – in small or large group(s)

3. 4.How will you manage his nursing care 5.Where could you find more information or help on how to manage this situation? Pain management Case Study (3)

4. 1.Yes, opiate dependent people, including those on methadone, need larger doses and more frequent opiate pain relief than those not dependent (see Guidelines Chapter 9.2 Altered Tolerance and effective pain management – Patients on methadone) 2.No, buprenorphine has a higher affinity to the receptor sites and therefore normal opiate pain relief may not work, even at high doses – specialist advice is needed here (see Guidelines Chapter 9.2 Altered Tolerance and effective pain management – Patients on buprenorphine) 3.No, but the morphine may delay or mask alcohol withdrawals – put the patient on an alcohol withdrawal scale and seek specialist advice. Diazepam may also need to be given (see Guidelines Chapter 9.1 Alcohol withdrawal) Pain Management Case Study (4) Brief guide to answers for the questions

5. 4.Good supportive/basic nursing care – inform & educate patient ongoing on pain relief options, involve him in decisions & options as much as possible, do not withhold any pain relief except for medical/clinical reasons, give pain relief as charted & advocate for more pain relief if indicated. Seek specialist advice as required refer to Guidelines 5.Local Drug & Alcohol services & NSW D&A Specialist Advisory Service 1800 023 687 24hr (refer to NSW Health Opiate Treatment Guidelines. www.health.nsw.gov.au/policies/gl/2006/GL2006_019.html) Pain Management Case Study (5) Brief guide to answers for the questions