1. Case Study 2 Clinical Case Conference May 30, 2014

2. Multidisciplinary Case Review Physical Therapist/OT Primary care physician Medical Assistants Social Worker Pharmacist Behaviorist Nurse

3. Case MD, 56 yo female, changing insurance – establishing with new pcp 9 years of low back pain 6 years of “total body” pain Methadone 90 mg three times daily hydrocodone/acetaminophen 5/325mg as needed – up to 6 tabs daily Pain Diagnosis : chronic pain syndrome, fibromyalgia Other Medical history: Type II diabetes, hyperlipidemia, fatty liver disease, obesity, remote tobacco history, depression, insomnia

4. Case – More History Immigrated from Cuba in 1997 where she was a lawyer – spanish speaking only In US worked at Goodwill sorting clothes Lived with alcoholic husband and 2 children Husband left soon after arriving and currently only one child living with her Injured back at Goodwill in 1998 and some time after that was declared disabled Brought Mother over in 2002

5. Exam/Data Obese female appearing stated age No acute distress, depressed affect Tender almost everywhere Right upper quadrant (RUQ) exquisitely tender Rest of exam relatively unremarkable Hemoglobin A1c 8.3, Creatinine 0.9, glucose 214, ALT 66 RUQ ultrasound from 1 year ago normal

6. How is she doing? Safety – MED dose Current function – PDI Psychosocial risk – PHQ – 9 – sTarT score Treatment Plan Care Assessment and Plan Creation

7. Medication Safety Opioid conversion to Morphine Equivalent Dose (MED) Hydrocodone 1 mg = morphine 1 mg Methadone: morphine chronic dosing 0-99 mg: 4:1 100-299 mg: 8:1 300-499 mg: 12:1 500-999 mg: 15:1 >1000 mg: 20:1 Do not use for backward conversion from morphine to methadone ! Our patientDosingTotal daily doseconversionMED Methadone90 mg three times daily 270 mg82160 mg Hydrocodone5 mg, six tablets daily 30 mg1 Total morphine equivalent dose MED =2190 mg

8. CON sortium to S tudy O pioid R isks and T rends Group Health + KP Northern CA For > 100 mg HR 8.87 (3.99 – 19.72) for all overdose events

9. Pain Disability Index 1.Family/Home Responsibilities: includes chores around the house (e.g. yard work) and errands for other family members (e.g. driving the children to school) No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability 2.Recreation: includes hobbies, sports, and other similar leisure time activities. No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability 3. Social Activity: participation in activities with friends including parties, theater, concerts, dining out, and other social functions. No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability 4. Occupation: includes activities that are related to one’s job. No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability 5. Sexual Behavior: refers to the frequency and quality of one’s sex life. No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability 6. Self Care: activities of personal and independent daily living (e.g. bathing, dressing) No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability 7.Life-Support Activities: basic life supporting behaviors such as eating, sleeping and toileting. No Disability 0__. 1__. 2__. 3__. 4__. 5__. 6__. 7 __. 8__. 9__. 10__. Worst Disability

10. PHQ-9 Over last 2 weeks how often have you been bothered by the following problems Not at allSeveral days> than half the days Nearly every day 1. Little interest or pleasure in doing things 0123 2. Feeling down, depressed or hopeless0123 3. Trouble falling or staying asleep, or sleeping too much 0123 4. Feeling tired or having little energy0123 5. Poor appetite or overeating0123 6. Feeling bad about yourself, that you are a failure and have let yourself or your family down 0123 7. Trouble concentrating on things, like television or reading 0123 8. Moving so slowly that other people have noticed – or being fidgety 0123 9. Thoughts you would be better off dead, or of hurting yourself 0123 Totals = 180 +6 +12 +

11. The START Generic Condition Screening Tool Thinking about the last 2 weeks tick your response to the following questions: DisagreeAgree 01 1 It’s really not safe for a person with a condition like mine to be physically active □□ 2 Worrying thoughts have been going through my mind a lot of the time in the last 2 weeks □□ 3 I feel that my problem in terrible and that it’s never going to get any better □□ 4 In general in the last 2 weeks, I have not enjoyed all the things I used to enjoy □□ Not at allSlightlyModeratelyVery muchExtremely □□□□□ 00011 5.Overall, how bothersome has your condition been in the last 2 weeks? Score______________ © Keele University 01/08/07 Funded by Arthritis Research UK

12. Creating a Treatment Plan Strengthen therapeutic alliance to the team Promote Safety – Opioid dosing – Material risk notification – Assessing for adverse effects Improve function – Educate about pain – Teach physiologic quieting skills – Pacing/ return to activity Decrease psychosocial risk – Recognize addiction and diversion