Download a 66-year-old man with opioid analgesia

CASE STUDY
A 66-YEAR-OLD MAN WITH OPIOID ANALGESIA
—
Kathryn Hahn, PharmD, DAAPM
The patient was a healthy 66-year-old man who
fell from a ladder, injuring his hip and lower back.
Pain from his injuries significantly impaired his ability to function normally, making it difficult for him to
walk or even to sit comfortably. He attempted to
relieve the pain using over-the-counter medications,
escalating over the following 2 days to 5 200-mg
ibuprofen tablets at a time. He went to his pharmacist and asked for “something stronger” for his pain,
but added that he “doesn't want to take narcotics”
because they are potentially addicting. The pharmacist conducted a brief pain assessment that
included the location of the pain, when the pain
started, how often the pain occurred, how the pain
felt, and changes in intensity of the pain over time.
On a scale of 1 to 10, the patient rated his current
pain intensity as 7, with a maximum of 8 and a minimum of 6. The pharmacist recommended that the
patient should see his primary care physician as
soon as possible. The pharmacist also advised the
patient that an opioid may be required to produce
adequate pain relief, and reassured the patient that
the risk of addiction for the treatment of acute pain
is very low.
oid prescription. After researching his medications at
home using the Internet, he did not want to take the
TCA because he “isn't depressed and doesn’t need an
antidepressant.” The pharmacist explained that the tricyclic has not been prescribed for depression, but to
increase the efficacy of the pain reliever. By combining
an opioid, a nonopioid analgesic (in this case, acetaminophen), and a TCA, the patient’s physician plans
to suppress pain by several different mechanisms,
which should result in greater pain relief with less risk
of adverse effects.
The pharmacist reviewed the potential adverse
effects of treatment with the patient, and noted that
opioid-induced sedation and nausea usually decline
soon after beginning treatment. The patient was
instructed to reduce the frequency of dosing during
the first 1 to 2 days if these effects were severe. The
pharmacist also emphasized that the opioid is likely to
cause constipation, and recommended a bowel regimen consisting of a combination tablet containing
senna (a natural vegetable laxative) and docusate sodium (a stool softener), at a dose of 8.6 mg/50 mg taken
1 to 2 times daily depending on need. The patient was
reminded to drink several 8-ounce glasses of water per
day while using this product.
TREATMENT PLAN
The patient’s primary care physician prescribed
oxycodone with acetaminophen 5 mg/325 mg 1 every
6 hours as needed, and a tricyclic antidepressant
(TCA) amitriptyline 25 mg once every bedtime (most
commonly seen TCA for pain) as an adjunctive agent.
At the pharmacy, the patient asked to fill only the opi-
OUTCOME AND FOLLOW-UP
The patient attained generally good pain relief during the first 2 hours after each oxycodone/acetaminophen dose, but he experienced increasing pain at
the end of each dose. His wife noticed increasing irritability and agitation while he waited for his next dose
of medication. Both the patient and his wife became
concerned that he was becoming addicted to his pain
medication, and he scheduled another appointment
with his physician. His physician assured him that his
behavior was a normal response to pain that is only
BACKGROUND
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CASE STUDY
partially treated, and was not a sign of addiction. The
patient’s oxycodone/acetaminophen dose was
increased to 5 mg/325 mg, 1 to 2 tablets every 4 hours
as needed for pain, in an attempt to eliminate end-ofdose failure (increased pain), while maintaining a dose
that is below the 4 g per day maximum recommended
for daily acetaminophen usage.
Two weeks later, the patient returned to the pharmacy to refill his prescription. His pharmacist performed a brief assessment of the patient’s pain relief
and adverse effects with his new treatment regimen.
This assessment includes both objective outcomes (eg,
hours able to sleep without awakening and number of
episodes of emesis) and subjective outcomes (eg,
patient pain rating and complaints of nausea or sleepiness). The patient achieved good pain relief and
reported few side effects. He was no longer troubled by
nausea, vomiting, or dizziness, although he still experienced some mild sedation shortly after each dose. He
experienced significant constipation for a few days
when he discontinued his bowel regimen, but his constipation resolved when he resumed treatment. His hip
and back pain gradually improved over the next 2
weeks, and he was able to attain adequate pain relief
with ibuprofen. His opioid dose was tapered (decreasing by 1–2 tablets each day) to prevent withdrawal
symptoms, although this risk is generally low in
patients using short-acting opioids for acute pain.
After another week, his pain resolved completely.
DISCUSSION
Many individuals with pain first discuss their
symptoms with a pharmacist. All patients should
undergo a brief, focused assessment of the location,
intensity, and character of the pain. Several rating
scales and interviewing systems have been developed
to assess pain, but the following questions should generally be included in all pain assessments:
• Where is the pain?
• When did the pain start?
• How often does the pain occur?
• What does the pain feel like?
• Has the pain intensity changed?
• What makes the pain better or worse?
• How does the pain affect your ability to
function?
• What treatments have you tried in the past, and
how well did they work?1
University of Tennessee Advanced Studies in Pharmacy
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Thorough patient education is essential to attain
the best possible outcomes for patients using opioids
for acute pain. Many patients are treated with combinations of medications that act by different mechanisms, and it is essential that patients understand the
role that each plays in the pain management strategy.
Patients must also understand the expected adverse
effects of opioid analgesics and any adjunctive therapies. Although tolerance to sedation, nausea, and respiratory depression usually develop quickly,
constipation typically persists for as long as patients are
taking opioids. A bowel regimen combining a stool
softener and a stimulant laxative is required for all
patients taking opioids.2
Although patients are often concerned about the
risk of addiction with opioids, addiction is a primary
neurobiological disease that is very unlikely to occur in
individuals with no history of substance use problems
who are using opioids for acute pain.3 Withdrawal
symptoms may occur with the abrupt discontinuation
of opioids, but this is not a symptom of addiction.
Withdrawal symptoms may be avoided by gradually
tapering the opioid dose before treatment is discontinued. Opioids given on a regular schedule over a period
of time can easily cause an abstinence syndrome. For
example, if the patient had been taking 2 hydrocodone
tablets every 4 hours for 2 to 4 weeks, he probably
would have experienced some withdrawal symptoms.
It is important to discuss this syndrome when dispensing opioid pain relievers because patients who do not
understand the potential for withdrawal symptoms
may believe that they are becoming addicted. They
often will not mention this to their healthcare
providers and carry an unfortunate misperception of
their “problem.” The distinction between dependence
and addiction is not clearly understood by most
patients, or even by many healthcare providers.
Tapering an acute opioid treatment regimen is usually
a natural process that occurs as the pain lessens and the
patient takes less pain medication. Therefore, many
patients do not notice that a dependence syndrome
has developed.
Many opioids are available for the treatment of
acute pain. With the exception of a small number of
relatively high-risk agents (eg, meperidine or
propoxyphene, which produce potentially dangerous
active metabolites), there is little evidence that the
different opioids vary significantly in their adverse
event profiles. New treatment alternatives continue to
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CASE STUDY
become available for patients with pain. For example,
new formulations of established analgesics (eg, sublingual sufentanil and iontophoretic transdermal fentanyl) have been developed to improve pain relief for
surgical patients. Tapentadol, an investigational analgesic that combines µ opioid receptor agonism with
norepinephrine reuptake inhibition, may provide pain
relief that is similar to morphine but with a lower incidence of adverse events.4 Ongoing randomized controlled clinical trials will continue to define the role of
these new agents in the management of acute pain.
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REFERENCES
1. Phillips SE. Pain assessment in the elderly. US Pharm.
2007;32:37-52.
2. Herndon CM, Jackson KC 2nd, Hallin PA. Management of
opioid-induced gastrointestinal effects in patients receiving
palliative care. Pharmacotherapy. 2002;22:240-250.
3. Strassels SA, McNicol E, Suleman R. Postoperative pain
management: a practical review, part 2. Am J Health Syst
Pharm. 2005;62:2019-2025.
4. Two new analgesics may help patients after bunionectomy.
Available at: http://www.joacp.org/index.php?option=
com_content&task=view&id=48&Itemid=58. Accessed
February 13, 2008.
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