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Case Presentations
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?
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
Case 1: Opportunities
• Emphasize non-opioid pain management
– Focus on functional gains/progress
– Engage in mental health care
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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
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?
RATHER…
Do the benefits of opioid
treatment outweigh
the untoward effects and
risks for this patient (or
society)?
Judge the opioid treatment –
NOT the patient
Nicolaidis C. Pain Med. 2011 Jun;12(6):890-7.
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.
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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?
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DSM-V criteria
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11.
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.