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Clinical Case Studies Developed by Dr. David Hunt Objectives When working with CPP, you will be able to: Describe Opioid management List assessment tools that may be useful (10 available) Explain the importance of a opioid management strategy Develop an Action Plan for treatment 2 Case of Mr. G.H. 54, Married, Carpenter Builds Movie Sets- “Workaholic” Mixed Chronic Nociceptive and Neuropathic Pain to Left Chest / Abdomen from Crush Injury 1996 Pain Report 3-5 /10 to 10/10 Spontaneous Electric pain – “zingers” Allodynia, Hyperalgesia, Sensory Changes Marked Muscle Spasm when Flared 3 Case of Mr. G.H. cont’d Medications: Meslon 80mgm in divided dose / 24 hrs Morph. IR10-20mgm for break through › 40 mgm / 24 hours Gabapentin 800mgm 8h – 2400mg / 24 hours Does not Tolerate TCA’s or SNRI’s Stable Medication Dosing for 7 Years Able to Work Full Time By Pacing his Activities 4 Case of Mr. G.H. cont’d 2008 Life Events Bilateral Carpal Tunnel Surgery Off Work for Several Months Father ill Died in Toronto Aunt had Cardiac Arrest at Fathers Funeral Marital Disharmony Wife had Nervous Breakdown Financial Pressure Increased Took on Heavier Work – Movie Set on a Mountain 5 Case of Mr. G.H. cont’d January 2009 escalation in medications Meslon 80mgm / 24hrs to 160mgm / 24hrs Morph.IR 40mgm / 24hrs to 80mgm / 24hrs Asking for Meds Early Left Meds in Toronto – “Sister can’t Find Them” Random Urine Screen Positive for: Cocaine, Marijuana, Opiates 6 Case of Mr. G.H. cont’d What would you do? 7 Concurrent Pain & Addiction Both pain and addiction can co-exist in the same patient This does not always preclude the use of opioid therapy, but does require more attention (and time): › more controlled assessment › more controlled prescribing › more controlled monitoring 8