6/18/2014 Clnical case discussions: Assessment and management of - - PDF document

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Joji Suzuki, MD Instructor in Psychiatry, Harvard Medical School Director, Division of Addiction Psychiatry Department of Psychiatry, Brigham and Women’s Hospital John Renner, Jr., MD, DLFAPA Professor of Psychiatry, Boston University School of Medicine Director, Addiction Psychiatry Residency Training Boston University Medical Center, and VA Boston Healtcare System

Clnical case discussions: Assessment and management of opioid use disorders in the general hospital setting

We have no relevant conflicts of interest to disclose

Case 1

• Paul is an 18 year high school student with hemophilia who presented to

the ED because of knee pain. Due to repeated bleeds into his knee joint and subsequent joint damage, he has had chronic knee pain for many years, at first managed with NSAIDs, but now oxycodone 15mg PO every 4-6 hours. This is his third admission for knee pain in the last year.

• Paul has no addiction or psychiatric diagnoses. He is socially active, and

doing well in school. He never asks for early refills, nor has he lost his

• scripts. His urines are always appropriate.
• On exam, Paul’s knee was swollen, tender, with decreased range of
• motion. The pain is as high as 8/10. The medical team initially offered
• xycodone, but Paul insisted hydromorphone works best for him.

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Case 1

• Paul tolerated the initial opioid regimen of hydromorphone 8mg PO q4,

and his pain was down to 2-3/10, which he found tolerable. He followed all treatment recommendations. No other behavioral issues noted.

• Then the team was contacted by Paul’s hematologist because he

thinks Paul sometimes exaggerates the pain. The hematologist acknowledges the pain and the opioid regimen are not atypical for this patient population, and Paul has been adherent to treatment in every

• way. Nevertheless, he recently took a course on safe opioid

prescribing, and didn’t want to be “duped” by the patient.

• The team is now concerned that the patient may be “drug-seeking”.

Worrisome history

• On chronic opioid

therapy

• Young male

Re-assuring history

• No prior psychiatric history
• No prior substance use history
• No family history
• No history of doctor or ED

shopping

• No history of early or lost

scripts

• No medication hoarding
• No calling of the clinic at odd

hours

• Legitimate reason for acute and

chronic pain

• Adherent to outpatient

treatment recommendations

What are some of the concerns raised based on his history?

Is there evidence that the patient is “drug-seeking”

• r not?

Potential “evidence” Yes/No Appearing intoxicated (pinpoint pupils, nodding off) NO change in pain rating after dosing Incongruence between pain score and behavior Leaving floor without permission or at odd hourscations Appearing intoxicated after returning, or after visitors leave Requesting specific route or medication Visitors who are intoxicated Family or prescriber voicing concern Major “evidence” Yes/No Evidence of tampering with IV lines (“white powder sign”) Evidence of hoarding or cheeking of pain medications Illicit drugs found in room Witnessed using drugs Overdosing No No No No No Yes No Yes No No No No No

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• Evidence present for non-medical use
• Consider discontinuing opioids
• Maximize non-opioid strategies
• Buprenorphine? Methadone?

High Risk High Risk

• Risk factors present that make monitoring

necessary

• However, no evidence of non-medical use
• Continue opioids
• Maximize non-opioid strategies

Moderate Risk Moderate Risk

• Risk factors not present
• No evidence of non-medical use
• Continue to monitor
• Continue opioids

Low Risk Low Risk

Case 2

• George is a 48 year old roofer who presented to the ED with 2-3

days of worsening pain, swelling and decreased range of motion

• f his left hand.
• George was reluctant at first, but admitted injecting about “1 gram”
• f heroin daily. He last used as he was coming in the ED because

the pain was 10/10. Pain is now about 8/10, described as “sharp and throbbing”, and says “I can live with a 6”. He denies other drug use.

• On exam, he is hemodynamically stable, and his dorsal surface of

the hand is tender and erythematous. He is diagnosed with cellulitis, and he is admitted and started on IV antibiotics.

Case 2

• George received oxycodone 15mg PO every 6 hours (60mg per

day) in addition to NSAIDs and acetaminophen.

• However, he reports the oxycodone barely works. For about 1-2

hours the pain is down to an 8/10, but returns back to 9/10. He asks if he can get more oxycodone for the pain.

• The team is reluctant to increase his opioid dose.

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Opioid dose Tolerance

Baseline need Acute pain

If the patient uses “1 gram” of heroin daily, should the current pain regimen be adequate in controlling his acute pain?

• Evidence present for non-medical use
• Consider discontinuing opioids
• Maximize non-opioid strategies
• Buprenorphine? Methadone?

High Risk High Risk

• Risk factors present that make monitoring

necessary

• However, no evidence of non-medical use
• Continue opioids
• Maximize non-opioid strategies

Moderate Risk Moderate Risk

• Risk factors not present
• No evidence of non-medical use
• Continue to monitor
• Continue opioids

Low Risk Low Risk

Guilty until proven innocent

• Assume pain is not real
• Unnecessary dosing of opioids is harmful.
• Patients must prove pain is real to receive

treatment

• Allow some “innocent” patients go untreated to

ensure no one ever receives opioids inappropriately

Innocent until proven guilty

• Assume pain report is real
• Untreated acute pain is harmful
• Clinicians must prove pain is not real to withhold treatment
• Allow some “guilty” patients go, in order to ensure all

patients in pain receive treatment

How do we know if the patient is “drug-seeking” or not?

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Is there evidence that the patient is “drug-seeking”

• r not?

Potential “evidence” Yes/No Appearing intoxicated (pinpoint pupils, nodding off) NO change in pain rating after dosing Incongruence between pain score and behavior Leaving floor without permission or at odd hourscations Appearing intoxicated after returning, or after visitors leave Requesting specific route or medication Visitors who are intoxicated Family or prescriber voicing concern Major “evidence” Yes/No Evidence of tampering with IV lines (“white powder sign”) Evidence of hoarding or cheeking of pain medications Illicit drugs found in room Witnessed using drugs Overdosing No No No No No No No No No No No No No

• Evidence present for non-medical use
• Consider discontinuing opioids
• Maximize non-opioid strategies
• Buprenorphine? Methadone?

High Risk High Risk

• Risk factors present that make monitoring

necessary

• However, no evidence of non-medical use
• Continue opioids (methadone a reasonable option)
• Maximize non-opioid strategies

Moderate Risk Moderate Risk

• Risk factors not present
• No evidence of non-medical use
• Continue to monitor
• Continue opioids

Low Risk Low Risk

Opioid dose Tolerance

Baseline need covered by methadone Acute pain covered by short acting

• pioids

A potential strategy for managing acute pain and the underlying opioid debt

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Case 3

• Michele is a 23 year old homeless woman with a history of opioid

dependence, who presented to the ED with a 2 week history of fevers, fatigue, chest pain, and shortness of breath. She initially thought she had the flu, but decided to seek care because the breathing problems scared her, and she also noticed painful bumps

• n her fingers. She injects about 1-2g of heroin daily. She last used

heroin on the day of admission.

• On exam, she is febrile, tachycardic, and tachypneic. She complains
• f being short of breath. Michele is admitted to the medical floor, and

the workup reveals she has endocarditis. She is started on IV antibiotics.

Case 3

• Michele complains of pain in her chest and fingers of 10/10, described

as sharp. She is noted to be nauseous and diaphoretic, with dilated

• pupils. The team start Michele on hydromorphone PO 8mg q4hours.

The opioid withdrawal and acute are well controlled, and pain is down to 2-3/10.

• However, on the third hospital day, a nurse discovered some white

substance in the IV tubing, and noticed Michele to be “nodding off” with pinpoint pupils. The nurse also discovered some hydromorphone pills which were hidden in her socks.

• When Michele was confronted, she denied tampering with the IV line,

and denied any knowledge of the pills in her socks.

30% 20% 16% 8% Left AMA Disruptive behavior Admit to misusing drugs in hospital Dead by 40mo f/u

n=124 drug users in London Hospital (Marks et al 2013)

Is non-medical use of opioids in the hosital common?

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How might patients use drugs non-medically in hospitals?

• Cheeking and hoarding medications to snort or inject
• Using own supply that was brought to the hospital
• Asking friend or family to bring supply
• Leaving the room to obtain supply
• Stealing from hospital supply

Could it be pseudoaddiction?? Is there evidence that the patient is “drug-seeking”

• r not?

Potential “evidence” Yes/No Appearing intoxicated (pinpoint pupils, nodding off) NO change in pain rating after dosing Incongruence between pain score and behavior Leaving floor without permission or at odd hourscations Appearing intoxicated after returning, or after visitors leave Requesting specific route or medication Visitors who are intoxicated Family or prescriber voicing concern Major “evidence” Yes/No Evidence of tampering with IV lines (“white powder sign”) Evidence of hoarding or cheeking of pain medications Illicit drugs found in room Witnessed using drugs Overdosing Yes No No No No No No No Yes Yes Yes No No

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• Evidence present for non-medical use
• Consider discontinuing opioids
• Maximize non-opioid strategies
• Buprenorphine? Methadone?

High Risk High Risk

• Risk factors present that make monitoring

necessary

• However, no evidence of non-medical use
• Continue opioids
• Maximize non-opioid strategies

Moderate Risk Moderate Risk

• Risk factors not present
• No evidence of non-medical use
• Continue to monitor
• Continue opioids

Low Risk Low Risk

Managing high risk patients

• Clarify if opioids are needed (for example, endocarditis is
• ften not painful)
• Consider continuing full agonist opioids if Michele can:

– Adhere to treatment plan – Show no further evidence of non-medical use – Avoid any illicit drug use while in the hospital

• However, if Michael is interested in medication-assisted

treatment, consider buprenorphine.

• Limited utility of methadone, except for managing acute
• pioid withdrawal. Unable to bridge to MMT, and dangerous

to use as pure pain medication.

Conclusions

• Drug users disproportionately utilize hospitals for care.
• Injection use leads to a variety of complications that cause significant pain.
• Opioid dependent patients are more likely to experience pain due to

tolerance, withdrawal, and hyperalgesia.

• Acute withdrawal should be managed.
• In assessing for potential non-medical use, utilize objective behaviors as

“evidence”. Patients cannot be solely responsible for “proving” the pain is real.

• Acute pain can still be adequately managed even for patients on methadone
• r buprenorphine
• Transition to outpatient is a fragile time, and risk should always be

minimized

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References

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Haber PS, Demirkol A, Lange K, Murnion B. Management of injecting drug users admitted to

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