Transcript Document

Clinical Case Studies
Developed by Dr. David Hunt
www.pspbc.ca
Case of Reverend R.G.
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Opiates, Addiction And Chronic Pain
 Have You ever Felt Uncomfortable or
Uneasy When a Patient with Severe
Chronic Pain Requests Increasingly High
Doses of an Opioid?
 Yes…
 No..
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 Can you explain why you feel
uncomfortable?
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Opiates, Addiction And Chronic Pain
I am uncomfortable because:
1. I am never sure if the patient really has pain as bad as they claim.
2. I have no way of knowing if the opioids are actually relieving the
pain…is “taking the edge off” enough to justify the doses?
3. I am worried the patient is abusing or misusing them.
4. I am worried about a College Review.
5. I do not generally worry about any of these potential problems.
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LEARNING OBJECTIVES
Using Case Studies Discuss Issues Around
Opiates, Addiction, and Chronic Pain
When working with CPP, you will be able to:
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Describe Opioid misuse/diversion
List assessment tools that may be useful (10 available)
Explain the importance of a opioid management strategy
Develop an Action Plan for treatment
Case of Reverend R.G.
 48, Married
 Failed Back Surgery Syndrome
 With Right Sciatica Post- Op.
Scarring
 Minister ½ Time
 Stable Medication Dose
 Low ORT Score
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Case of Reverend R.G. cont’d
Medications:
 HM Contin 9 mgm q8h
 HMIR. 2-4mgm q6-8h PRN
 ( average 12mgm / 24hrs )
 Gabapentin 900mgm q8h
 Nortryptaline 40 mgm qhs
 Celexa 20 mg O.D.
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Case of Reverend R.G. cont’d
 Gentle Exercise Program 20-30mins – 5/7Days
 Denies Significant Mood or Sleep Problems
 No Nausea, Sedation, Sweating or Constipation
 Recent Random Urine Test Negative for Drugs of
Abuse
Question: Any concerns?
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Case of Reverend R.G. cont’d
 Rev.R.G.Stopped all Hydromorphone 3 months Earlier
 Continued to Refill Rx – “Just in Case of a Flareup”
 Kept Remaining Drug in Bathroom Drawer
 14 Year Son,Acting Out,Moody,Suddenly Failling at
School,Seemed to have More Money…
What would YOU Do? How would YOU Treat?
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Drug Misuse / Diversion
 If the Patient is Misusing / Diverting, Don’t Expect to
Always Catch on Right Away
 No Matter how Smart We Are, We Can and Will be
Fooled by a Professional Drug-Seeker
 With Careful Observation, Careful Prescribing
Practices and Careful Documentation Over Time, all
Drug Misusers Will Eventually Slip Up
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