Transcript slide template

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
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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
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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
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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
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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
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Case of Mr. G.H. cont’d
 What would you do?
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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
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