6/18/2014. Clnical case discussions: Assessment and management of opioid use disorders in the general hospital setting. Case 1

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1 Clnical case discussions: Assessment and management of opioid use disorders in the general hospital setting 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 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 oxycodone, but Paul insisted hydromorphone works best for him. 1

2 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. 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. What are some of the concerns raised based on his history? Worrisome history On chronic opioid therapy Young male Re-assuring history prior psychiatric history prior substance use history family history history of doctor or ED shopping history of early or lost scripts medication hoarding calling of the clinic at odd hours Legitimate reason for acute and chronic pain Adherent to outpatient treatment recommendations Is there evidence that the patient is drug-seeking or not? Potential evidence 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 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 / / 2

3 High Risk Evidence present for non-medical use Consider discontinuing opioids Buprenorphine? Methadone? Moderate Risk Risk factors present that make monitoring necessary However, no evidence of non-medical use Low Risk Risk factors not present evidence of non-medical use Continue to monitor 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 of his left hand. George was reluctant at first, but admitted injecting about 1 gram of 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. 3

4 If the patient uses 1 gram of heroin daily, should the current pain regimen be adequate in controlling his acute pain? Opioid dose Acute pain Baseline need Tolerance High Risk Evidence present for non-medical use Consider discontinuing opioids Buprenorphine? Methadone? Moderate Risk Risk factors present that make monitoring necessary However, no evidence of non-medical use Low Risk Risk factors not present evidence of non-medical use Continue to monitor How do we know if the patient is drug-seeking or not? 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 4

5 Is there evidence that the patient is drug-seeking or not? Potential evidence 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 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 / / High Risk Evidence present for non-medical use Consider discontinuing opioids Buprenorphine? Methadone? Moderate Risk Risk factors present that make monitoring necessary However, no evidence of non-medical use (methadone a reasonable option) Low Risk Risk factors not present evidence of non-medical use Continue to monitor A potential strategy for managing acute pain and the underlying opioid debt Opioid dose Acute pain covered by short acting opioids Baseline need covered by methadone Tolerance 5

6 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 on 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 of 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. Is non-medical use of opioids in the hosital common? 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) 6

7 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 or not? Potential evidence 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 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 / / 7

8 High Risk Evidence present for non-medical use Consider discontinuing opioids Buprenorphine? Methadone? Moderate Risk Risk factors present that make monitoring necessary However, no evidence of non-medical use Low Risk Risk factors not present evidence of non-medical use Continue to monitor Managing high risk patients Clarify if opioids are needed (for example, endocarditis is often 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 opioid 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 or buprenorphine Transition to outpatient is a fragile time, and risk should always be minimized 8

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