Case Study 1
Ruben Halperin, MD MPH
May 30, 2014
• BG 56 year old male
• Active problem list
HIV+
• Bacterial pneumonia , twice in last 5 years
• Neuropathy – HIV?
• lipodystrophy
COPD > 40 pack years of tobacco
History of poly-substance abuse, clean since age 42
Orthostatic hypotension
Hypogonadism
Depression with anxiety and insomnia
Hepatitis C
Chronic lumbar pain with radiculopathy
• Arrives by wheelchair, flat affect, on oxygen
• Doctor appointments are only time he leaves
house
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Active Medication List - May 2011
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ROXICODONE 5 MG TAB (OXYCODONE HCL) 1 -2 po q 4 hrs prn pain
increasing by 5 - 10 mg q 4 hours until adequate pain control is reached not
to exceed 9 tablets daily
METHADONE HCL 10 MG TAB (METHADONE HCL) Four tablets by mouth TID
NEURONTIN 300 MG CAPS (GABAPENTIN) Three by mouth three times a day
REGLAN 10 MG TAB (METOCLOPRAMIDE HCL) 1 tab at meals and bedtime
FAMOTIDINE 40 MG TAB (PEPCID ) 1 tablet by mouth every morning
ENSURE LIQ (NUTRITIONAL SUPPLEMENTS) 4 cans qd prn
ANDRODERM 5 MG/24HR (TESTOSTERONE) Apply 2 patches to skin daily,
PAXIL 40 MG TAB (PAROXETINE HCL) One by mouth once a day
LORAZEPAM 1 MG TAB (LORAZEPAM) 1-2 tabs by mouth TID prn (Max 6/day)
TRAZODONE HCL 100 MG TABS (TRAZODONE HCL) One by mouth qd
ASPIRIN 81 MG EC TAB (ASPIRIN)
FLOMAX 0.4 MG CP24 (TAMSULOSIN HCL) 1 by mouth daily
FLORINEF 0.1 MG TABS (FLUDROCORTISONE ACETATE)
PROCHLORPERAZINE MALEATE 10 MG TABS (PROCHLORPERAZINE
MALEATE) 1 by mouth three times a day as needed nausea
XANAX 1 MG TABS (ALPRAZOLAM) 1/2 - 1 by mouth twice a day as needed
IMODIUM A-D 2 MG TABS (LOPERAMIDE HCL) 1 by mouth daily as needed
PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE)
ADVAIR DISKUS 100-50 MCG/DOSE MISC (FLUTICASONE-SALMETEROL)
* MARIJUANA per OAR 333-008-0020(4)(b)
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Opioid Risks/side effects/complications
Opioid induced ventilatory impairment
• Central sleep apnea
Opioid endocrinopathy
Narcotic bowel syndrome
Opioid Induced Hyperalgesia
Step 1: June 2012
Address depression and anxiety
– Add bupropion xl 150 mg daily
– ↓ paroxetine to 30 mg daily
2 weeks later
– ↑ bupropion xl to 300 mg daily
– ↓ paroxetine to 20 mg daily
– First meeting with behaviorist
Step 2: July 2012
Mood and level of activation improved on bupropion
Pain education – 2 classes
Physical Therapy
• Started Pool therapy (patient was afraid of land based therapy
By August he was paying for it himself so he could go 3
days/week
Starts going to church for first time in 10 years
• Less social isolation
• Distraction from pain/suffering
Step 3: September 2012
Methadone ↓ by 5 mg/ week
Week 0: 40 mg – 40 mg – 40 mg (120 mg)
Week 1: 40 mg – 40 mg – 35 mg
Week 2: 40 mg – 35 mg – 35 mg
Week 3: 40 mg – 35 mg – 30 mg
Week 4: 35 mg – 35 mg – 30 mg (100 mg)
Week 5: 35 mg – 30 mg – 30 mg
…
At 30 mg tid he started feeling mentally clearer, and on
his own, started cutting by 10 mg / week
Still seeing behaviorist
Still doing pool therapy
Step 3.5 September 2012
Lorazepam cut to 1 mg three times daily,
then ↓ 0.5 mg every 2 weeks
Week 0:
1 mg – 1 mg – 1 mg
Week 2:
Week 4:
Week 6:
Week 8:
1 mg – 0.5 mg – 1 mg
1 mg – 1 mg
1 mg – 0.5 mg
1 mg qd prn
Step 4: October 2012
Starts land based therapy, continues pool
Still seeing behaviorist
Stops Marijuana on his own after a
discussion with the pastor at his church
For the first time, arrives at appointment
walking
Step 5: November/December 2012
Off Methadone Mid November
Starts tapering oxycodone on his own, is off
by late December
Stops Lorazepam by later December
Nausea improved so we stop
metoclopramide, prochlorperazine,
immodium
Because BP is up, we stop fludricortisone
and bp stays up
Active Medication List - January 2013
•NEURONTIN 300 MG CAPS (GABAPENTIN) Three by mouth three
times a day
•ENSURE LIQ (NUTRITIONAL SUPPLEMENTS) 4 cans qd prn
•ANDRODERM 5 MG/24HR (TESTOSTERONE) Apply 2 patches to dry
skin daily,
•PAXIL 20 MG TAB (PAROXETINE HCL) One by mouth once a day
•BUPROPION XL 300MG TAB One by mouth once a day
•TRAZODONE HCL 100 MG TABS (TRAZODONE HCL) One by mouth
once a day
•ASPIRIN 81 MG EC TAB (ASPIRIN)
•FLOMAX 0.4 MG CP24 (TAMSULOSIN HCL) 1 by mouth daily
•XANAX 1 MG TABS (ALPRAZOLAM) 1/2 - 1 by mouth twice a day as
needed anxiety
•PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL
SULFATE)
•ADVAIR DISKUS 100-50 MCG/DOSE MISC (FLUTICASONESALMETEROL)
Function
January 2013: able to walk 20 – 30 blocks
• COPD has improved with increased activity
• If you ask him about pain, he admits he still has some pain
Attending church regularly, they offer him, and he takes,
a job doing janitorial work
No longer uses wheelchair
Loses some of his state benefits because he is making
an income
Lessons?
1. High doses of opioids carry risk for adverse effects
– often lead to loss of function
– Require more medications to mitigate side effects
2. Patients can come off opioids, but there needs to be
something else first
– Mental health treatment
– Pain education
– Physical therapy, pacing, address fear of movement
3. Many patients want to come off opioids, but are afraid*
of:
a)
b)
c)
Increased side effects
Worsening pain
Declining funtion
4. Set appropriate expectations
– Withdrawal can temporarily increase pain