Addiction and Pain
By
Gary D. Carr, MD, FAAFP
Diplomate ABAM
Past President FSPHP
Medical Director PHN
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4/8/2015
Case One
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John is a 28 YO WM followed at FP Office with usual illnesses.
Fall from ladder at home with Compression FX L-3 and severe
L Ankle FX.
Back treated with brace. Ankle had ORIF with “good result”.
Continued pain – both sites. Occ. Swelling L Ankle.
Early analgesics – Oxycontin 40mg BID & Lortab 10 QID PRN
Now 1 year S/P accident and still requiring Lortab 10 up to TID.
No other apparent Problems…
Without meds says pain prevents his concentrating, can’t sit still
for over 30 min, and interferes with sleep.
Seems inappropriately irritated over my attempts to cut back or
D/C Lortab
4/8/2015
What Do You Think?
What Do You want to Know?
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4/8/2015
More History
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No significant medical illnesses
No other routine meds
Works as Assistant VP of a Local Bank
Married to RN. 2 children 2 and 4 YO
No known family history of addictive illness.
He does not know father’s side of family.
Denies problems at work or home.
4/8/2015
More History
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Casual conversation with a friend resulted in
disclosure that Patient was reportedly
intoxicated at time of his accident. (Reporter
did not know of relationship with LMD and
Patient)
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What do you want to know?
4/8/2015
More History
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Patient admits he had “a little too much to drink”
when he had accident. Denies drinking to this extent
except on rare occasions.
Admits “A couple” beers at night.
Wife confirms his story. Reserved.
Non-narcotic substitutions for pain:
NSAIDS – GI upset
venlafaxine and duloxetine – Both caused
“Nightmares” and “Detached Feeling”
PT – “Seemed to make pain worse”
F/U with Orthopedist – Doesn’t think he should still
4/8/2015
be requiring Lortab…
Revelation
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Wife comes in crying. Says that she lied about ETOH.
Drinking “too much” every day. Didn’t tell LMD because he
“promised to stop” and “he would have been furious”.
“I believed he needed it for his pain control”.
Her visit is prompted by the fact she’s learned he is getting
Lortab on the internet. Appears he is really taking about 18 –
20 /day.
She also saw a bill from a pain management clinic in a
neighboring state
What now???
4/8/2015
Intervention/Treatment
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Successful intervention conducted.
Had 1 month IP and 3 months IOP.
Continued problems with Lumbago at night managed
without narcotics
Contract with LMD including agreement to avoid all
mood altering substances including alcohol. Urine
Drug screens.
Appears committed to recovery
Active in AA/NA
Things better at home
4/8/2015
Setback
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6 months sober – Jet Sky accident. Recurrent back
pain, Neck Sprain, Fractured wrist… Non-Narcotic
meds not working.
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What can we do for him??
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NOTE: Just because he is an addict, we don’t want
him to suffer. Yet, we do not want to prompt relapse.
4/8/2015
Acute pain treatment
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Treated with: NSAID, Skelaxin, and Cymbalta
(tolerated this time), and physical therapy.
Pain persisted. Given Suboxone SL 8 mg 1 – 2 per
day with good pain control. Wife administered.
Tapered and D/Ced after three weeks without
difficulty
Was this appropriate therapy?
Was it appropriate for the wife to administer?
What are the risks?
What were other alternatives?
4/8/2015
Follow Up
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John is now sober over 2 years.
Active member of AA, has sponsor, works
steps, chairs meetings, has first sponsee
Wife doing OK but won’t go to Alanon
So far, so good.
4/8/2015
Case Two
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Frank is a 48 YO WM followed with Ankalosing
Spondylitis, Recurrent Major Depression and Anxiety
– anxiety predominates
He is a single high school teacher
Has Rheumatologist
Has been on multiple non-narcotic pain Rxs. Over
past 4 years Rheumatology has been giving Lortab
up to 100/ month – more typically about 30 / month
Functioning at work. No overt sign of impairment
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Is this appropriate RX Management to this point?
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4/8/2015
More History
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Anxiety with Depression managed predominately with SSRIs
and combination Serotonin and norepinephrine with variable
success.
Worsening complaints of pain when anxiety/depression active.
Has refused past attempts to have him see therapist
Occasionally requests Xanax (alprazolam) which has been
provided intermittently at dose of .5 mg ½ tid and 1 at HS.
Recently requesting more Xanax and running out a few days
early.
One report of “lost prescription on vacation”.
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Is this concerning?
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4/8/2015
Indicator of Trouble?
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Fired by Rheumatologist because he had gotten an
RX of Lortab via ER and did not tell Rheumatologist.
Had signed a pain control contract with
Rheumatologist. Seemed surprised this was “such a
big deal”. Denies trying to hide this from anyone.
Irritable/defensive affect
F Hx: Patients father had a history of “needing a lot
of prescription pain medication for his stomach”.
Died in MVA at age 55.
What do you do?
4/8/2015
More Problems
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LMD talked Rheumatologist into resuming care
3 months latter Rheumatology discovered another
RX for Lortab from another primary care doc.
LMD calls local pharmacies and discovers 5 different
providers of Lortab on near monthly basis Taking up
to 12 – 18 per day.
What do you do?
4/8/2015
Intervention
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Intervention conducted.
Admits a problem.
Initially blamed Rheumatologist and LMD saying we
failed to adequately manage his pain
Does not have financial resources for treatment (and
probably not the motivation).
And leaving work “will mean the loss of my job”.
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What do you do?
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4/8/2015
Patient Management
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Patient refuses AA/NA. Does not think he
has a problem. Thinks he took Lortab over
inadequately treated pain and Anxiety
Willing to take Suboxone
Willing to see a therapist
Willing to execute contract with LMD
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What will you do?
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4/8/2015
Patient Management
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Sent to a therapist familiar with addictive illness,
depressive illness and anxiety D/O.
Contract –
1) Meds from one Pharmacy and one provider.
2) Regular urine drug screens
3) Suboxone 8 mg SL TID “for pain”
4) SSRIs for Anxiety and Depression
5) Must see individual therapist regularly
Discussion…
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4/8/2015
Initial Resistance
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Initially, Frank delayed seeing therapist
Requested increase in Suboxone beyond 4 / day
Was angry, depressed, had insomnia, and ranked his pain as
7/10.
Shortly after he started seeing a therapist, his complaints
decreased
Duloxetine 60mg (Cymbalta) and Amitriptyline 100mg were
clinically helpful for pain, depression and insomnia.
Why would a therapist be beneficial for Frank?
NOTE: I believe Frank would be happier and do even better with
his Anxiety/Depression if he were doing 12 step work.
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4/8/2015
Follow Up
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Patient followed under contract now for 1.5 years.
No escalation with Suboxone (3/day)
No Benzodiazepenes
Sees therapist regularly – looks forward to it
It is noted that increased pain increases his depression and
vice versa
Urines negative for unauthorized drugs of abuse or ETOH
Enjoys making bird houses for sale in his wood working shop
Stable if not “happy, joyous, and free”
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Discussion…
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4/8/2015
Case Three
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Angela is a 66 YO WF, Married with 2 grown
children.
Her husband is a supervisor at a local factory
Angela has been in recovery from Opioid
Dependency and Alcoholism for 14 years
and is very active in her recovery process.
Angela’s husband is not involved in recovery
4/8/2015
More History
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Angela developed a breast lump. Her last
mammogram had been 5 years ago and she had not
kept F/U apts for her female exams.
She was diagnosed with Breast CA Metastatic to the
skeletal system with lesions in her Lumbar Spine,
Femur, and Ribs.
She was treated with Radiation treatments. Refused
Chemo.
She has intractable pain.
What are the pain management
considerations/options?
4/8/2015
More History
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Suboxone was tried for pain relief. This caused
“H/As” and she did not like “how it makes me feel”.
Her Oncologist suggests Fentanyl Patches with
Percocet 7.5 for breakthrough pain.
Is this appropriate management?
Should it matter that her disease is a terminal illness?
4/8/2015
Angela’s Management
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Angela was given Fentanyl Patches 50mcg which she tolerated
well.
She takes occasional Percocet 7.5 but says these do cause
some drug craving
She uses one pharmacy and her LMD does all Rxing.
She is able to make her AA meetings most weeks. When
unable, her AA friends bring a meeting to her home.
She dislikes having to take pain medications and for some time
struggled with this meaning she had “lost sobriety”.
She remains lucid, engaged in life, and reasonably happy – she
attributes her positive mental attitude to her recovery
Individual therapy has been offered but she feels like her needs
are met in AA.
Discussion…
4/8/2015
Contact Me
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Gary D. Carr, MD., FAAFP, Diplomate ABAM
5192 Old Hwy 11, Suite 1
Hattiesburg, MS, 39402
Office: 601-261-9899
Cell: 601-297-6777
E-Mail: Docgcarr@aol.com
Web: www.professionalshealthnetwork.com
4/8/2015