1. Clinical Case Studies Developed by Dr. David Hunt

2. 2 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

3. 3  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 Case of Mr. G.H.

4. 4 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 Case of Mr. G.H. cont’d

5. 5  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 Case of Mr. G.H. cont’d

6. 6 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 Case of Mr. G.H. cont’d

7. 7  What would you do? Case of Mr. G.H. cont’d

8. 8  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 Concurrent Pain & Addiction