Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 2
Wayne is an 86-year-old who lives at home with his wife. He was diagnosed with ALS 6 months ago, with deterioration occurring first in his diaphragm. He has been experiencing increasing muscle weakness in his legs and uses a walker or a wheelchair to get around in his home. He uses a bilevel positive airway pressure device except when eating or bathing and finds it helpful. He takes the following medications: fish oil, a statin, a thiazide diuretic, and a non-benzodiazepine sedative to help him sleep. Lately he has been complaining of pain and stiffness in both of his knees and hips, which interferes with his sleep. He is physically deconditioned due to a lack of exercise, and has become increasingly withdrawn socially, which worries his wife and family members. He asks if you can prescribe something to ease his pain.
1. Is Wayne a good candidate for an ER/LA opioid? Why, or why not?
2. Is he a better candidate for an immediate-release opioid? Why or why not?
3. Would Wayne’s current medication need to be adjusted if he were to be prescribed an ER/LA opioid?
4. What kinds of non-opioid treatments might be tried to help Wayne with his pain?
Other adverse events In addition to risks of misuse, addiction, respiratory depression, and overdose death, there are many well-known side effects associated with chronic opioid use that can significantly compromise quality of life, including constipation, nausea or vomiting, sedation, pruritus, erectile dysfunction, menstrual changes, fracture, immunosuppression, hallucinations, and hyperalgesia. Gastrointestinal side effects Constipation is one of the most common opioid- related adverse events, affecting most patients to at least some degree, and which usually does not resolve with continued exposure. 28 To mitigate this side effect, patients should use a mild stimulant laxative such as senna or bisacodyl and increase the dosage in 48 hours if no bowel movement occurs. Physicians should perform a rectal examination if no bowel movement occurs in 72 hours. If there is no impaction, consider other therapies such as an enema, suppository, or magnesium citrate. 90
Table 2. Behaviors indicative of opioid misuse 9
Behavior
Frequency in patients with opioid misuse
Requested early refills Increased dose on own
47% 39% 35% 26% 18%
Felt intoxicated from pain medication Purposely over sedated oneself Used opioids for purpose other than pain
Figure 4. Risk of overdose rises with daily milligram morphine-equivalent dose. 88
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