Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 5
Jeremiah has been your patient since he was a young boy. Now 33 years old, you have seen Jeremiah grow up into a physically strong, but emotionally vulnerable young man. Jeremiah struggled in school and chose to enter a training program for masons rather than pursue college. A self-described “partyer” who reports regular use of alcohol and cannabis, Jeremiah nonetheless has not reported any impacts of his substance use on his personal or work life. He has, in fact, been successful in both, earning a good living as a mason and supporting his wife and two sons. But Jeremiah is currently on workman’s compensation to recover from a compound fracture of his left foot and ankle sustained when a large section of a chimney he was working on collapsed and fell. He also tore the rotator cuff in his right shoulder when he fell backwards against the scaffolding poles during the accident. Both injuries required surgical interventions and his recovery has been slow. Jeremiah was prescribed a short-acting opioid after each surgery, which he has continued to use. He has been regularly attending physical therapy sessions to restore strength in his left leg and to increase the range of motion in his right shoulder, but he complains that the therapy sessions are painful and that he doesn’t think they’re helping. He says his boss suggested that a long-acting opioid would be easier to use and would provide him more steady pain relief.
1. How would Jeremiah’s substance use affect your decision-making process related to his request for an ER/LA medication?
2. What steps might you take before agreeing to a trial of an ER/LA medication for Jeremiah?
3. What specific kind/dose of ER/LA medication might be most appropriate for Jeremiah if no contraindications were found in the pain and substance abuse assessment?
4. Name three specific functional goals that might be used as the basis for a pain management agreement with Jeremiah.
Primary care providers should prescribe naloxone to patients at risk of overdose, including those: • With renal or hepatic dysfunction • Taking opioid doses >50 MMED • Co-prescribed benzodiazepines or other sedating medications • With a history of overdose or OUD • Starting treatment for opioid use disorder Many states allow patients, family members, caregivers, and/or friends to request naloxone from their local pharmacist. Anyone receiving naloxone should be taught how to use the device and about the common signs of overdose (slow or shallow breathing, gasping for air, unusual snoring, pale or bluish skin, not waking up or responding, pin point pupils, slow heart rate).
A variety of naloxone products are available. The intranasal device with atomizer and intramuscular (IM) shots require the most manipulation in order to administer. Intranasal naloxone and the auto-IM injector are easier to use, but vary greatly in terms of price and insurance coverage. Successful opioid tapering Patients who do not achieve functional goals on stable or increasing opioid doses or those with unacceptable side effects, should have the opioid tapered or discontinued. Patients sometimes resist tapering or discontinuation, fearing increased pain. However, a 2017 systematic review found that dose reduction or discontinuation resulted in reduced pain (eight studies), improved function (five studies) and improved quality of life (three studies), although the evidence was not strong
because the analysis included poor-quality studies with uncontrolled designs and the interventions and outcome measures were heterogeneous. 142 Recommendations for tapering schedules vary. One source recommends a 10% decrease weekly based on years of opioid use (i.e., 10% decrease monthly for patients using opioids ≥4 years). For patients on high-dose opioids (i.e., ≥90 MMED), taper 10% until patient is taking 30% of the total initial dose, then recalculate 10% taper based on the new total opioid dose to slow taper. 143 The rate of opioid taper should be adjusted based on patient-specific factors such as the severity of withdrawal symptoms.
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