Case study 1 Instructions: Spend 5-10 minutes reviewing the following case and considering the questions that follow. Peter is a 70-year-old who presented to the emergency department almost a year ago with new onset of painful rash to the right thorax. He described the pain as 9-10 with a sharp, shooting type sensation. He was subsequently diagnosed with herpes zoster. He was admitted and placed in isolation. He received treatment and spent 6 days in hospital before being discharged. About 6 months ago he saw his primary care physician (PCP) for persistent burning pain in the same area. His PCP explained to him that he had post herpetic neuralgia and prescribed treatment. He returns to the clinic today with similar complaints and is asking about alternative treatments for the pain. Questions 1. What are the subdivisions of chronic neuropathic pain? _______________________________________________________________________________________________ 2. Which noninvasive, nonpharmacologic approaches to pain management would you discuss with this patient? _______________________________________________________________________________________________ 3. Which steps can be taken to address the possible barriers to effective pain care? _______________________________________________________________________________________________ Assessing Mental Health
● Suicidal ideation is addressed by items on the PHQ-9 and BDI-II . This is an important assessment for patients with chronic pain. ● The Beck Anxiety Inventory (BAI) emphasizes somatic components of anxiety 112 and can be found here: https://res.cloudinary.com/dpmykpsih/ image/upload/great-plains-health-site-358/ media/1087/anxiety.pdf ● The Generalized Anxiety Disorder-7 (GAD) and GAD-2 are validated and recommended to assess for generalized, panic, and social anxiety disorders, and PTSD. 64,113,114 These tools are available here: PMID: 32582485 Newer systems such as the Stanford-developed and implemented Collaborative Health Outcomes Information Registry offer more in-depth pain assessment through the use of item banks that capture many physical, psychological, and social functioning domains. 115 A number of risk factors are associated with poorer outcomes in opioid therapy. 101 These factors include: 118 ● Nonfunctional status (e.g., severe physical debility) due to pain. ● Exaggeration of pain. ● Unclear etiology for pain. ● History of rapid opioid dose escalation. ● Young age (<30 years). ● Tobacco use. ● Poor social support.
Screening tools to assess patients with pain for mental health disorders ahead of prescribing opioids include: ● Patient Health Questionnaire-2 (PHQ-2) , a two- item screen for depressive disorder that leads to more detailed assessment if either item is positive. 109 The PHQ-2 is available at the following link: https://www.hiv.uw.edu/page/mental-health- screening/phq-2 ● Patient Health Questionnaire-9 (PHQ-9) , this nine-item screen for depressive disorder may be used initially or as a follow-up to the PHQ-2. 110 This tool and its variations are brief, reliable, valid, and easy to score. The PHQ-9 is available at the following link: https://www.hiv.uw.edu/page/ mental-health-screening/phq-9 ● The reliable and valid Beck Depression Inventory-II (BDI-II) is a self-report measure of depression severity. 111 This 21-item tool is available here: http://www.hpc-educ.org/Files/Danz/BDII.pdf Assessing social history, including substance use Patients to be treated with opioid therapy should be screened for the risk of opioid misuse and OUD and monitored regularly. Misuse of prescription opioids is common whether from casual sharing of prescription pills, recreational or experimental use by non- patients (including adolescents), all the way up to and including development of OUD in at-risk populations. Yet clinically it is not always easy to differentiate between appropriate use of prescribed opioids and behavior that may indicate a problem. There is reason to suspect that a pattern of seeking opioids from multiple sources is a strong indicator of misuse and possible OUD. 116 A list of behaviors suggestive of opioid misuse is shown in Table 5. 116,117
● Personal history of SUD. ● Family history of SUD. ● Psychological stress. ● Psychological trauma. ● Psychological disease. ● Psychotropic substance use. ● Focus on opioids. ● Sexual trauma.
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Book Code: MDCO1025
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