Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 3
Giorgio, 62, has a long history of chronic pain in his back from degenerative disc disease. He has had three surgeries and tried trigger point injections and multiple medication regimens that include NSAIDs and gabapentinoids before being prescribed oxycodone for pain. He began to request higher oxycodone doses, citing difficulty sleeping and inability to function. He began to visit the clinic without an appointment, demanding opioids and behaving in an agitated and aggressive manner toward clinic staff. He was transitioned to methadone at 30 mg daily. The methadone relieved his pain at first, but analgesia began to wane, and his dose was increased until it reached 120 mg daily. As his pain continued to worsen, his HCP refused to raise his methadone dose any higher. Giorgio has a history of depression but does not take antidepressants. He can no longer work because of the pain, which he describes as at least a constant 9/10 on the numerical pain score. He is restless and finds it difficult to sit still during examination. A routine UDT turned up evidence of methamphetamine. During follow-up of the result, he admits to seeking out the street drug and also to procuring a few doses of heroin. He has a history of alcohol-use disorder that was in remission for many years but admits to recent relapse.
1. What opioid risk factors and clinical signs and symptoms can be observed in Giorgio?
2. What type of specialty referral is advisable for Giorgio?
3. How might the Opioid Tapering Flowchart shown Figure 4 be used to evaluate and treat this patient?
Individualized psychosocial supports may include supportive counseling, recovery coaching, recovery support services, and other services that may be needed by particular patients. Patients who present with or develop OUD or mental health disorders or both and who also have persistent pain require multidisciplinary care. 3 Patients with co-occurring pain and OUD should be offered MOUD. 147,22 For any population with trouble accessing treatment for OUD, including poorer urban areas and rural areas with limited treatment options, expanding the number of qualified HCPs able to treat OUD with buprenorphine in an office-based setting leads to more ready diagnosis and treatment. Because OUD medication is best combined with evidence-based psychological and behavioral therapies, the growing popularity and feasibility of accessing telehealth sessions is another possible means of expanding access to currently underserved communities. Opioids and Concurrent Cannabis Some patients who are taking opioids for pain are also using cannabis concurrently. However, synthesis of the data has been incomplete to guide clinical choices, and the short- and long-term health and safety effects have remained elusive. There are some data suggesting those who take medical cannabis are similar demographically to those who use cannabis recreationally. 148 A prospective cohort study of patients with musculoskeletal pain who are also on a stable dose of opioids was conducted to compare those who endorsed past-month cannabis for pain to those who denied any cannabis or illicit drug use. 149
Of 17% who endorsed past-month cannabis use for pain, 31% had a current medical cannabis card, and 66% reported that cannabis was helpful for reducing pain. Those who used cannabis for pain had higher rates of nicotine use, risk for prescription opioid misuse, and hazardous opioid use. No difference between groups were found in opioid dose, pain intensity, pain interference, or depression severity. The most common route of administration is smoking, despite risks of pulmonary effects. Some evidence suggests vaporization may be safer in this regard, although other research notes similar exposure as smoking to carbon monoxide and other respiratory toxins. 150 Other delivery options including edibles and extracts. Patients may develop cannabis-use disorder (CUD) and be unable to stop use on their own even though it is interfering with their health and function. Signs of CUD include: 149 • Using a larger quantity or over a longer duration than intended • Unsuccessful attempts to limit or quit • Significant amounts of time spent obtaining cannabis • Cravings • School or occupational impairment • Social or interpersonal impairment • Reduction of social, occupational, or recreational activities • Recurrent use in physically harmful situations • Continued use despite recurrent physical or psychological harms
Because some patients who are taking opioids will elect to use cannabis, HCPs should be aware of certain clinical recommendations: 150 • Keep current with relevant federal, state, and institutional policies and laws • Establish goals of care for cannabis use • Screen for signs of misuse, CUD, and diversion • Counsel patients on harms and risks on the basis of symptoms, condition, and comorbidities • Advise on routes of administration using current evidence base • Continually monitor similarly to opioids (informed consent, written agreement, regular follow-up, functional status, considering periodic urine testing, symptom severity, and use of other medications or substances) • Monitor for other harms, including car accidents and falls • Advise on discontinuation or referral to CUD treatment if pain relief and function goals are not being met without harm Although not specific to pain therapy, useful measures to screen for CUD include: • Single question: How often in the past year did you use marijuana (never, less than monthly, monthly, weekly, daily or almost daily) 149 • The 8-item Cannabis Use Disorders Identification Test-Revised (CUDIT-R) 151 • Comprehensive Marijuana Motives Measure 152 The Basics of Addiction Medicine Definitions and terms used to discuss addiction have evolved over time. Certain phrasing that is potentially stigmatizing has fallen out of usage, and
• Tolerance • Withdrawal
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