Case Study 1

Ruben Halperin, MD MPH

May 30, 2014

• BG 56 year old male• Active problem list

HIV+• Bacterial pneumonia , twice in last 5 years• Neuropathy – HIV?• lipodystrophy

COPD > 40 pack years of tobaccoHistory of poly-substance abuse, clean since age 42Orthostatic hypotensionHypogonadismDepression with anxiety and insomniaHepatitis CChronic lumbar pain with radiculopathy

• Arrives by wheelchair, flat affect, on oxygen• Doctor appointments are only time he leaves house

• Active Medication List - May 2011

• ROXICODONE 5 MG TAB (OXYCODONE HCL) 1 -2 po q 4 hrs prn pain increasing by 5 - 10 mg q 4 hours until adequate pain control is reached not to exceed 9 tablets daily

• METHADONE HCL 10 MG TAB (METHADONE HCL) Four tablets by mouth TID• NEURONTIN 300 MG CAPS (GABAPENTIN) Three by mouth three times a day • REGLAN 10 MG TAB (METOCLOPRAMIDE HCL) 1 tab at meals and bedtime• FAMOTIDINE 40 MG TAB (PEPCID ) 1 tablet by mouth every morning• ENSURE LIQ (NUTRITIONAL SUPPLEMENTS) 4 cans qd prn • ANDRODERM 5 MG/24HR (TESTOSTERONE) Apply 2 patches to skin daily,• PAXIL 40 MG TAB (PAROXETINE HCL) One by mouth once a day • LORAZEPAM 1 MG TAB (LORAZEPAM) 1-2 tabs by mouth TID prn (Max 6/day) • TRAZODONE HCL 100 MG TABS (TRAZODONE HCL) One by mouth qd• ASPIRIN 81 MG EC TAB (ASPIRIN) • FLOMAX 0.4 MG CP24 (TAMSULOSIN HCL) 1 by mouth daily • FLORINEF 0.1 MG TABS (FLUDROCORTISONE ACETATE) • PROCHLORPERAZINE MALEATE 10 MG TABS (PROCHLORPERAZINE MALEATE)

1 by mouth three times a day as needed nausea • XANAX 1 MG TABS (ALPRAZOLAM) 1/2 - 1 by mouth twice a day as needed• IMODIUM A-D 2 MG TABS (LOPERAMIDE HCL) 1 by mouth daily as needed• PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE) • ADVAIR DISKUS 100-50 MCG/DOSE MISC (FLUTICASONE-SALMETEROL) • * MARIJUANA per OAR 333-008-0020(4)(b)

Opioid Risks/side -effects/complications

Opioid induced ventilatory impairment• Central sleep apnea

Opioid endocrinopathy

Narcotic bowel syndrome

Opioid Induced Hyperalgesia

Step 1: June 2012

Address depression and anxiety– Add bupropion xl 150 mg daily– ↓ paroxetine to 30 mg daily

2 weeks later – ↑ bupropion xl to 300 mg daily– ↓ paroxetine to 20 mg daily– First meeting with behaviorist

Step 2: July 2012

Mood and level of activation improved on bupropion

Pain education – 2 classes

Physical Therapy • Started Pool therapy (patient was afraid of land based therapy

By August he was paying for it himself so he could go 3 days/week

Starts going to church for first time in 10 years• Less social isolation• Distraction from pain/suffering

Step 3: September 2012

Methadone ↓ by 5 mg/ week

Week 0: 40 mg – 40 mg – 40 mg (120 mg)

Week 1: 40 mg – 40 mg – 35 mg

Week 2: 40 mg – 35 mg – 35 mg

Week 3: 40 mg – 35 mg – 30 mg

Week 4: 35 mg – 35 mg – 30 mg (100 mg)

Week 5: 35 mg – 30 mg – 30 mg…

At 30 mg tid he started feeling mentally clearer, and on his own, started cutting by 10 mg / week

Still seeing behaviorist Still doing pool therapy

Step 3.5 September 2012

Lorazepam cut to 1 mg three times daily, then ↓ 0.5 mg every 2 weeks

Week 0: 1 mg – 1 mg – 1 mg

Week 2: 1 mg – 0.5 mg – 1 mg

Week 4: 1 mg – 1 mg

Week 6: 1 mg – 0.5 mg

Week 8: 1 mg qd prn

Step 4: October 2012

Starts land based therapy, continues pool

Still seeing behaviorist

Stops Marijuana on his own after a discussion with the pastor at his church

For the first time, arrives at appointment walking

Step 5: November/December 2012

Off Methadone Mid November

Starts tapering oxycodone on his own, is off by late December

Stops Lorazepam by later December

Nausea improved so we stop metoclopramide, prochlorperazine, immodium

Because BP is up, we stop fludricortisone and bp stays up

Active Medication List - January 2013

•NEURONTIN 300 MG CAPS (GABAPENTIN) Three by mouth three times a day •ENSURE LIQ (NUTRITIONAL SUPPLEMENTS) 4 cans qd prn •ANDRODERM 5 MG/24HR (TESTOSTERONE) Apply 2 patches to dry skin daily, •PAXIL 20 MG TAB (PAROXETINE HCL) One by mouth once a day •BUPROPION XL 300MG TAB One by mouth once a day•TRAZODONE HCL 100 MG TABS (TRAZODONE HCL) One by mouth once a day •ASPIRIN 81 MG EC TAB (ASPIRIN) •FLOMAX 0.4 MG CP24 (TAMSULOSIN HCL) 1 by mouth daily •XANAX 1 MG TABS (ALPRAZOLAM) 1/2 - 1 by mouth twice a day as needed anxiety •PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE) •ADVAIR DISKUS 100-50 MCG/DOSE MISC (FLUTICASONE-SALMETEROL)

Function

January 2013: able to walk 20 – 30 blocks• COPD has improved with increased activity• If you ask him about pain, he admits he still has some pain

Attending church regularly, they offer him, and he takes, a job doing janitorial work

No longer uses wheelchair

Loses some of his state benefits because he is making an income

Lessons?

1. High doses of opioids carry risk for adverse effects– often lead to loss of function– Require more medications to mitigate side effects

2. Patients can come off opioids, but there needs to be something else first– Mental health treatment– Pain education– Physical therapy, pacing, address fear of movement

3. Many patients want to come off opioids, but are afraid* of:a) Increased side effects

b) Worsening pain

c) Declining funtion

4. Set appropriate expectations– Withdrawal can temporarily increase pain