Treating Pain in a Patient Abusing Drugs

Author: V. Dimov, M.D.

A 47-year-old African American female (AAF) was admitted to the hospital with the chief complaint (CC) of fever and body pain for seven days. She also c/o chronic chest pain for six years without an obvious cause.

Past medical history (PMH)

Bacterial endocarditis secondary to IV drug abuse. She has a history of asthma and chronic pain for which she takes Percocet.

Medications

Celexa; Benadryl, Atrovent, Percocet PRN, Oxycontin 40 mg PO BID

Allergies

PCN, Lidocaine

Social history (SH)

IV drug abuse (IVDA) to heroin. She recently became addicted to Percocet, methadone, Roxanol, and other pain medications used to treat her chronic pain syndrome. She is a smoker but denies drinking.

Physical examination

Vital signs 37.9-20-120-120/62
Chest: CTA (B)
CVS: Clear S1 S2
Abdomen: Soft, BS+, NT, ND
Skin: multiple areas of scarred, leathery skin secondary to her longstanding IV drug abuse, very difficult to get an IV access in ER
Neuro: AAO x 3, non focal

What is the most likely diagnosis?

Viral infection?
Pneumonia?
UTI?
Bacterial endocarditis?

All these are possible but the most dangerous one to think about is endocarditis.

What happened?


Positive Blood Cx in Endocarditis; Urine toxic screen in IVDA (click to enlarge the images).

Broad spectrum ABx were started for presumed endocarditis. Blood Cx showed GPC 2 of 2. ID was consulted and TEE was ordered.

Patient was started on her home medications:

Oxycontin 20 mg PO BID
MS 4 mg IV q 3 hr
Tylenol 650 mg PO q 6 hr
Senna 2 tabs PO QHS

She continued to complain of chest pain and back pain.

Do you think that this is a good choice?

Opioids are not the medications of first choice when treating chronic pain in drug addicts because of the abuse potential.

What to do?

Patient agreed to start opioid withdrawal protocol with Buprenex and it was prescribed as below:

Buprenex protocol:
Buprenex 0.3 mg SQ q 4 hr x 24 hr
and then
Buprenex 0.2 mg SQ q 4 hr x 24 hr
and then
Buprenex 0.1 mg SQ q 4 hr x 48 hr

Ibuprofen 600 mg PO q 6 hr (NSAIDs require GI prophylaxis with Protonix 40 mg PO QD)
Elavil 50 mg PO QHS (for sleep)

No opioids to be given without calling the pain management team first.

She will be evaluated for inclusion in a methadone program


ABx for Endocarditis and Buprenex protocol for IVDA (click to enlarge the images)

Final diagnosis

Bacterial endocarditis in IVDA patient
Drug-seeking behavior

What did we learn from this case?

Drug addicts often complain of chronic pain in order do get opioids prescriptions. You have to be extremely cautious when prescribing narcotics to such patients because of the abuse risk. It is advisable to request an addiction specialist consult in such cases.

Buprenex is the medication of choice for withdrawal protocol and for short-term pain management. Patients with an addiction problem may report less pain relief with Buprenex as compared to MS because Buprenex does not cause the euphoria characteristic of MS. In fact, Buprenex 0.4 mg is equal to 10 mg of MS.

Combining Oxycontin and Buprenex is not advisable because of the agonist/antagonist properties of Buprenex. In other words, Buprenex will antagonize some of the Oxycontin analgesic effect.

Bacterial endocarditis is a well known complication in IVDA patients and should be suspected, investigated and promptly treated.

References
Methadone Therapy for Opioid Dependence - AFP 6/01
Clinical guidelines for the use of buprenorphine in the treatment of opioid addition - NGC 2004
Severe opiate withdrawal in a heroin user precipitated by a massive buprenorphine dose - case report - MJA 2002

OPIOID WITHDRAWAL - BUPRENEX PROTOCOL (SVCH)

PHYSICIAN'S ORDERS


______ 1. Buprenex 0.____ mg. subq q 4 hrs. x 24 hours, then

______ 2. Buprenex 0.____ mg. subq q 4 hrs. x 24 hours, then

______ 3. Buprenex 0.____ mg. subq q 4 hrs. x 24 hours, then

______ 4. Buprenex 0.____ mg. subq q 4 hrs. x 48 hours, then discontinue.

______ 5. Hold Buprenex if patient is lethargic.

______ 6. Vistaril 50-100 mg po q 4 hrs. prn for anxiety and/or agitation.

______ 7. (MALE) Benadryl 50 mg + Elavil 50 mg po qhs prn for sleep, MR x 1.

______ 8. (FEMALE) Benadryl 50 mg + Trazadone 50 mg po qhs prn for sleep, MR x 1.

______ 9. Bentyl 20 mg po q 8 hrs. prn for abdominal cramping.

______10. Motrin 600 mg po q 6 hrs. prn for Myalgies and Arthralgies.

______11. CINA q 4 hrs. for first 48 hours, then q 8 hrs. if score is <> 90.

______13. Clonidine 0.05-0.1 mg po q 2-4 hrs. prn if CINA > or = 6 and if
SBP > 90.



Physician's Signature______________________________
Date and Time_____________


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