Two Patients with Pain - Who Qualifies for Chronic Opioid Treatment?

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

Objective: Review Ohio criteria for chronic opioid treatment

Patient 1

A 37 yo AAF with with chronic back pain. She has had a lifelong right hip pain related to an injury in childhood. Patient had a hip replacement in August of 2002. She reports that at the end of 2002, she began having low back pain radiating down the anterior legs bilaterally to the feet. This pain is daily and unremitting. She has been entered into a pain management program and she has been on various medications including Tylenol #3, Tylenol #4, Duragesic patch, Neurontin, amitriptyline, and Keppra. The patient had an EMG of her right leg, and this was normal. MRI of the lumbar spine was done recently and was completely normal.

Past medical history (PMH)

DM2, depression, and four C-sections.

Medications

Pain medications listed above, insulin 70/30, Januvia, and Zoloft.
NKDA.

Social history (SH)

Smoker, marijuana use in the past.

Physical examination

WNL.

The neurology consultant thought that her symptoms would be consistent with neurogenic claudication but she had no evidence for lumbar spine canal stenosis. There were no disk herniations to explain the symptoms. She had electromyography a year ago which was completely normal. She did not have any evidence of diabetic peripheral neuropathy on her examination. It appeared that her pain was not neurological.


MRI lumbar spine w/o contrast - WNL (click to enlarge the images).

Final diagnosis

Back pain may be due to lumbar sprain. Patient also had an aberrant behavior demanding opioids. She was homeless, temporarily living at a place where drugs were abused. She reported trying her friend's Duragesic patch which helped her.

Would you prescribe Duragesic patch or Oxycontin to this patient?

You should not.

She does not fulfill the Ohio criteria for chronic opioid treatment. She does not have an organic cause for her back pain and she is at risk for drug addiction (marijuana use in the past, environment in which drugs are used).

What happened?

Tylenol 650 mg q 6 hr and Motrin 600 mg q 8 hr were started. She was discharged home with TENS unit and PT/OT.

Patient 2

A 62 yo AAF was admitted to hospital with CC: epigastric pain, sharp, continuous, not radiating, 8-10/10 in intensity, no relieving factors except pain medications. She has been taking Percocet for pain. There is no history of diarrhea, jaundice, colicky pain, anorexia, blood in stools, or melena. No chest pain, SOB, cough, or sputum expectoration. No fever or chills.

Past medical history (PMH)

Chronic pancreatitis, HTN, Stroke.

Past surgical history (PSH)

(B) hip and knee joint replacement, tubal ligation.

Medications

Norvasc, Famotidine, Percocet 2 tabs q 6 hr PRN pain, Ultram PRN.

Allergies: PCN, Darvocet.

Social history (SH)

Quit alcohol ten years ago, smokes 1/2 pack a day. No history of any illicit drug use.

Physical examination

Thin lady in NAD.
Abdomen: Soft, +BS, mild epigastric tenderness.

Would you prescribe chronic opioids for this patient?

Remember, you have to follow the Ohio criteria for chronic opioid therapy. Patient needs to have an organic evidence of disease. Amylase and lipase were normal. CT of the abdomen showed evidence of chronic pancreatitis - dilated ducts, fibrosis and calcifications (in contrast with the younger patient described above who had all tests reported as normal). She does not have any history of drug abuse (another contrast to the drug-seeking patient above).


CBC, CMP, amylase and lipase (click to enlarge the images).


Chronic pancreatitis on CT abdomen; CT report (click to enlarge the images).

What did we learn from these two cases?

Follow the Ohio state criteria to see if your patient qualifies for chronic opioid treatment.

Criteria:

1. Clear-cut diagnosis requiring chronic pain medications. The diagnosis should be documented. See the example with the CT scan which showed chronic pancreatitis above.
2. Non-opioid pain management possibilities were exhausted.
3. There is an impairment of function
4. Patient has seen a specialist in the anatomical area where the pain is located.
5. Drug dependence ruled out or evaluated.

References

Guidelines for prescription of oral opioids for chronic, noncancer pain - NGC 2002.
Pain Management Guidelines from the Ohio Medical Board.
Opioids for chronic nonmalignant pain - Postgrad Med 1999.
Treatment of Nonmalignant Chronic Pain - AFP 01/00.

Related reading

Methadone may cause sudden cardiac death even in therapeutic doses. Notes from Dr. RW, 01/2008.
Evidence mounts for link between opioids and cancer growth - drugs may stimulate growth and spread of tumors. University of Chicago, 2012

Published: 03/11/2005
Updated: 01/31/2011

4 comments:

  1. What a fascinating study. I really don't see why a history of drug use is even a concern when evaluating whether or not they should qualify for chronic opioid treatment. The fact is, even if they've never used anything, they will be using some of the most dangerouds drugs there are, although for a medical purpose. Personally I think pain relief is a goal all its own and should be pursued by (almost) any means available.

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  2. chroic back pain in a 37 year old is difficult to treat. there is no real history of trauma, a childhood injury is noted but has she had any pain in the intermediate period of her life. what exacerbates the pain? what eases the pain? how does she cope with ADLs. maybe a course of alternative therapies, such as acupuncture, or hydrotherapy to strengthen back and abdominal muscles to improve core strength, may be useful.

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  3. Marijuana use in the past,ruled out opioids?That has to be one of the most silly and retarded thing I have read in a long time!I could see alcohol abuse or cocaine abuse,etc.But cannabis?utterly ridiculous.Why not ask the patient how much coffee they drink a day?Caffeine is a powerful drug.I swear their "really"need to be some changes in medical protocol.For years I suffered chronic pancreatitis,they did not even once check my blood for elevated amylase or pancrease,etc.And when they did find out what I suffered from,let me put it this way for years it's all I could do to get out of bed,the medical community is so afraid of a certain government agency they even make CANCER victims suffer!It's down right draconian.Seriously,their really needs to be some changes made.And to think,this is suppose to be the greatest nation on earth(not in pain control were not)!That is all I have to say for now,if your in chronic debilitating pain god help you.

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  4. Well, history of drug abuse (cannabis included) makes drug abuse in the future more likely. Caution is warranted.

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