This is Dr. Stephen Wyatt, and I'm sitting with Dr. Will Wright. And we're going to now review a case that's indicative of what you've just reviewed in the previous module. >> So we'll start on, this is a 44-year-old male with some chronic pain. So he is currently being treated with Vicodin hydrocodone bitartrate and acetaminophen, one tablet every six hours for compliance of chronic low back pain. You're concerned about quote drug-seeking behavior and prescription of opioid misuse because the patient has been periodically presenting the local emergency rooms asking for opioid analgesics. And over the last several months has been asking for more and more doses of Vicodin, stating that just the current dose is not handling and not being sufficient manage his pain. Imaging studies of the patient's back shows some minor degenerative abnormalities. But the pathology is just not quite consistent with the level of severity of symptoms and pain that he's experiencing or reporting. Moreover, the patient on three occasions and then this last year has come back to the office asking for early refills. Because his prescription was either stolen or lost. And he's been unwilling to consider non-opioid pain management treatment options so far. So when you continue to assess and gather information, you find that he started having alcohol at the age of 14 as his first use. You notice that while he drank heavily primarily on the weekends during his college years that never got to a point where he was drinking daily. And he did not think his alcohol use caused any problems. Otherwise, he also states he currently drinks socially with his last drink of about two 16-ounce beers roughly two weeks ago. Regarding his use of opioid analgesics, he started initially after a football injury to his back around the age of 20. He continued to use pharmaceutical opioids in college, and in his early 20s, using it via the snorting routes. And over the years, he has received opioid analgesics off and on from a variety of different doctors, and has at times bought them on the street to quote treat his back pain. So in his early 30s, opioid began to escalate significantly leading to a referral to an outpatient addiction program where he was detoxed from opioids using methadone and encouraged to go to Narcotics Anonymous. He never really thought he had a problem with opioids but rather that his problem was just standing from this back pain, and that was it. So he never quite engaged with NA properly. He remained opioid free for a few months, but then resumed his use. He says no other drugs are used but he is a pack a day smoker. Psychosocially, he's been married several times, divorced twice with no children from those two marriages, currently living with a girlfriend of about two years. And they have a one-year-old son. His girlfriend, who you've also interviewed getting some collateral information, is concerned the family and friends have seen some changes in the patient's mood and alertness including problems with confusion and memory over the last six months or so. She's complaining and explaining that the patient has been spending more and more and more and more time trying to get his pain medications and has been neglecting his responsibilities to the family and his son. He's a contractor and so working long hours. And he knows he has lost jobs over the last few years secondary to this quote unquote back pain and that he is close to potentially lose another current job. His urine and breathalyzer tests have been negative except for opioids. So Dr. Wyatt, when when you hear this scenario, you hear all these details of this case, what do you think as far as diagnosis of opioid use disorder dependence or what we call pseudoaddiction? >> So we'll pseudoaddiction is not a very clearly defined entity. The idea is that somehow we're undertreating his pain. So that's the reason why he continues to go to the emergency department or comes back in for early prescriptions because he's just not getting adequate pain relief. And it's certainly something that we want to be very clear about when receiving a patient with or without a opiate use disorder or any substance use disorder that we we've made a correct diagnosis, that were identifying the pathology appropriately and that sort of thing. I think a few things are indicative of his being more of an opioid use disorder. And I think much of this I know this was reportedly a new patient that was already on these medications had been on them for a period of time prior to this presenting to this particular clinician. But you want to get a lot of that history that we're now getting about his previous drug use prior to even initiating opioids and then obviously being very careful in using opioids for this patient. The idea that he doesn't come in saying I'm just in such severe pain, I need more medication, instead, he's saying that somehow it was lost or stolen is a little disconcerting. And then certainly, the idea that what pathology you do see doesn't appear to meet your expectations in terms of the amount of pain that he should be experiencing. >> So the pictures not quite matching up. >> Exactly, and I think that that's something that people should be very cognizant of, that clinicians need to be cognizant of that. And it will help the patient from getting into trouble and help the physician from getting into trouble, that when we start to see these things that we step back and start to think about where we head with this. And I often will present it to the patient of I want you to get healthy. If my prescribing for the opiates in this particular scenario is not conducive to good health, and then when you add to it that social history that we've been presented with in terms of changes in his changes in his interaction with the family, and now some potential job obligations is certainly more of a problem that we would want to try to attend to. >> Well, lot of folks are saying, Dr. Wyatt, Dr. Wright, I mean, a lot of times we're getting patients that are referred on these things, referred to these matters. And we may not have been the initial one to start medication. And so, for my example, I definitely think due diligence on our part if we inherit patients is getting that history that we that we found in this particular scenario, even if it wasn't you who initiated the pain medications. Because as you can see from this scenario, it seems like there was a lot more in the background than was initially I'm sure presented when he started on his pain medications. >> Yeah, again, I think that to clearly state to the patient our intention is to help you get healthy. And that's identifying opiate use disorder as a disease that I want to help you with. And it's not maybe saying it directly like that to the patient, but just the pointing out the impact that opioids maybe having on their well-being and their relationships and work and livelihood along with the fact that you want to be very clear that you're not disregarding the discomfort that he's experiencing. >> Before we're going on to that next question, they also wanted to pick out we hear and the terms drug-seeking behavior a lot. And we put in quotes there in this scenario. What do you make of that term when you hear drug-seeking behavior? >> It's disturbing. >> [LAUGH] >> It's disturbing because it really is a pejorative term like what is drug-seeking behavior? And that's what we really need to identify that these behaviors are biologically-driven. And when the neurobiology, the brain is set up in a particular way, it's going to do particular things. And in this case, his salience to the drug is significant. And his down-regulation of any kind of consequences like maybe even having to do with former relationships, two divorces or his interaction now with his current girlfriend or ability to get to work, all those things could be put at significant risk because the drive to get drug is so great. And to not look at this as a choice, but more as clearly a biologic drive and saying things like drug-seeking behavior is just, it doesn't allow for us to open that door to what else is really going on here that we might be able to treat appropriately. >> Again, that disease process. >> Exactly. >> Like I tell a diabetic, you're just insulin-seeking. >> That's right. >> So with this scenario, what treatment would you choose with the knowledge that you have now at this point? >> Well, you want to let him know about other modalities like naltrexone. If you determine that the pain is minimal and he doesn't really need anything for at level of an opioid for pain. That could be a scenario that you would entertain. And then certainly, methadone might be another alternative. But I really think in this particular case, buprenorphine would be most appropriate. I think that first of all to explain to the patient that buprenorphine has a 30 to 1 morphine equivalent. Now that's for acute pain. That's how all morphine equivalents are actually determined because there's such variability for chronic pain. But at the same time, it is very effective as an analgesic. And we just need to keep in mind that it's used differently in that way and we can discuss that. But in this case, to start him on buprenorphine, I think would have significant potential for him being able to better understand what level of pain he has. Because it is long-acting, it would stabilize his opiate use in a way that there would be less, in the way of any kind of withdrawal pain that he might experience. And it has a certain effect partly because of the pharmacology of buprenorphine that he may find himself getting back into other activities, increase his activity in general, mobilized, maybe some of his muscles in his back or his back in general. So I've had numerous patients that would have been in this scenario and gotten on buprenorphine and just found that really, they didn't have nearly the back pain they thought they had. In his particular case, I think with all the information that we've been given that's indicative of opiate use disorder rather severe that he probably would be someone that we would get on it and be a really need to manage on buprenorphine even after his back pain might resolve to better treat his opiate use disorder. >> And I have had chronic pain folks that once they've gotten on it, their pain has become much more manageable. Even if it's still some discomfort there, they're able to kind of accept and look through that pain and continue to do things. >> Right. >> So it's definitely been helpful not just for the pain but also the acceptance of what pain is doing in their life, too. Last question, if opioid maintenance is started, how might you manage pain that may pop up or are ongoing? >> We've touched on this a little bit but buprenorphine, again, is a good pain medicine. It should be noted however that when we're using it for opiate use disorder, we use it on typically once a day dosing, also you can use it twice a day. But most of the time, patients begin to recognize or they feel fine for a good 24 hours, but it doesn't have an analgesic effect for a full 24 hours. And so typically, we would split it into either three or four times a day. Typically, you can use the same dose. You don't necessarily have to go up on the dose. But you would split it into a three-time or four-time a day dosing schedule, and then of course, to be using ibuprofen or acetaminophen along with it, so non-opioid pharmaceutical management. And or in this case, I really think just getting him up, getting him moving particularly for back pain could be very effective. So possibly some physical therapy or something else to help him with his pain. It so often results in decreased activity, that is the use of. And so even some of his disability will improve with stabilization of his disease with buprenorphine. >> I think one's kind of stabilized on buprenorphine, definitely encouraging even the non-pharmacological interventions that initially when somebody's having significant pain or reports of significant pain, they may not be as ready to accept other alternatives. I think that's where I've definitely seen some benefit after they've gone some stability, then you start really encouraging diet and exercise and those non-pharmacological agents and interventions in addition to the non-opioid NSAIDs and other stuff as well. >> Right, very good. >> Well, I think that that will wrap up this particular case, and hopefully, learn some more in-depth concepts that are indicative of what we've covered.
