Mr. X is a 48-year-old iron worker who was injured in 2002 and has experienced ongoing pain issues since. He takes various medications for pain, mood, sleep and headaches. He has a history of substance use issues including past heavy alcohol use and current problematic use of prescription opioids. His opioid medications have been tapered but he continues to report high levels of pain. His case presents complex challenges around adequately treating his pain while managing his risk of addiction relapse.

1. Challenging Cases:
Treating Pain and Addiction
Launette Rieb, MD, MSc, CCFP, FCFP, dip. ABAM
Clinical Associate Professor, UBC
Director, St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship
FME & CPSBC 27th Annual Pain and Suffering Symposium
March 7-8, 2014, Vancouver, BC, Canada

2. Learning Objectives
 Participate in group discussion of cases
 Help generate a differential diagnosis
 Gain ideas of management strategies for
patients with pain and addiction
 Reflect on your own practice and identify
patients that may need a new approach

3. Mr. N.
 28 yr old construction worker – work injury
 Dx: Complex Regional Pain Syndrome
 Right hand – all sign and symptom categories
 Verbal and standardized screens negative for
substance use disorders – some low level
alcohol and marijuana use
 UDS: Cocaine +, oxycodone + (prescribed)

4. Mr. N, cont’d
 Broaching the topic:
 “Your urine drug screen has come back.
Do you have any ideas about what it might
have shown?”
 Rapport/honesty + things not on the UDS
 “It has come back with cocaine. Some
people in pain use cocaine. Do you want to
tell me about your experience?”

5. Mr. N. cont’d
 “If you are using cocaine I can help you get
treatment and help you with your pain”
 Addiction history came spilling out
 Years of struggle with alcohol and cocaine
– predating injury but worsened by it
 Totally out of control now, frightened
 By the end of the conversation – relieved

6. Mr. N. cont’d
 Plan: Residential drug and alcohol Tx 103d
 Returned drug and alcohol free, off opioids
 Then a multidisciplinary pain management
program could begin
 PT, OT, Psych, Kin, med management
 Participated well
 One binge drinking episode – re-stabilized
 Good concurrent 12 step involvement

7. Mr. N. cont’d
 Medications blister packed:
 Gabapentin 1200 mg q8h
 Amitriptyline 125 mg hs – with a plan to taper
 Cymbalta 60 mg ii qam
 Naproxen 500 q 12 h
 Quetiapine 25 mg bid-tid prn
 Employer supportive: RTW modified duties
 Though in pain he felt he could deal with it
 He felt the treatment he received saved his life

8. Mr. N. Reflections
 What could have happened if I had not
done a UDS on assessment?
 What would you do if he denied cocaine
use even once the sample was confirmed?
 What other techniques do you use to
encourage patients to reveal their substance
use histories to you?
 What would you offer if his USD was
oxycodone -, opioid+, and cocaine+ ?

9. Mr. D.
 47 year old married at home father, degree
is psychology, no family history of SUD
 Age 19: L4-5 discectomy for prolapse
 Post-op give Tylenol #3
 He mixed these with ETOH to get high
 10 years later – recurrent disc – surgery
 Initially successful then increasing low back
pain over the next year

10. Mr. D, con’t
 GP managed
 Tried different medications, low dose at 1st
 Hydromorphone short acting up to 80 mg/d
 Would run out early, would crush and smoke
 Prozac 60 mg/d
 Ativan 4 mg/d
 Pain still unmanageable on above regime
 Referred on

11. Mr. D., con’t
 Multidisciplinary hospital based pain clinic
 Medications altered, various medications combined
 Opioids were increased over time to the level below:
 Fentanyl Patch 150 mcg/h q2 d (prescribed q3d)
 +/- fentanyl solution 100 mcg/2ml vile 3-5/d
 Fentanyl film (Onsolis) 600 mcg bid = 1200 mcg/d
 Tramadol (Ultram) 50 mg ii bid = 6 tabs/d = 300 mg/d
 Methadone tablets 60 mg bid = 120 mg/d
 Hydromorphone - short acting 80 mg/d (snorting)
 Morphine equivalent dose = 1,830+ mg/d

12. Mr. D., con’t
 Other medications
 Fluoxetine 80 mg/d (adverse rxn - duloxetine)
 Diazepam 2.5 mg bid (+still using lorazepam)
 Sudafed 2 tabs/d
 Caffeine pills and energy drinks
 He still felt pain, otherwise felt “Great!”
 Function: ran triathlons, others see sedation
 Total cost to wife’s insurance = $3,000/wk

13. Mr. D., con’t
 Voluntary admission to a medically
supervised residential treatment facility:
education, 12 step, group, 1:1, CBT, etc.
 Methadone and fluoxetine same dose at 1st
 Stopped tramadol on admission
 Stopped all fentanyl after 2 d taper
 Added quetiapine 25 mg q6h
 No withdrawal seen

14. Mr. D., con’t
 Tapered the methadone over 3 weeks to 5
mg tid
 Dose held until in withdrawal
 Switched to Butrans patch 10 mcg initially
– not quite enough
 Then over to Suboxone titrated to 6 mg/d
where he has maintained for 8 months

15. Mr. D., followup
 Now 9 months since admission to recovery
 Current meds
 Suboxone 6 mg/d
 Prozac 60 mg/d and tapering
 Seroquel 125 mg/d and tapering
 Has attended 12 step daily, has a sponsor
 No relapses or slips, despite divorcing
 No more pain issues, GAF 95/100

16. Mr. D., Reflections
 Primary pain disorder or substance use
disorder?
 Opioid induced hyperalgesia?
 How can the opioids besides methadone be
stopped abruptly without withdrawal?
 How can Suboxone and 12 step combined
control both the pain and addiction issues?

17. Ms. J.
 19 year old street entrenched female youth
 Pierced, tattooed, black clothes torn
 Presents asking for methadone
 Past Medical History
 Severe ankle sprain a year prior, air cast
 Initial x-ray negative
 Ongoing pain, ER visits – “drug seeking”
 Friends helped out with pills then heroin
 No mood issues, sleep broken

18. Ms. J., cont’d
 Medications
 Ibuprofen 400mg 1-2 prn
 Acetaminophen ineffective
 Substance Use History
 Tobacco started age 12, currently 1ppd
 Marijuana started age 13, currently 2-3 jnts/d
 Alcohol started age 13, 2 beer/wk, rare binges
 Heroin – started 6 months prior with smoked
heroin escalating to ¾ gm/d iv divided tid

19. Ms. J., cont’d
Social history
 On the street since age 17
 Father alcoholic, violent, she left home
 Recent breakup with boyfriend
 Has a dog which makes housing a challenge
 Exam – bony tenderness right ankle
 What are the next steps?

20. Ms. J., cont’d
 Management
 Converted to methadone 85 mg/d
 Referred to community counselor for housing
 X-ray, CT, bone scan – occult fracture and
low grade osteomyelitis
 Antibiotics
 Surgical intervention – internal fixation
 Temporary oxycodone for several weeks
following surgery

21. Ms. J., cont’d
 Management, cont’d
 Physiotherapy
 Tapered off methadone
 Decreased tobacco and marijuana
 Social follow-up
 Grade 12 equivalent study and exam
 Applied and accepted to be a youth counselor

22. Ms. J., Case Highlights
 What can begin as pseudo-addiction
(seeking pain relief but labeled as drug
seeking) can become full blown addiction
 People who fall outside the average (due to
class, race, sexual orientation, body
ornamentation, age, lifestyle, etc.) can be
misdiagnosed or not fully seen
 Treat the underlying condition
 Challenge yourself to see whole the person

23. Ms. J, Reflections
 How would your management change if
her investigations had been negative?
 What if she was in an abusive relationship
where she was being assaulted?
 What if her pain was unbearable even on
methadone?

24. Mr. L.
 44 year old man presented in 2004
 Heroin 2 – 3 gm/d for many years
 Detoxed in the past but craving > relapse
 Hepatitis C positive
 Mild to moderate OA knees
 Converted to methadone 210 mg/d
 Stable for 2 years, urine drug screens clear

25. Mr. L., cont’d
 2006 he decides to sells condo and travel
 Voluntary rapid taper from methadone
 Relapses in Europe due to exposure
 Returns and re-stabilized on methadone
 Another rapid taper (10 mg/d) for travel
 Getting some knee pain at end of taper
 Declines NSAIDS, acetaminophen

26. Mr. L., cont’d
 Oxycodone 5 mg bid controlled pain
 Leaves for China
 2008 re-appears after hospitalization for
endocarditis secondary to intravenous use
 Attending a residential “detox”, given…
 Methadone 100 mg/d (daily dispensed)
 Oxycodone (IR) 20 mg iii tid = 180 mg/d
 Diazepam 10 mg bid - tid prn (weekly disp.)

27. Mr. L., cont’d
 Patient reports knee pain very high
 He curtails walking, and is not attending
physiotherapy, nor swimming
 He looks sedated in the office, but he
claims it is due to poor sleep from pain
 What could be going on? Next steps?

28. Mr. L., cont’d
 Changed to long acting oxycodone 80mg tid
 Patient reports it doesn’t work – wants IR
 Tapered off diazepam
 Daily dispensed all medication, witnessed 1st
dose, upset at being “treated like a child”
 Pain reported to be worse, less function
 What next?

29. Mr. L., cont’d
 Offered TCAs, NSAIDS, atypical anti-
psychotics, SNRIs, neuromodulators, etc.
 All declined for various reasons, including HCV
 Physiotherapy prescribed, pool pass, not used
 Orthopaedic surgeon reviews – offers bilateral
knee replacements, patient declines
 Hepatologist contacted
 Ok to take acetaminophen up to 1500 mg/d
 Ok to take NSAIDs like ibuprofen full strength
 Patient declines

30. Mr. L., cont’d
 Patient continues to buy benzodiazepines
off the street or get from other MDs
 I write letters to the other MDs
 Methadone increased slowly to 200 mg/d
 Continued dramatic pain complaints
 What next?

31. Mr. L., cont’d
 Considering OIPS and OD risk…
 Oxycodone tapered to elimination
(involuntary – not happy)
 Methadone increased to 260 mg/d
 Once completed…
 Pt less sedated, reports lower pain, attends
physio with some positive results, goes to
UBC for continuing education classes

32. Mr. L., cont’d
 Then he starts to report more pain
 Pt has clear UDS so we can split his
methadone dose (q8h), makes no difference
 Patient wants oxycodone and diazepam
 He gets an advocate to protect his rights
 Claims I refuse to treat his pain
 What next?

33. Mr. L., cont’d
 Pt. says he wants tapered off methadone
 December 2009 the pharmacist calls to say
he saw Mr. L. hand his methadone to
another person who drank it.
 Mr. L. called in for discussion – and he
says he hasn’t been taking his methadone –
he sometimes “shares” it with a friend.
Admits to selling oxycodone previously.

34. Mr. L., cont’d
 All methadone prescribing stops and a
letter is given to him about why
 He presents angry, threatening to report me
to CPSBC, shows me a letter to this effect
 Care transferred to colleague (same clinic)
 Letter written to Mr. L. outlining options
 Soon colleague must discharge him too.
 Observations or questions?

35. Mr. X
 48 y.o. male iron worker
injured 2002
 Fall, R knee: torn cartilage,
meniscus, ACL with OR
 Knee gives way leading to other falls
 Pain with any movement
 Wakes at night moaning in pain
 Not working, limited household chores

36. Mr. X, cont’d
Past Medical History
 Low back injuries ++ ongoing pain, Tyl #4
 # elbow, torn rot. cuff, # pelvis, # ribs, #leg
 Asthma
 Motorcycle accident killing 1st wife
 Depressed mood, anxiety, abuse issues
 Cluster headaches

37. Mr. X, cont’d
Medications
 Salbutamol 2 puffs prn
 Topiramate 25 mg q6h (for cluster h/a)
 Buproprion 150 mg bid (for mood)
 Diazepam 10 mg 1-2 hs prn (for sleep)
 Meperidine 50 mg 2 q4h (tapered to 1 q6h)
 Tylenol #4 2 q4h prn (tapered to 1 q6h)w/d

38. Mr. X, cont’d
Substance Use History
 Caffeine - 1 cup per d
 Nicotine - 1ppd since age 15, stopped
along with his spouse 5 yrs ago
 Marijuana - None (gets paranoid)

39. Mr. X, cont’d
 Social drinking age 22-40s
 Escalated at 24 when wife killed
 Stopped briefly once spouse returned
 Back up to scotch 26 oz per day with
tolerance, loss of control, compulsion,
preoccupation, personality changes, anxiety
only w/d symp. (spouse drinks wine)
Alcohol

40. Mr. X, cont’d
 Tyl #4 for 7 yrs for back pain
 After knee injury T#4 - 4 q4h
 Morphine tablets initially, off now
 Meperidine 50 mg “chewing them like candy”
 Hiding pills from wife, running out early
 One heroin use (guilt, biker stigma)
Opioids

41. Mr. X, cont’d
 “Recreational use” from 20s-40s
 “Problem” after 1st wife killed after a
divorce and post knee injury
 2002-03: cocaine 1-2 gm IV every 1-2 d
 Paranoid, $ problems, tolerance, loss of
control, depression, use despite
consequences. Stopped after wife left.
Cocaine

42. M. X, cont’d
Speed (amphetamines)
 Used in his 20s to stay alert on long
motorcycle road trips.
 Last use 20 yrs ago.
No other street drug or herbal remedy use

43. Mr. X, cont’d
 Diagnosis
 Chronic knee and low back pain
 Substance dependence: alcohol, cocaine,
opioid, nicotine in remission
 Depression in partial remission
 Recommendations
 At home taper and stop ETOH, family MD
informed, if problems then residential detox
 In Pain Management Program (PMP) taper
meperidine, codeine and benzodiazepines

44. Mr. X – Follow Up
 Self tapered ETOH, diazepam &
meperidine at home prior to PMP
 During PMP he fell and # ribs, wrenched
knee again, delays in taper of codeine
 Almost off codeine with much better
function and lowered pain by end of PMP
 Sharing international award winning poetry
 He and spouse happy with achievements

45. Mr. X - Reflections
 Opioid induced pain sensitivity?
 Primary mood induced pain sensitivity?
 Alcohol induced mood changes…?
 Or primarily substance use disorder driven
on intake by alcohol dependence, which
once treated regulated all other responses.
 Your thoughts?

46. Your Cases
 Do you have any examples of a patient
with past dependence that was at high risk
of relapse until the pain got under control?
 Other cases from your practice you’d like
the group’s input on?

47. Summary
 Develop a differential diagnosis
 Special considerations need to be applied to those
with present or past addiction
 Analgesic control is needed to prevent relapse to
substance dependence in those with past addiction
 Substance dependence can develop when exposed to
severe untreated pain – see the whole person
 Active substance dependence needs addressing in order
to then get pain under control
 You can be compassionate and set clear
parameters for care to benefit all!

48. Good Resource

49. Resources
 Butler D and Moseley G L. Explain Pain.
Noigroup Publications, Adelaide, Australia
(2003)
 Moseley G L. Painful Yarns. Dancing
Giraffe Press (2007)
 See references in my plenary talk