Pain Cases

1
Pain Cases
Frank D. Ferris, MDMedical Director, Palliative
Care Standards CENTER FOR PALLIATIVE STUDIES San
Diego Hospice and Palliative Care Education and
Research in the Art and Science of Palliative
Care Department of Family and Preventative
Medicine, UCSD School of Medicine Department of
Family and Community Medicine, andJoint Center
for Bioethics, University of Toronto
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Addiction
Tolerance
Physical dependence
3
Addiction . . .

• Psychological dependence
• Compulsive use
• Loss of control over drugs
• Loss of interest in pleasurable activities

4
Addiction . . .

• Continued use of drugs in spite of harm
• A rare outcome of pain management
• particularly, if no history of substance abuse

5
. . . Addiction

• Consider
• substance use (true addiction)
• pseudoaddiction (undertreatment of pain)
• behavioral / family / psychological disorder
• drug diversion

6
Tolerance

• Reduced effectiveness to a given dose over time
• Not clinically significant with chronic dosing
• If dose is increasing, suspect disease progression

7
Physical dependence

• A process of neuroadaptation
• Abrupt withdrawal may ? abstinence syndrome
• If dose reduction required, reduce by 50 q 23
  days
• avoid antagonists

8
Lisa, 23 year old ?
9
Lisa, 23 year old ?

• IV DU x 10 years, intermittent, ongoing
• You cared for her for past 3 years
• Abdominal pain, nausea
• Marked weight loss, anorexia / cachexia
• Lives alone, intermittent support from boyfriend
• Home-based nursing care

10
Lisa, 23 year old ?

• Endoscopy proven invasive MAC in stomach wall
• CD4 5, RNA gt750K
• Pain chronic aching, burning
• 8 9 / 10 while awake
• No relief from paracetamol or ASA

11
Lisa, 23 year old ?

• 1 week
• Pain 2 / 10 while awake
• Falls asleep easily, wakes 1 x for prn analgesia
• Using Morphine 20 mg PO q 4 h 6 _at_ Morphine 10
  mg PO / 24 hours extra
• Asking for less pills to take

12
Lisa, 23 year old ?

• You (the nurse) are concerned about
• Quantities to be dispensed
• Risk of drug activity in household
• Concurrent IV DU by friends
• Personal safety of healthcare providers

13
David, 28 year old ?
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David, 28 yo ?

• IV DU
• HIV x 4 years, AIDS x 2 years
• CD4 20, RNA 175K
• 2 month Hx ? pain feet, lower legs, 8 / 10
• Hypersensitive to light touch / bed sheets
• Difficulty walking / wearing shoes
• Frequent falls

15
David, 28 yo ?

• Lives at home with parents
• After 12 years difficult relations (IV DU)
• Parents want him to be comfortable
• Worried about too much pain medication in home
• David abusing it

16
David, 28 yo ?

• Girlfriend is HIV
• Sometimes stays with David
• One child, HIV-
• Mother, father provide care

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• Pain Cases
• Summary