Assignment: Opioid Case Discussion

Opioid Case Group Discussion

Patient rounds involve various disciplines coming together to discuss the patient’s condition and coordinate care. They are used as an educational tool and also help keep everyone on the same page when it comes to the treatment plan. The following case is found in the textbook (Pharmacotherapy: Principles and Practices. Chisholm-Burns et al, eds. 5th edition. McGraw-Hill.

New York 2019. ISBN-978-1-260-01944-5; Chapter 34. “Patient encounter”). Assignment: Opioid Case Discussion. After reading the assigned chapters, resources identified in Dynamed and Evidence based practice guidelines, please present the case to your peers. This will be your initial post. Please be sure to address all the questions and your responses are well researched and include supporting, evidence based guidelines such those of the WHO, CDC, APS, etc. Assignment: Opioid Case Discussion

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You will then provide an evaluation of TWO peer submissions of the same case. These response posts / evaluations shall include a complete response (with references) either endorsing or refuting the post you are evaluating based upon your research and references (including the text). The response posts / evaluations will have one additional step; you will assign a rating to each of your TWO peers’ initial post using a five star rating system.

5 STARS = Excellent
4 STARS = Above Average
3 STARS = Average
2 STARS = Below Average
1 STAR = Poor

Rate the post by clicking on the number of stars you think the post deserves in the Ratings area of a user’s post. You can give a maximum of five stars. [Ratings: ☆☆☆☆☆]

In essence, you will have three posts total. Your initial post and a two response posts (one for each of two classmates you are grouped with).

Assignment: Opioid Case Discussion Part 1:

HPI: A 78-year-old man who is to undergo a left above the knee amputation due to a limb abscess

PMH: Peripheral artery disease for 18 years; cardiomyopathy, benign prostatic hypertrophy for 13 years

FH: Mother had osteoporosis; father had diabetes

SH: Lives with wife; has two grown children

Meds: Aspirin 81mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; pantoprazole 40 mg daily; tamsulosin 0.4 mg daily

Pain Assessment: Patient rates pain as 8 on a scale of 0 to 10. Assignment: Opioid Case Discussion

Based on the type of injury, what type of pain is this patient likely to experience?
What type of pain management regimen would you suggest in the postoperative period? Explain your answer

Part 2:

Following surgery he was placed on morphine patient-controlled analgesia (PCA). He has been using 55 mg of morphine/24 hours with adequate pain control; however, he developed redness and itching on his neck that is believed to be due to the morphine.

Current Meds: Morphine PCA; aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily; heparin 5000 units twice daily until discharged home. He will be discharged to a skilled nursing facility for rehabilitation therapy.

You would like to convert him to a combination preparation of hydrocodone and APAP for as-needed pain relief.

What dosing regimen would you suggest?
What would your monitoring plan include for this patient?
How would you assess pain response?
The patient is concerned about the redness and itching that he developed while on morphine. Would you document this as an allergic reaction?
What other interventions or education may be necessary at this time? Assignment: Opioid Case Discussion

Assignment: Opioid Case Discussion Part 3:

The patient was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy 6 days each week.

Current Meds: Aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily, heparin 5000 units twice daily until discharged home, hydrocodone/acetaminophen 5/325 mg every 6 hours as needed for pain.

Pain Assessment: Patient reports pain of 7 out of 10; worse with movement.

Physical therapy notes indicate patient is unable to complete therapy goals due to complaints of pain.

Based on this information, what would you recommend to optimize pain control?
Prescribers play a critical role in prescription drug misuse and abuse prevention. What steps can be taken to identify signs of dependence and abuse and what education can you provide to the patient regarding the negative effects of medication misuse?

Part 4:

The patient has been at the skilled nursing facility for 4 weeks and is making progress toward rehabilitation goals; however, he complains that his leg is throbbing and feels like pins and needles. As a result, he requests to rest several times during her therapy sessions. During unit rounds, his therapist inquires whether her previous pain medication should be reordered.

Pain Assessment: 4 out of 10

What additional recommendations would you have at this time regarding pain management?
Are there any other therapeutic issues that should be addressed?

Opioid Group Discussion Example

Several conditions lead to limb amputation. Most often, limb amputation is due Diabetes mellitus and peripheral vascular disorders. Monitoring and treating pain in a patient after amputation is one of the key components of patient management. Effective treatment could lead to effective coping and recuperation of the patient and vice versa.

After amputation, the patient experiences phantom pain. The pain feels like it’s originating from the amputated parts of the leg. Phantom pain is due to damage to the nerves serving the amputated parts. Amitriptyline, duloxetine, hydrocodone and pregabalin are useful {Limakatson, Madden and Parker n.d.} Phantom pain is quite notorious majorly because it involves severe incapacitating neuropathic pain requiring a multidimensional approach.

The patient should be monitored for pain response and possible drug interactions on changing therapy. It should also involve psychotherapy, physical and occupational therapy. The redness and itching a mild allergic reaction. According to Powell, Mueller and Reynolds {2019}, the itching and erythema should not be recorded as an allergic reaction as it would alter drug prescription and deny the patient effective pain therapy. Assignment: Opioid Case Discussion

The patient should, however, be assessed for opioid intolerance or psycostimulation due to opioid allergy. Education to the patent on possible drugs side effects, drug reactions could prove important at this point. Education on importance of maintaining therapy is also important.

Phantom pain can be quite challenging to control and requires optimization of therapy especially when the pain does not cease. In this case, use of stronger opioid analgesics could be helpful. Drugs even those used in management of pain could lead to dependence and abuse. Revising the drug dosage and adherence are necessary to ensure the patient is not abusing the drug.

More so, observing signs such as headache and decreased level of activity with withdrawal or replacement of certain medications could be useful in assessing for dependence. Use of the Pain Disability Assessment Scale would prove useful in determining if the patient has developed drug dependence {Tetsunanga et al. 2018} Assignment: Opioid Case Discussion

Psychotherapeutic interventions are also important. The doses of gabapentin can be tapered of gradually until the patient reports of no pain. The patient should also be monitored for drug interactions. The patient is on life aspirin and should be assessed for gastrointestinal side effects of aspirin. I would recommend mirror therapy as a psychological method of pain management and also aid in coping {Finn et al., 2017}. The patient is not bedridden hence withdrawal of heparin or administration of heparin in tapering doses would be necessary.

Effective treatment of pain after amputations is quite a challenge. Available medications are quite inefficient I the management of tis notorious type of pain. More research should be done to establish effective treatment therapy. Meanwhile pharmacologic and non-pharmacologic methods should be used in managing the pain in these patients with close monitoring by the medical team. Assignment: Opioid Case Discussion

Assignment: Opioid Case Discussion References

Limakatso, K., Madden, V. J., & Parker, R. Treatment recommendations for phantom limb pain in people with amputations: an expert consensus study.https://www.researchgate.net/profile/Katleho_Limakatso/publication/336679410_Treatment_recommendations_for_phantom_limb_pain_an_expert_Delphi_study/links/5dac918992851c577eb934be/Treatment-recommendations-for-phantom-limb-pain-an-expert-Delphi-study.pdf

Finn, S. B., Perry, B. N., Clasing, J. E., Walters, L. S., Jarzombek, S. L., Curran, S., Rouhanian M.,Keszler M, S., Hussey-Anderson L. K., Weeks S. R., Pasquina P. F., & Tsao, J. W. (2017). A randomized, controlled trial of mirror therapy for upper extremity phantom limb pain in male amputees. Frontiers in neurology, 8, 267.https://www.frontiersin.org/articles/10.3389/fneur.2017.00267/full

Assignment: Opioid Case Discussion Tetsunaga, T., Tetsunaga, T., Nishida, K., Kanzaki, H., Misawa, H., Takigawa, T., Shioaki Y., & Ozaki, T. (2018). Drug dependence in patients with chronic pain: A retrospective study. Medicine, 97(40). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200516/

Powell, M. Z., Mueller, S. W., & Reynolds, P. M. (2019). Assessment of opioid cross-reactivity and provider perceptions in hospitalized patients with reported opioid allergies. Annals of Pharmacotherapy, 53(11), 1117-1123.https://journals.sagepub.com/doi/abs/10.1177/1060028019860521