COMMENTARY

Managing Opioid Overuse: A Case

Charles E. Argoff, MD

Disclosures

October 09, 2013

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A Case of Chronic Pain and Overuse of Opioids

This is Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Management Center at Albany Medical Center in Albany, New York. I would like to discuss a patient case and then follow up with some interesting information about relevant ways of managing the issue that developed with this patient.

I have been taking care of a 55-year-old woman who for many years has been known to have chronic stable multiple sclerosis. During this time, she also developed an independent peripheral nerve injury and peripheral nerve problem that wound up being quite painful to her. It has been documented by electromyography that she has peroneal nerve injury. She had been treated with propoxyphene for many years and seemed to benefit from it. She was referred to me by our multiple sclerosis specialist because she continued to experience burning pain, and pain in general, in a pattern that was consistent with peroneal nerve injury and was unresponsive to anything but propoxyphene at a time when propoxyphene was coming off the market. Sequential trials of medications like baclofen, gabapentin, pregabalin, tramadol, and various other opioid-type medications were not particularly helpful to her, so she was referred for further consideration.

After seeing her initially and confirming the diagnosis and the likely cause of her pain, we decided to use a number of different approaches. Unfortunately, she was not interested in any interventional approaches. A variety of different treatments resulted in a trial of oxymorphone extended release 10 mg, initially 5 mg every 12 hours, and then titrating up to 10 mg every 12 hours. Several weeks into the 10-mg-every-12-hours dose, I received a phone call from her saying that she had "run out" of her medication early. As part of my evaluation and treatment, we had had a baseline urine drug screen, which was sent out for analysis. Her urine drug test results were actually consistent with the medications she was being prescribed, but when she called, it was clear that she had overutilized the medications. She had used more than was prescribed, so I brought her into the office.

At this time I explored with her why she had done this, and she explained that the use of oxymorphone extended release at 10 mg every 12 hours was not helping her sufficiently. We agreed to a trial of a higher dose, and she re-signed a treatment agreement showing that she understood very clearly that she was being given another chance to adhere to our treatment recommendations, and that if she violated the agreement again, it would be grounds for discontinuing the opioid regimen as well as asking her to see another practitioner.

She returned 2 weeks later because I did not give her a full month's prescription. She appeared to be using her medications responsibly and had an appropriate urine drug screen. Several weeks after that, it was clear that that dose of oxymorphone extended release was not helping her sufficiently. Rather than only raising her oxymorphone dose, I elected to suggest adding one of the neuromodulatory agents that she had previously used, specifically gabapentin. However, she had been unable to tolerate gabapentin in the past, so we elected to use one of the 2 newer longer-acting agents that are gabapentin-based. I prescribed the gastroretentive formulation of gabapentin, which is a once-daily treatment, and had her return for follow-up in 1 month. The combination of oxymorphone extended release 10 mg every 12 hours and the gastroretentive form of gabapentin 1800 mg/day resulted in the best improvement she has had in quite a long time. She was much more comfortable at work, much more comfortable in general, and quite stable. Another urine drug screen yielded expected results, and this is how I am following her now.

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