Pain Management - In class application - 2023
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School
Portland State University *
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Course
563
Subject
Medicine
Date
Dec 6, 2023
Type
pptx
Pages
7
Uploaded by sabnamk1997
Management of Pain – In
Class Cases
Justin Kullgren, PharmD, FAAHPM
Palliative Medicine Clinical Pharmacy Specialist
The Ohio State University Wexner Medical Center
James Cancer Hospital
Case 1
•
TZ is a 67 yo male s/p herpes zoster infection
complaining of a constant chronic burning
pain near his shingles outbreak, with an
occasional sharp, shooting pain. TZ rates his
baseline pain 4/10, with exacerbations of
7/10. TZ has a PMH of depression, HTN, and
afib. He has no history of renal or hepatic
dysfunction. Reports he has tried
acetaminophen and ibuprofen with minimal
benefit.
•
Current medications include:
•
sertraline 100 mg PO daily
•
losartan 100 mg PO daily
•
metoprolol tartrate 25 mg PO BID
•
What type of pain is TZ
experiencing?
•
What specific symptoms are
characteristic of this pain?
•
Provide a therapeutic
recommendation:
Case 2
•
KJ is a 78 yoM who has multiple myeloma and chronic
pain because of it. KJ is fairly active, and he reports his
pain is acceptable with at worst a 7 and his breakthrough
medication brings his pain to a 2. Recently he has noticed
low back pain that is different than his cancer pain. It
started in the last 5 days and nothing has helped, even
the heat pack he has at home. Occasionally he has
experienced some nausea the past few days with early
satiety. When you ask about his last bowel movement he
can’t recall but knows it was at least a week ago. He does
admit to running out of Senna and Miralax around that
time and didn’t get anymore. He was having a bowel
movement daily until he ran out. Physical exam reveals a
solid abdomen and abdominal x-ray shows no
obstruction but a lot of stool.
•
Current medications: MS Contin 30 mg twice daily,
morphine IR 7.5 mg every 4 hours as needed (using 3
doses daily), omeprazole 20 mg daily, ondansetron 4
mg every 8 hours as needed for nausea, and oxybutynin
5 mg three times a day for bladder spasms
1.What factors are contributing to
KJ’s constipation? Are there
changes that can be made?
2.Is it appropriate to use Movantik
(naloxegol) or Relistor
(methylnaltrexone) in this
situation? Explain.
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Case 2
•
KJ is a 78 yoM who has multiple myeloma and chronic
pain because of it. KJ is fairly active, and he reports his
pain is acceptable with at worst a 7 and his
breakthrough medication brings his pain to a 2.
Recently he has noticed low back pain that is different
than his cancer pain. It started in the last 5 days and
nothing has helped, even the heat pack he has at home.
Occasionally he has experienced some nausea the past
few days with early satiety. When you ask about his last
bowel movement he can’t recall but knows it was at
least a week ago. He does admit to running out of
Senna and Miralax around that time and didn’t get
anymore. He was having a bowel movement daily until
he ran out. Physical exam reveals a solid abdomen and
abdominal x-ray shows no obstruction but a lot of stool.
•
Current medications: MS Contin 30 mg twice daily,
morphine IR 7.5 mg every 4 hours as needed (using 3
doses daily), omeprazole 20 mg daily, ondansetron 4 mg
every 8 hours as needed for nausea, and oxybutynin 5
mg three times a day for bladder spasms
•
Recommend the best bowel
regimen for KJ.
A.
Movantik (naloxegol)
B.
Relistor (methylnaltrexone) until
bowel movement, senna PRN
C.
Bisacodyl suppository daily until
bowel movement, docusate daily
D.
Bisacodyl suppository now, Senna
two tablets BID, Miralax daily,
bisacodyl suppository as needed
if no bowel movement
Case 3
•
SM is an 83-year-old female with Alzheimer’s dementia, CKD 3 and
multiple myeloma who is admitted to the hematology service for
complicated UTI and gram-negative bacteremia. Her course is complicated
by AKI, hyperactive delirium as well as moderate to severe acute on
chronic nociceptive back pain, found to have new lytic lesions in her
thoracic and lumbar vertebrae. Prior to admission her pain is moderately
controlled with acetaminophen, diclofenac gel, heat and massage therapy.
Her pain did not improve with trial of oxycodone 5 mg. The bedside RN
notes that the patient becomes
drowsy and more confused when the
oxycodone is increased to 10 mg, though pain does improve some.
•
What is the best option to manage her pain?
Case 4
•
A patient is brought to the hospital
after being in a severe MVA. The
patient sustained multiple broken
bones and is in severe pain. The
patient is started on multiple analgesic
agents, including opioids. The patient
has received oxycodone 10 mg every 4
hours as needed – averaging 6 doses
per day. Oxycodone is effective and
well tolerated. The patient is expected
to have a mixed severe pain syndrome
for 2 – 3 weeks.
•
PMH
•
A-fib
•
CKD II
•
Psoriatic arthritis
•
Is this patient a good candidate for
celecoxib?
•
Is this patient a good candidate for
methadone? If so, how would you
dose it?
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Case 4
•
The patient above has been using the oxycodone 10 mg for the past
20 days, an average of 6 doses per day. The patient’s condition and
pain is rapidly improving and is planning discharge tomorrow to a
rehab facility related to injuries sustained from the accident. Should
the opioids be tapered? If so, recommend a tapering plan.