Plain films are taken; they are positive for osteonecrosis bilaterally. They show involvement of more than 30% of the femoral heads bilaterally, and early collapse of the right femoral head.
Due to the severity of Mr. Smith’s symptoms, and radiographic findings indicating involvement of more than 30% of the femoral head, he was referred to an orthopedic specialist for a surgical evaluation. He returns 1 month later. The orthopedic surgeon was reluctant to operate. The patient has chronic thrombocytopenia due to cirrhosis from HCV infection, and will not accept blood products because of his religious beliefs as a Jehovah’s Witness. As a result, the surgeon did not feel that a total hip replacement, which is what he would have recommended, would be safe.
Mr. Smith's Concern
Mr. Smith is frustrated because he continues to have substantial pain, which is present most of the time. On a scale of 0 to 10, he rates his pain as an 8 at its worst, which is when he is exercising, and a 5 when he is resting. His pain is now not only significantly limiting his exercise, but his ability to participate in his volunteer and church activities. He does not think the ibuprofen is easing the pain to any substantial degree. He is concerned that he will not be able to return to the activities that he enjoys.
Question: Which of the following is the best response to Mr. Smith's concern?
Option 1: Encourage the patient to “work through the pain.”
Option 2: Prescribe a fixed dose of 5 mg of oxycodone and 325 mg of acetaminophen to be taken by mouth every 6 hours as needed for pain, dispense 180 tablets, and schedule him for follow-up in 3 months.
Option 3: Prescribe a 1-tablet dose of 5 mg oxycodone to be taken by mouth every 6 hours around the clock, plus 1 tablet by mouth every 2 hours before exercise and as needed for pain; dispense 120 tablets. Also provide a prescription for docusate and senna. Schedule him for follow-up in 2 weeks. Encourage him to remain physically active during this time.
Option 4: Tell the patient that you would ordinarily prescribe opioids like oxycodone, but because of his history of substance-use disorder, he is likely to become addicted and you would not recommend it.
Discussion of Answer Choices
Option 1: This is not the best response.
This patient has severe, continuous pain, worsened by exertion, which is interfering with the things he likes to do and has had a negative impact on his functional status. There is no reason he should have to “work through the pain” when there are medications such as opioids that may help and merit a therapeutic trial. However, the patient should be encouraged to remain physically active despite his pain, acknowledging that this can be challenging, but is important. Becoming physically inactive often leads to increased stiffness and ultimately increased pain, an important cycle for patients to understand.
Option 2: This is not the best response.
Although this patient’s intake of acetaminophen would not exceed the recommended maximum of 3g/day, it is probably better to avoid acetaminophen if possible in this patient with chronic liver disease. Prescribing oxycodone alone would be preferable. Also, when initiating opioids, it is important to remember that all opioids cause constipation, which unlike other opioids side effects, does not diminish with time. It is prudent to prescribe a bowel regimen, such as docusate and a sennoside, when initiating opioids. Finally, patients started on opioids should be seen back within two weeks, to assess efficacy and side effects.
Option 3: This is the best response.
A 5 mg dose of oxycodone is a reasonable starting dose for someone in moderate pain. Because this patient’s history of injection drug use was many years ago, it is not possible to know how that will impact his current tolerance. It is always preferable to start low and titrate up. Continuous analgesia is provided by the 5 mg dose of oxycodone by mouth every 6 hours on a scheduled basis. He may also benefit from “breakthrough” pain medications for flares, and for use before exercise. This is provided by the 5 mg dose of oxycodone he can take every 2 hours as needed. Doses of the standing oxycodone may be titrated based on his use of “as needed” oxycodone. Once he is on a stable pain regimen, the patient may be switched from an around-the-clock regimen of oxycodone to a long-acting opioid, such as long-acting oxycodone, long acting morphine or a fentanyl patch. All patients started on opioids should be informed that constipation is an expected side effect of opioids, and that they will need a bowel regimen to prevent opioid-induced constipation. Prevention of constipation is important, as opioid-induced constipation can become quite severe and cause significant distress. Typical regimens include a stool softener such as docusate with a stimulant laxative such as senna or bisacodyl, or an osmotic agent such as polyethylene glycol. Patients with chronic pain should be encouraged to remain physically active, as inactivity can lead to stiffness, increased pain and decreased function.
Option 4: This is not the best response.
Patients with histories of substance-use disorders may be safely prescribed opioids without becoming addicted. These patients need more frequent monitoring, and substance-use disorder issues must be addressed, but safe usage can be achieved. This patient is already a part of a substance abuse recovery program and has a therapist. However, it is extremely important that he continue to continue to take part in the recovery program. If he is agreeable, the provider may also let the patient’s therapist know that opioids are being prescribed. This communication will alert the therapist if there are any changes in the patient’s behavior that may need further comanagement or investigation.
It is important to note that if the patient had evidence of a mood disorder such as depression or anxiety, as mood often negatively influences pain regardless of the etiology of the pain, it would be essential to treat the mood disorder before prescribing opioids, or alongside the opioids. However, this is not the case with Mr. Smith.
Regardless, it is important to treat this patient’s disabling pain. A trial of NSAIDS has been ineffective, and long-term NSAIDS should be used judiciously, especially in patients with other risk factors for bleeding (e.g. cirrhosis and thrombocytopenia). Cirrhosis is a relative contraindication for acetaminophen. Therefore, pharmacologically, opioids are the best option, and with close monitoring, the benefits outweigh the risks.
In addition to the pain medications, you also refer him to a physical therapist, who confirms that his pathology is intraarticular, and that physical therapy will provide added benefit.
What sorts of modalities might PT use to reduce Mr. Smith’s pain?
Although there is limited evidence with regard to physical therapy and osteonecrosis, physical therapy has been shown to be beneficial in patients with osteoarthritis. Based on that literature, this patient’s pain may be treated with a variety of modalities including manual therapy, exercise, heat, ice, and ultrasound. Additionally, Mr. Smith might benefit from an assistive device that allows him to decrease weight bearing on his hips, which will help with pain. Given that he is young and athletic, crutches or bilateral canes may be more acceptable to him.
This patient’s pain falls into the category of chronic non-cancer pain. The definition of chronic pain is pain lasting 3 months or more, without evidence of ongoing tissue injury. Although there are no guidelines specific to patients with HIV, the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) drafted guidelines for the use of chronic opioid therapy in patients with chronic noncancer pain. This discussion draws heavily from those guidelines.
Use of opioids in patients with a history of substance-use disorder
Patients without a personal or family history of substance-use disorders are unlikely to develop addiction or abuse while receiving chronic opioid therapy for the management of non-cancer pain. However, patients with a history of substance-use disorders are at higher risk, which often requires a standardized multidisciplinary approach to treatment. The data vary widely, but in these patients, development of iatrogenic substance-use disorders or addiction may be as high as 3%.
The APS/AAPM guidelines state that before prescribing opioids, physicians should assess the patient’s risk for substance-use disorder and addiction. In addition to taking a thorough history, there are also tools such as the Screener and Opioid Assessment for Patients with Pain (SOAPP-R) that can help physicians risk-stratify patients. The risks and benefits of opioids for each patient must be considered.
For example, a patient with a remote history of substance abuse disorder and no affective disorder is a much better candidate for opioid therapy than a patient with active substance abuse disorder and comorbid depression.
For high-risk patients who are likely to benefit from opioid therapy, such as patients who have a more recent history of substance-use disorder and psychiatric illness, the guidelines state, “clinicians may consider chronic opioid therapy … only if they are able to implement more frequent and stringent monitoring parameters. In such situations, clinicians should strongly consider consultation with a mental health or addiction specialist.” This can be challenging, because psychiatric and addiction specialists are often difficult to find, and due to insurance barriers, may be inaccessible to many HIV-infected patients. In some areas, there are pain clinics that also include psychiatric care and substance abuse counseling under one roof. Referral to such an interdisciplinary pain clinic may be the optimal solution for high-risk patients who need an interdisciplinary approach and close monitoring.
For more information on treatment of chronic pain in patients with active or past substance abuse, please refer to the Substance Abuse and Mental Health Services Administration’s Treatment Improvement Protocol, at : http://store.samhsa.gov/shin/content/SMA12-4671/TIP54.pdf
When patients are initiated on opioids, it is important that the patient is aware that the opioid is a “time-limited trial,” which may be tapered if the risk of the opioid begins to outweigh the benefit, or if the opioid is ineffective.
Opioid Misuse Behaviors
Opioid misuse behaviors have been described in the literature, and include a pattern of prescription problems such as lost or stolen medications, and obtaining opioids from several sources. For patients taking opioids, development of opioid-misuse behaviors is more common than addiction. In some studies, opioid-misuse behaviors develop in as many as 34% of patients receiving opioids for chronic non-malignant pain who have a history of addiction. These behaviors are detrimental to the patient, because they reinforce a destructive pattern of behavior. In addition, providers may feel inadequately trained to address these behaviors, which can lead to frustration.
It is unclear whether such misuse behaviors are actually related to addiction. However, despite this, current standard practice is to recognize this pattern of behavior when it occurs, so that it can be addressed with the patient directly. One must always consider the differential diagnosis of such a behavior (e.g. in a patient making frequent calls to the clinic, severe ongoing pain, undertreated depression, personality disorder, in addition to addiction or diversion). Patients with misuse behaviors may be referred to substance abuse counseling, psychiatric care, and interdisciplinary pain settings when appropriate to help with appropriate diagnosis and treatment. During this process, it is important to continue to re-evaluate the risk/benefit ratio of the opioid, but in many circumstances, the opioid may be safely continued with proper monitoring.