The missed diagnosis. Melinda Allen, DO, FACOI

Transcription

1 The missed diagnosis Melinda Allen, DO, FACOI

2 62 year old female Previous patient, not seen in 3 years Referred to office for PT/INR control by cardiologist due to difficulty for past 12 months. Mechanical AVR 3 ½ years earlier Nonsmoker, married, retired office assistant HTN, Depression, Alcoholism 20 years earlier, denies any alcohol use Has been seeing cardiologist and using urgent care for acute problems

3 Enalapril 10mg BID Metoprolol 100mg BID Warfarin 10mg QD, varied to 5mg No OTC products other than multivitamin daily and occasional Tylenol. Denies significant changes in her diet. Cardiologist cannot identify the cause of the INR derangements with varying INR s from 1.5 to 5and often over 6. No bleeding diathesis

4 Gave the patient education on how medication works and interaction with diet Switch to non-generic Coumadin only. Avoid all salads and greens, vegetables, etc. (which I rarely tell patients to do) Avoid all OTC products, even occasional Tylenol and Multivitamin Nothing but her prescription medications. RTC in 4 weeks, will work on getting home PT/INR monitoring system in meantime.

5 For acute gastroenteritis, intractable nausea and vomiting for three days, unable to keep anything down, diarrhea, etc etc INR 7 On the first night patient requests something for pain, and IM demerol 50mg and phenergan 50mg given. Little response, and so repeated in 30 minutes. Mild response. HMMMM. I expected a better response than this. Pulled the patient up on the ODT

6 Oklahoma Drug Tracker Wonderful tool! Easy to Use! Underlined, underscored, IMPORTANT Pt was given 30mg Oxycontin 4x daily Last prescription was 29 days ago Prescribed by pain management in OKC for Fibromyalgia

7 Had long talk with patient. (not family yet) Asked about inappropriate use. Patient denied. States her pain doc told her to take off one week every month. I discussed this was unusual approach, and I felt her hospitalization was due to withdrawal symptoms. Patient admitted she had been having some problems on her week off. I discussed other options and Suboxone treatment. Patient restarted on her meds with improvement and discharged to home. She had to discharge her pain management doctor also. (if I was going to manage her coumadin I needed to be in control)

8 Office followup-brought her husband Did discuss opiate action, abuse, addiction, etc. and that Nancy was addicted. Both patient and husband showed some interest in alternative therapy INR was running 3 to 4. Adjusted dose down. Advised cause of abnormal INR s were opiate action and withdrawal Did well for about 2 months, INR 3.0

9 Brought to neighboring ER with confusion, terrible headache, nausea, accelerated HTN. INR 11 CT head showed diffuse intracerebral bleed Life-lighted to Tulsa for treatment Recovered with 14 days of hospitalization and INR correction. Difficulty getting blood pressure under control. I was never called/informed. Happened towards the end of her rx

10 Husband brings her to office. Still having headaches, confusion better. Patient and husband admit that she was in withdrawal at time this happened. Never discussed with treating Tulsa doctor, patient and family were never asked. Husband and patient realize that opiate pain management is no longer an option and that patient is addicted. Are now interested in alternative treatment

11 Cultural change that all suffering is avoidable Many Americans today believe that any kind of pain is indicative of pathology Drug Addicts don t look like Drug Addicts any longer Physicians are not trained to look for withdrawal symptoms Patients/Addicts will do anything to protect their supply as the only reward system activated is now the opiate/dopamine system

12 Mu receptors-pain relief, mood alteration (euphoria and decreased anxiety), respiratory depression, constipation, cough supression, miosis, supression of ACTH, (endorphins) Heroin, morphine, fentanyl, oxycodone, hydrocodone, methadone Partial- Buprenorphine, Stadol +/- (buprenorphol) Tramadol-weak but metabolized to stronger version and inhibits norepinephrine reuptake and stimulates serotonin release Full Antagonist-Nubain (nalbuphine)

13 Kappa receptors- pain, dysphoria, possibly protective against addiction (dynorphin), increase in pulmonary artery pressures, up regulation of mu receptors(in addicts) Pentazosine, Nalbuphine partial-stadol-(buprenorphol) Delta receptors-pain, improved mood, convulsant effect, addiction and nausea, vomiting and pruritis (due to histamine release) Noradrenergic inhibition Changes in brain function can be seen after only one month of daily use and persist for up to 5 months

14 Long term use of opiates causes cells to internalize their mu and delta opioid receptors. Increased opioid levels or potency are needed to generate the same effect. Intracellular second-messenger systems (G-proteins and camp) mediating the activity of opioid receptors are down-regulated in the presence of high levels of potent exogenous opioids. Remaining opiate receptors cannot produce the same response they were capable of.

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16 Chronic user Pet scan highlighting glucose metabolism in red

17 Miosis OPIOD think of pinpoint pupils Respiratory Depression- develop tolerance Constipation Lowered Blood Pressure Lowered Heart Rate Sedation Mental Clouding Calming A tendency to form addiction is energy from a first dose of opiate/heroin due to excess dopamine release

18 Dreaded clinical condition VITALS- Tachycardia, Hypertension, Fever CNS-Craving, Restlessness, Insomnia, Anxiety Muscle cramps, Yawning, Mydriasis, Tremors ENT-Lacrimation, Rhinnorhea GI- Nausea, Vomiting, Diarrhea Skin-Piloerection, Chills, Diaphoresis Restless Leg Syndrome Hypertensive, Runny nose, Restless, Tachy, Back ache, Everything that can squeeze is squeezing! Except the eyes!

19 16 year old female, recurring admissions to the hospital for abdominal pain, nausea. First visit- diagnosed with gastroenteritis 2 nd visit- Gallbladder- abnormal hida scanhad cholecystectomy 3 rd visit- unclear. EGD done. Presumably Gastroenteritis, not improving on PPI therapy Family requested records I recommended a urine proporphyrin level when they picked up records, and gave them information on this

20 20 year old, returns to my practice. Has been diagnosed with Acute Intermittent Porphyria (labs show urine levels 3 above normal) level 47 Difficulty with recurring abdominal pain During the next 12 months admits to opiate addiction. Taking oxycontin from friend (free) I had diagnosed a 28 year old nurse with recurring constipation and abdminal pain with opiate addiction in 2005, never suspected it in Kaycee.

21 No experience with prescription pain management in rotations or residency Experience only in hospital pain management Supply due to cultural changes Desire to get good ratings on patient surveys Time!! Lack of communication between physicians New Diagnosis of Fibromyalgia!! No adverse consequenses for not treating addiction but there are for not treating pain!

22 17 year old male, high school athlete, senior, good grades. Works part-time Friends calling after hours Their son has just been diagnosed with bipolar disorder and they are wanting help Depressed, anxious, acting erratically Have done urine drug screens when his behaviors were bizarre, all clean Diagnosis- Opiate addiction Clue- muscle spasms, restlessness

23 30year to 50 year old (or any age) Family or personal history of abuse of any kind (drug, tobacco, sexual, physical) Insomnia Anxiety Hypertension Restless Leg Syndrome Consider subacute withdrawal or even remote history of cocaine/opiate/marijuana addiction

24 Patient characteristics that affect risk of abuse include Personal or family history of alcohol, drug abuse or addiction History of cigarette smoking Younger age DUI or drug related legal problems History of depression History of childhood sexual abuse-changes in mu and kappa opioid receptors

25 Benefit outweighs the risk Is considered short term (lack of evidence in effectiveness in treating long-term noncancer pain) Discuss with patient when dispensing how long their pain should expect to last If continued requests for pain treatment, initiate the Pain Assessment and Documentation Tool.

26 Four A s Analgesia sufficient to engage in Activities of daily living while Avoiding adverse events and Aberrant medication-related behaviors. Evaluate and compare the patient s current level of function with what the patient might expect to be able to do if prescribed opioids. Set SMART goals. Specific, Measurable, Action-oriented, Realistic, and Time-dependent

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30 Be aware of withdrawal signs/symptoms Everything that can be squeezed is squeezing, (except eyes) Use the tools available Oklahoma Drug Tracker, Urine Drug Screens Pill Counts, Assessment Tools Physician Communication Important Consider all diagnosis Do not profile the patient Opiate addiction crosses all boundaries, races

31 Evaluate pain, is narcotic necessary, how long, give the minimum number of pills necessary, Be SMART! If patient requires more- SCREEN your patient, evaluate their risks, do risks outweight benefit. For chronic pain management, (PADT) Patient Assessment and Documentation Tool and Current Opioid Misuse Measure

32 Questions????????? NIH/ National Institute on Drug Abuse/The Science of Drug Abuse and Addiction Cecil s Textbook Of Medicine-23 rd Edition Wikipedia Medscape US Pharmacist, Opiate Education