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Case discussion

Multidisciplinary clinical discussion regarding a patient with complex pain

As you have seen over the last four steps, the perioperative pain management of patients with opioid tolerance and opioid use disorder (OUD) poses a number of challenges. In this step, you will observe a multidisciplinary discussion which takes place in order to formulate a perioperative pain management plan for a patient with OUD. Read the case summary below before watching the video, then join the discussion at the end of this step.

The UCLH Complex Pain Team is an interdisciplinary team with experience in the management of complex pain (pain associated with multiple physical and mental health comorbidities, significant polypharmacy, complex psychosocial circumstances or substance misuse) in an inpatient and outpatient setting. In this video, you will see how psychological and social support can be provided practically, in order to complement pharmacological pain management.

Case summary

Alfie is a 59-year-old man with a background of chronic lower back pain and sciatica following MRSA discitis and spinal surgery 10 years ago.
He underwent a hip replacement two years ago which now requires a revision surgery, following periprosthetic infection. He has been referred from pre-assessment clinic to the UCLH Complex Pain Team for a preoperative pain management plan and advice as his surgery has been scheduled in two weeks.
He uses street drugs recreationally: he sniffs cocaine once or twice a month and smokes heroin weekly. He has also previously been diagnosed with alcoholic pancreatitis, and continues to consume alcohol in excess.
He has previously missed many appointments with substance misuse and persistent pain services in the community due to reported difficulty caused by his shift work, although it is likely his chaotic lifestyle and drug and alcohol consumption are also a significant barrier.
One month ago he was admitted to hospital following an impulsive overdose of prescribed opioids. He reported this took place with no suicidal intent and with the intent of “numbing the hip pain”, in the context of an alcohol and cocaine binge.
During that admission the patient’s daughter expressed concern regarding her father’s increasingly chaotic lifestyle and suggested there might have been other episodes of near-overdosing recently.

Medication

  • MR morphine tablets 60 mg BD
  • IR liquid morphine (Oramorph) 20 mg PRN (‘when pain bad at night’)
  • Amitriptyline 150 mg ON
  • Diclofenac suppositories 50 mg BD
  • Lidocaine 5% medicated patches applied directly to the back
  • Thiamine
  • Vit B Compound tablets

Social circumstances

Lives alone, currently not working due to hip pain. Previous shift worker. Has a daughter who tries to be supportive but their relationship is not as close as it used to be.

Your turn now

Use the comments section below to discuss this case.
What features of this patient’s background do you think are particularly relevant to his perioperative pain management?
What do you think would make this particularly challenging?
What do you think are the most important risks factors that should be considered in this case?
Are there any important points you can think of which were not discussed in the video?

Please do not share any details that could be patient-identifiable. You can ‘like’ and comment on other learners’ comments, as well as ‘follow’ other learners so you don’t miss their comments.

This article is from the free online

Opioids and Surgery

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FutureLearn - Learning For Life

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