When starting opioid therapy for a patient after non-opioid therapies have been used, the patient should be started on a short acting drug at the lowest dose possible. In our case study, the patient was taking the short acting opioid at the maximum dosage around the clock, instead of using it when the pain was in the moderately severe to severe range, as prescribed. When taking a pain medication in a way not indicated, the patient can develop a tolerance to the opioid and require a stronger dose to achieve pain control.
As degenerative disc disease is a chronic pathology, this patient will continue to experience pain and requires multifocal pharmacological management. The hydrocodone ordered for the patient was ordered with a maximum dosage of between 40 mg (if the patient took 10 mg hydrocodone every 6 hours) and 120 mg (taking 20 mg every 6 hours). As the patient is already taking the maximum dosage, an extended release equivalent dose would be more effective. The conversion of our patient’s hydrocodone dose to oxycodone, a pure agonist opioid, would be a maximum dosage (which is the current amount the patient is taking) of 80 mg per day (Brennan et al., 2020) dosed as 40 mg every 12 hours. The medication could be written for oxycodone 20 mg 1-2 pills every 12 hours as needed for severe pain with education provided to the patient to start with the lowest dose.
A prescriber needs to be noticeably clear when prescribing these medications and ensure the patient understands how it is being written and signs an opioid contract for how they would take it (Dowell et al., 2016). Another appropriate intervention would be to refer the patient to a pain clinic as they have additional therapies available, in addition to trained addiction therapists and doctors. However, all providers must be aware of the drawbacks of opioid therapy and their potential for abuse. In the elderly population, usage of oxycodone shows a significantly greater incidence of respiratory depression (Kinnunen et al., 2019). As such, our patient must also be prescribed naloxone, an opioid antagonist, and he and other family members must be educated on how and when to use it (Chimbar, 2018).
At some point in their lives most people experience headaches. However, it is important to be able to distinguish a typical headache from a more severe headache such as a migraine, cluster headache, or tension related headache. Migraine headaches have an unclear etiology but activation of the trigeminovascular pathways resulting in an imbalance in serotonergic and noradrenergic neurons is a widely accepted pathology (Goadsby et al., 2017). Migraine headache symptoms include a unilateral pulsatile or throbbing pain indicated in the moderate to severe category, along with photosensitivity, nausea, and vomiting (Goadsby et al., 2017). Migraines tend to effect females three times as often as men. Research suggests that approximately 38% of those with episodic migraines would be benefitted by prophylactic treatment, however only 3-13% utilize it (Ha & Gonzalez, 2019, p. 17).
CM is endorsing severe, prolonged headaches lasting 2-3 days each, at a frequency of twice monthly. Additional symptomatology indicates mild anxiety and difficulty sleeping. In order to evaluate triggers to migraines, CM will be encouraged to keep a headache diary for 30 days in which she documents headache quality, intensity, length of time, other symptoms such as nausea and vomiting, whether or not she experienced aura, food she consumed, medications she took, her menstrual cycle, and the daily weather. If CMs neurological examination is normal and she does not have any red flags such as seizures or swelling of her optic nerve, then an imaging study is not indicated (Charles, 2017). A complete medication history will also be obtained, as some medications, such as oral contraceptives, proton-pump inhibitors, and selective serotonin-reuptake inhibitors can exacerbate migraines (Ha & Gonzalez, 2019).
Most providers agree that preventative therapy should be initiated when migraines occur at least once per week or for 4 or more days per month (Charles, 2017). CM will be provided with a serotonin receptor agonist, commonly referred to as a triptan, such as sumatriptan or zolmitriptan, to take at the onset of a migraine (Ha & Gonzalez, 2019). After CM completes her headache diary, it can be analyzed to determine the best prophylactic therapy. First-line prophylactics for migraines include beta blockers such as propranolol, anticonvulsants such as valproic acid, antiepileptic such as topiramate, and tricyclic antidepressants such as amitriptyline (Ha & Gonzalez, 2019). Venlafaxine has also been used as a prophylactic with good results. Venlafaxine’s mechanism of action is to decrease 5-HT levels which affect development of vestibular symptoms (Liu et al., 2017). As CM uses an inhaler for asthma, beta blockers such as propranolol would not be a good first line option for her, but instead topiramate or venlafaxine would be considerations. Since CM also endorses mild anxiety, venlafaxine would be a good first line therapy for her. Studies show that venlafaxine decreases the number of migraine attacks per month significantly, in addition to decreasing their length and severity (Ha & Gonzalez, 2019). CM will have the maximum benefit in combination therapy, utilizing cognitive behavior therapy and relaxation therapy along with her medication.
References
Brennan, M., Fudin, J., & Perkins, R. (2020). Practical pain management. Opioid calculator. Retrieved September 30, 2020, from http://opioidcalculator.practicalpainmanagement.com
Charles, A. (2017). Migraine. New England Journal of Medicine, 377(6), 553–561. https://doi.org/10.1056/nejmcp1605502
Chimbar, L. (2018). Naloxone effectiveness: A systematic review. Journal of Addictions Nursing, 29(3), 161–171. https://doi.org/10.1097/JAN.0000000000000230
Dowell, D., Haegerich, T. M., & Chou, R. (2016). Cdc guideline for prescribing opioids for chronic pain—united states, 2016. JAMA, 315(15), 1624. https://doi.org/10.1001/jama.2016.1464
Goadsby, P. J., Holland, P. R., Martins-Oliveira, M., Hoffmann, J., Schankin, C., & Akerman, S. (2017). Pathophysiology of migraine: A disorder of sensory processing. Physiological Reviews, 97(2), 553–622. https://doi.org/10.1152/physrev.00034.2015
Ha, H., & Gonzalez, A. (2019). Migraine headache prophylaxis. American Family Physician, 99(1), 17–24.
Kinnunen, M., Piirainen, P., Kokki, H., Lammi, P., & Kokki, M. (2019). Updated clinical pharmacokinetics and pharmacodynamics of oxycodone. Clinical Pharmacokinetics, 58(6), 705–725. https://doi.org/10.1007/s40262-018-00731-3
Liu, F., Ma, T., Che, X., Wang, Q., & Yu, S. (2017). The efficacy of venlafaxine, flunarizine, and valproic acid in the prophylaxis of vestibular migraine. Frontiers in Neurology, 8. https://doi.org/10.3389/fneur.2017.00524
