please answer all the questions the attached 2 filed and make sure to answer questions correctly.

PAIN 708 Module 4 – Risk Reduction and Harm Reduction

Case Homework

Patient Case 1, Part 1:

Date: 02/21

VAS: 8/10 7-day average: 8-10/10

Calvin Peters is a 55-year old patient who presents to the pain management clinic for a follow-up visit for radicular pain that radiates down bilateral arms. Prior history of cervical pain s/p cervical fusion in 2011 and Osteoarthritis since 2014. Today he states that his pain has been worsening due to the cold weather. He describes his pain as stiffness in the neck and shoulders, which gets worse at night, causing the muscles in his arms and neck to “twitch”. He also states he has a “shooting” pain radiating down both arms. His pain causes frequent awakenings throughout the night. Since being laid off from his job 4 months ago, he states he hasn’t felt himself lately, and that he has trouble finding interest in his daily activities. He recently started gardening as a hobby, which although has helped improve his mood, has caused worsening pain and stiffness in his knees.

Pain quality: persistent dull ache and stiffness in the neck and shoulders; shooting and burning sensation radiating down bilateral arms; increased swelling and tenderness of bilateral knees.

Activities: Able to perform all ADL, but with significant pain

Aggravating factors: Lying down at night; cold weather; sitting on his knees while gardening

Alleviating factors: medications; changing sleeping position multiple times during the night

Time/Consistency: persistent pain at baseline; cervical pain worse in the evening; morning stiffness and pain in the knees

Side effects: none reported

Goals for therapy: Patient states that his goal is to be able to play with his grandchildren and to help his wife more around the house

Review of Systems:

Sleep: Wakes up 3-4 times a night due to pain and has trouble falling back asleep

Energy: Low, decreased since being laid off from work

Mood: “Down”; “not myself lately”

Appetite: “Good”; three meals a day and snacks in-between meals.

Weight: no recent changes in weight

Bowel function: one bowel movement every other day

Mental status: alert and intact cognitive function

PMH:

Chronic persistent cervical pain, s/p cervical fusion in 2011

Hypertension

Osteoarthritis

ADHD

Social Hx:

(-) EtOH

(-) Recreational drug use

(-) Tobacco

Family Hx:

Father – MI 2009 (Living)

Mother – T2DM (Living)

Allergies:

Sulfa – rash

Current Medications:

Hydrocodone-acetaminophen 5 mg/325 mg; 1-2 tablets PO q6hr PRN; reports taking 2 tablets q6hr consistently Oxycodone ER 15 mg PO q12hrs; reports 1 tablet q12hrs consistently

Atorvastatin 40 mg PO QD

Lisinopril 10mg PO QAM

Aspirin 81 mg PO QD

Tylenol 8 hr arthritis pain ER tablets PO TID; reports taking 1 tablet TID consistently

Dextroamphetamine-amphetamine XR 20 mg PO QAM

Medications previously tried and failed for pain management:

Nortriptyline- Patient experienced dry mouth; patient also reported ineffective

Vitals (02/21):

Physical Exam:

General: Patient appears well nourished; appears to be in moderate distress while grasping and massaging neck, shoulders, arms, and hands

HEENT: PERRLA, EOMI

Respiratory: CTAB, No rhonchi or rales

Cardiovascular: RRR. Normal S1, S2. No M/G/R

Abdomen: Soft, non-tender; (+)BS

Neuro: alert and intact cognitive function

Labs (02/21):

1. Explain the pathophysiology of CP’s pain; in other words, is CP experiencing neuropathic pain, nociceptive pain, or both?

1. Describe how CP’s chronic pain has affected his quality of life. What should CP expect from the treatment and management of his chronic pain?

1. Assess CP’s PEG Pain Screening Tool at this visit and explain why pain assessment tools are an important factor in treating pain.

1. Use the PQRST-U method for pain assessment to assess patient CP.

1. Assess CP’s CURES Report. Explain your assessment.

1. Assess CP’s UTOX. Explain your assessment.

1. Calculate CP’s Morphine Milligram Equivalents (MME) per day based on his reported use of opioid medications. Differentiate MME calculations from equianalgesic dosing.

1. What is your assessment of CP’s pain and is he indicated for changes to his current regimen?

1. What changes to CP’s pain medication therapy would you recommend and why?

1. Per CDC Guidelines, what non-pharmacologic treatments have been shown to be effective in managing chronic pain? What non-pharmacologic treatments would you recommend to CP, if any?

Patient Case 1, Part 2:

Date: 05/19

VAS: 4/10 7-day average: 4-5/10

Patient CP returns to the pain-management clinic for a follow-up visit. His mood appears to be improved since last visit and he states that his pain control has also significantly improved after implementing all of the recommendations you, the pharmacist, made at his previous visit 3 months ago. He reports adherence to all medications that were recommended at last visit. He continues to take his opioids as follows:

• Hydrocodone-acetaminophen 5 mg/325 mg; 1 tablet PO q6hr PRN Pain (takes 1 tablet every 6 hours consistently)

• Oxycodone ER 15mg; 1 tablet PO PO q12hrs (takes 1 tablet every 12 hours consistently)

The patient expresses interest in stopping his opioid therapy but admits that he is scared to suddenly discontinue medications that he has been taking for so long.

1. Is it safe to discontinue CP’s opioid therapy at this visit? Why or why not?

1. Come up with an initial recommendation for CP to begin his opioid taper.