Clinical Conundrum Thursday

Mr M. is a 58 year old man with severe, chronic neck pain.  He has a history of hypertension, tobacco dependence, stomach ulcers, mild kidney disease, alcoholism (in remission for 10 years), and a “bleeding problem”.  He has no history of heart disease, stroke, depression, or diabetes.  His family history is significant for heart disease in his father and alcoholism in his mother and two of his siblings. He was referred to you by a friend after expressing dissatisfaction with all his previous doctors.

His neck pain began nearly fifteen years ago after a minor traffic accident.  He has had multiple imaging studies that show significant arthritis of the spine at the level of the neck, but no compromise of the spinal cord.  There is some pressure on the nerves exiting the neck that supply the right arm.  He has some pain in that arm, but has full use of it.  His pain prevents him from keeping a steady job, and he often feels so bad that he doesn’t bother to eat.

A surgeon offered to operate on several occasions, but warned the patient that the bleeding problem would increase the risk.  He takes ibuprofen tablets by the handful throughout the day, which gives him significant relief.  He says that he has been told that the ibuprofen caused his ulcer, which bled bad enough to land him in intensive care and required a transfusion of eight units of blood (that’s a lot of blood).  He saw a pain specialist who tried a few different medications, but would not use any narcotics because of the risk of  “addiction”.  His previous family doctor also warned him against using any narcotic pain relievers.

Today in the office, he appears tired and thin.  His blood pressure is elevated, and his brow is furrowed.  He turns his head carefully when you walk in the room.   He has full strength in all his extremities, except for some equivocal weakness in his right hand.  The rest of his exam is normal.  Laboratory examination shows mild anemia and some kidney dysfunction.  His blood is negative for alcohol and for drugs of abuse.  You review his MRIs which are consistent with what he has told you.

The patient tells you that you are the last resort; he practically begs you for help.  He has heard so many good things about you.  He has heard of some pill that starts with “V” that really helps some people.

How would you approach this case?

35 Comments

  1. Galwayskeptic

     /  December 2, 2010

    A magic pill that starts with a “V”… Gregory House, you have a lot to answer for. 😉

  2. aLan

     /  December 3, 2010

    Just give him the Viagra and leave him alone for 15 minutes, the stiffness will have subsided by then.

  3. leigh

     /  December 3, 2010

    sounds like to start the discussion, he at least should be clearly informed that vicodin is a narcotic, with a thorough explanation of the positives and negatives of narcotic therapeutics.

  4. CanadianChick

     /  December 3, 2010

    Ok, I’m not a doctor, I don’t even play one on TV, but can I play??

    First, if he’s taking a shitload of ibuprofen, and it seems to help, he needs to be put on a stronger NSAID to save his stomach. Could be that the “v” medication he’s referring to is Voltaren, which is effective but damn nasty on the stomach. Maybe something like ketoprofen or Celebrex. Might want to also consider a PPI to protect the stomach.

    Car accident and long standing neckpain since – could it be thoracic outlet syndrome? I don’t know how well established that is, but when I read court documents related to car accidents, that pops up frequently. There doesn’t seem to be any universally accepted treatment beyond physiotherapy & cortisone. Botox, xylocaine and surgery are mentioned a lot but with chequered success IIRC.

  5. BB

     /  December 3, 2010

    And to add to what Canadian Chick wrote (I’m not a physician,nor do I play one on TV), cannot the patient be given Cytotec or something like it to protect his stomach along with Voltaren or another, better NSAID? Could he have meant Vioxx?

  6. Jimbo Jones

     /  December 3, 2010

    If ibuprofen is causing him to have ulcers and, by extension, bleeding, that’s the immediate target of the first consult. Like CanadianChick said, sub in something stronger/easier on the stomach/non-ulcer-generating. This is all very temporary, though.

    With regards to the ‘v’ drug, I’d make sure I knew what was being asked for. If vicodin, I’d be extremely wary of providing it, but open to the idea. Either way, I’d explain the differences between the effects of ibuprofen, that did work in the past, and the drug that he wants, going through how it may not provide the same relief. The narcotic nature of vicodin would also be brought up. Given the history of alcoholism, I’d want some idea of his liver function, especially given that his kidneys are already starting to fail. I’d bring up that both liver function and kidney function are likely to worsen under any painkiller regimen, but that vicodin is noted for being particularly nasty on livers (apparently; source is wikipedia and therefore untrustworthy…)

    For further treatment, he clearly needs some permanent relief. I’d set up a consult with a psych to evaluate whether his depression can be helped with either CBT or drugs, depending on which type I’m sending him to. Given the elevated blood pressure, I think I’d be sending him to a psychologist and hoping for CBT to work. I’d explain this as not that I think it’s in his head, it clearly isn’t, but I’m wondering if the psych can help him deal with it better.

    But it sounds like this patient’s problem isn’t likely to be fixed with anything short of surgery. Maybe look into treating the bleeding problem with clotting factor transfusions, at least for a period before and after the surgery? If the alternative NSAID doesn’t have any effect on his ability to clot, keeping him out of pain well enough to function is key to keeping his spirits up. I’d want to talk to the surgeon who offered to operate and get said surgeon’s opinion on how to reduce risk factors for the patient, as well.

    I hope insurance costs aren’t going to ruin my little fantasy spending spree…

  7. Dianne

     /  December 3, 2010

    I’m not a neurologist, rheumatologist, or orthopedist and really don’t know what, if anything, can be done about the underlying arthritis. Given the number of people who haven’t been able to do much, I suspect that the answer is “not much”.

    So, to address the pain control issue: He needs to get off ibuprofen. It’s destroying his stomach, leading to life threatening ulcers, and may be contributing to the kidney failure. It’s also pretty clearly not working. When someone comes to you emaciated because they are in too much pain to eat, they’re probably not drug seeking.

    I’d go for a narcotic. The risk of addiction is high, but he’s already spending his life in pain, without a productive job because of the pain, and destroying his body with “non-addicting” pain meds. If he is able to function on a stable dose of narcotic pain meds, I’d suspect his life will get better, even if he is, technically, addicted to them.

    I suspect the “v” drug is vicodin. It wouldn’t be my first choice. I think he’d be better off with a long acting narcotic like MSContin or Oxycontin, which will release the drug into his body slowly, avoiding the buzz and crash that short acting pain meds would give. It might be necessary to hospitalize him on a PCA pump to determine his needs, then convert him to long acting narcotics. Then get him to stop the ibuprofen before it kills him. If he needs breakthrough pain meds, I’d say this might be a case where celebrex could be of use. (Though it does have some increased risk of cardiac disease associated with it so better treat the tobacco addiction and hypertension promptly.)

    • This would be my general approach as well—dose finding with a short acting agent perhaps, such as oxycodone, and then conversion to long acting narcotic with short-acting narcotic for breakthrough, along with cbt if possible, and a signed narcotic contract with all of the caveats.

      • Mike

         /  December 3, 2010

        I always lol @ the abbreviation “CBT”.

        Nevertheless, I think it’s a good idea. I noticed that few people yet mentioned behavioral/psychotherapeutic interventions.

        All the pharmacological stuff already said seems sane to me, but:

        I’d make sure to recommend him to a chronic pain support group. It (probably) wouldn’t help his symptoms at all, but if he were open to it (and this is very possible, since it’s likely he’s had experience with support groups as a recovered/recovering alcoholic) it could greatly improve his quality of life. I’d be worried about the connotation that referring him to a “chronic” pain support group would have (ie. that I couldn’t cure his pain,) and I’d be sure to make it clear that while I could help his pain, I probably couldn’t do away with it completely; just make it more manageable.

        Dietary counseling would also be something to think about – working with the patient to figure out ways/foods he could eat even when he’s in pain, to help keep his overall health from deteriorating too much more.

  8. Dianne

     /  December 3, 2010

    Then there’s this “bleeding problem”. The first thing that requires is more history. When does he bleed? Has he always had this problem or is it a new problem? Does he bruise easily? Do his gums bleed when he brushes his teeth? Does he ever have joint bleeding or deep tissue bleeding? Has he ever been hospitalized with bleeding? Has anyone in the family had a similar problem? These sorts of questions might help determine if he has a coagulation or a platelet defect. Screening labs would include a PT/PTT and CBCD.

    My strongest suspicion is that the bleeding problem is a drug effect-another reason to get off ibuprofen since NSAIDs inhibit platelet function. However, he could have a lot of things. The differential on the coagulation side might include hemophilia, acquired factor deficiency (liver damage being the most likely etiology there), acquired factor inhibitors (probably due to cancer-always in the differential of a smoker), or even a lupus anti-coagulant. If the last, he was probably told he had a “bleeding problem” based on a prolonged PTT. However, his problem is not going to be bleeding but clotting. On the platelet side, ITP, drug effect, vWD, a number of exotic platelet activation defects, secondary thrombocytopenia (again, likely related to liver dysfunction), MDS, and other bone marrow failure states are possible. Finally, he might have pseudothrombocytopenia, in which the apparent low platelet count is due to clumping in the tube and there is no in vivo problem at all.

    In short, it could be anything. More information please?

    • Well, in my own mind (since the case is made up) i was thinking vWD for this guy.

      • Dianne

         /  December 3, 2010

        Oops. After commenting I re-read the post and realized that you’d said that the CBC showed only mild anemia, which eliminates all the platelet number problems. VWD is another reason for him to get off the ibuprofen. On the other hand, it may have some protective effect as far as heart disease goes so maybe it’s not all bad for him. Also there’s no reason he can’t have surgery with proper preparation, which might include DDAVP or humate-P, depending on the type and severity of his disease, and monitoring after surgery. Surgeons are such wimps about bleeding issues.

  9. Vicki

     /  December 3, 2010

    This won’t solve everything, but a check for Helicobacter pylori infection sounds like a good idea here. He might have that and damage from the ibuprofen. I’d worry that if we took him off the ibuprofen and the stomach pain continued, he might decide to start taking it again, even if he was getting other pain treatment.

    (I’m not a doctor, and I think the professionals here have covered most things.)

  10. GoatRider

     /  December 3, 2010

    What about physical therapy?

  11. I’m a recovering alcoholic – I think I’ve said that before. When I had meningitis, my doctor exhausted every non-narcotic he could think of before he sat down on my bed and told me that morphine was really the only other thing he could try.

    I was terrified, but he promised me that he would not discharge me from the hospital without a good plan and extensive follow up. I successfully navigated that course with his help.

    I know, we addicts scare doctors. But if you’re like me and probably like him, we’re scared too. And good conversation and planning can get you through it.

  12. I’d go for a narcotic. The risk of addiction is high, but he’s already spending his life in pain, without a productive job because of the pain, and destroying his body with “non-addicting” pain meds. If he is able to function on a stable dose of narcotic pain meds, I’d suspect his life will get better, even if he is, technically, addicted to them.

    I’m not a doctor either, but this seems sane to me. Without some serious pain management, this guy’s life is going to suck (and if he keeps taking the Ibruprofen, probably end soon) anyway. If the choice is between a risk that his life is going to suck due to a drug problem vs. the certainty that his life is going to suck due to unmanaged chronic pain issues… seems like a clear choice.

  13. chall

     /  December 3, 2010

    My first reaction was that if he is an alcoholic (even if he doesn’t drink now/anymore) his liver function is probably permanently damaged and therefore the “handfull of ibuprofene” a day is making things much worse. Even if he isn’t anemic, his body is most likely not doing things the “regular” way (i.e. nutrient uptakle etc). It’s not unusual for former addicts to have major traumas in their organ tissues as you probably know very well?!

    I’d think that the risk of him getting addicted to narcotics compared to the fact that he clearly already is addicted to ibuprofene (which is making his liver and bleeding ulcer worse) is comparable. I mean, if you were alright we treating him at the hospital or do a dose dependant slow release narcotics, I think that would give you a better base line to assess him and his pain?

    I wouldn’t go with Vicodin though. It’s too linked to “fast addiction”… slower acting drugs would be less obvious addiction triggers.

    Oh, I’m not an MD but have experience with alcoholics and pain management.

  14. Give him a prescription for some fucken opiates and let him start to enjoy his life. This fucken puritan bullshitte that people should suffer because drugs that make you feel good are evil is fucken despicable.

    • Dianne

       /  December 4, 2010

      While I basically agree, it’s not that simple for a couple of reasons:
      1. If I read Pal’s scenario correctly, the patient is concerned about addiction and may be reluctant to take narcotics.
      2. The life of a narcotic addict isn’t all fun and games and he’s at high risk for addiction.

      So it’s not as simple as tossing him a random narcotic and telling him to go wild. It has to be the right narcotic in the right dose to maximize pain control and minimize addictive potential. And only after discussing the situation with the patient and ensuring that he’s willing to take narcotics. If he’s unwilling for any reason then this plan is off the table and we have to think of something else.

      • It’s a lot fucken better to have a controlled addiction to an opiate that alleviates his suffering, than to be in the state he is in now as described. The motherfucker isn’t even fucken eating, he’s in so much distress. The only reason addiction per se is considered intrinsically bad is because of this puritan bullshit that anything that feels good is evil. Yeah, uncontrolled escalating addiction is bad. But a controlled addiction that allows this poor fucke to eat again is good, even if he is technically addicted.

        • GoatRider

           /  December 4, 2010

          Comrade, I’m not against profanity, but when you use it like punctuation, what are you going to say when you really need emphasis?

        • Dianne

           /  December 4, 2010

          I fuckin agree. But he should get the option that gives him the best chance of a controlled addiction or even if he’s really lucky no addiction rather than the first narcotic that comes to mind. Hence the whole discussion above about use of long acting narcotics and other methods to reduce his chances of ending up in a different circle of hell than he currently inhabits.

          • Who the fucke said he shouldn’t get the best possible option? My point is that as things stand now, avoidance of opiate addiction per se is granted much too much weight in the chronic severe pain decisionmaking process, and for reasons that have nothing to do with the wellbeing of the patient and everything to do with bullshitte puritanical thinking. Capisce?

    • Dunno about the fucken US, but in the fucken UK the fucken War On Drugs and fucken Harold Shipman leave doctors fucken wary of prescribing anything even slightly fucken addictive even if it’s in the patient’s best fucken interests.

  15. He has what I would call “classic” low nitric oxide. All his symptoms fit a low NO etiology (but maybe not the bleeding so much). The anemia is a response to the low NO, hemoglobin is the sink for NO, when the basal NO level goes down, hemoglobin levels go down too.

    I think it started with the car accident. It was probably being hit from behind. Minor in that there were no immediate injuries, but a sudden shock like that can trigger a “fight or flight” response in a heart beat. Not resolving that “fight or flight” physiological state is what leads to chronic low NO and all of these symptoms of chronic low NO. I think he confabulated the timing of the car accident and becoming sober. Accidents while under the influence are much less likely to lead to the chronic symptoms often called whiplash (which sounds like what he has) because alcohol blunts the transition to fight or flight.

    The arm pain and hand weakness might be carpal tunnel which would be easy to fix with surgery.

    I would ask about sleep, my guess is that he has terrible insomnia (also a sign of low NO). I would check his B12 status. His diet is probably crap and not enough. He needs to start eating lettuce, a couple of times a day (for the nitrate). I would look for autoimmune stuff, ask about Raynaud’s. He needs major stress reduction. I would ask about situational stress/anxiety and consider a beta blocker for blood pressure. Propranolol might be a good choice because it is non-specific. If some of his problems are due to non-specific adrenergic effects secondary to stress from pain, propranolol might help. It does reduce portal hypertension which might explain some of the stomach bleeding.

    You have to get him off ibuprofen and on to an opiate. You need to use your anti-addiction bedside manner and assure him that if he follows your instructions, you will not let him get addicted, and will stay with him until he is through this thing, and point out that he already is addicted to ibuprofen. It sounds like he is quite motivated to stay not addicted, and may be shocked if you call his ibuprofen abuse an addiction, but explain that one definition of addiction is when you require something to physically function and that something is adversely impacting your life (which the ibuprofen is). In any case addiction to opiates is a lot more benign than addiction to alcohol (medically, not legally).

    I don’t know enough about which opiates to recommend one. Conceptually I like morphine because it is more “natural”, in that humans do synthesize small amounts of morphine. It does act as a signaling molecule and helps trigger resolution of the fight or flight state. Doses to do that are much below the doses needed for pain. It is good for peripheral inflammatory pain, and the pathway you want to trigger is discussed here:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840166/?tool=pubmed

    I think, given this patient’s addiction history, that you want to start him on opiates very slowly, and only gradually go up, with the objective of making the pain more bearable and reducing the stress response secondary to the pain for long term resolution of the stress-pain-stress-pain cycle rather than producing a pain-free state (which would likely result in tolerance, higher self-dosing and addiction).

    What he really needs are my bacteria, but they are not available yet. 😦 The pain he is experiencing is (mostly) due to a low NO status, not a specific thing that can be otherwise treated. Every treatment other than raising his NO level doesn’t get at the core problem and his body will mostly compensate for by lowering NO levels even more. I think that lot of patient contact during the transition off ibuprofen and onto an opiate (maybe even daily) will be helpful to him via a combination of placebo effect and stress relief (they are essentially the same) due to the contact. Once he appreciates that he can rely on you to help when ever he needs it, stress from that worry will go down.

  16. CanadianChick

     /  December 4, 2010

    What about something like tramadol for the pain to start? It’s an opioid but isn’t it generally considered to have a really low dependency profile? I know it’s been a huge benefit for me (acute RA) – I don’t like the brain fuzzing effects of most narcotics – I will lie about my pain levels to NOT get narcotics (leading to amusing conversations in the ER), but tramadol (or tramacet) hasn’t caused that for me, not even to the mild degree of codeine.

    If that provides SOME relief, it might be easier to sell the patient on something a bit ‘heavier’ for relief from more severe pain.

  17. I’m betting that tramadol won’t do a damned thing. Assuming that there are no surgical interventions that are practical or useful, pharmacologic therapy with opiates is very reasonable.

    • Dianne

       /  December 5, 2010

      Any thoughts on combined therapy, maybe narcotics and something like a tricyclic antidepressant in neuropathic pain dosage? (If any TCAs can safely be given in a person with shaky kidneys and unknown but probably moderate to poor liver function.)

    • Dianne

       /  December 5, 2010

      Two other random thoughts: One, even if surgery is an option, unless the operation is going to take place in the next 24 hours, opiates might still be a reasonable short term option. In fact, a short course might be less likely to have risk of addiction. Two, this might be a case where methadone is useful: it can be effective in chronic pain without having as much risk of addiction and need for increased dosage. Some sickle patients love it, as long as you make it clear that you’re not giving it to them because you think they’re addicts.

  18. The problem with tramadol is that it has serotonin releasing properties and so there is a risk of serotonin syndrome. It also has norepinephrine uptake inhibiting properties which is something I think would not be appropriate. I like that it is a very specific mu-opiate receptor agonist, but via a metabolite which involves the liver and this patient likely has impaired liver function so dose regulation becomes more complicated and it isn’t clear how tramadol would work for him.

    He is likely going to need long term pain management, and using something that messes with serotonin and norepinephrine is going to complicate that.

    A cannabinoid might help a lot and reduce the required does of opiate needed.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925209/

    Of course that is much more problematic from a legal standpoint than opiates.

  19. DLC

     /  December 6, 2010

    Late to the party.
    I like the pain control angle, but I’d also like to look at possible root causes.
    But let’s get the pain controlled first, and get some weight back on him.
    That blood loss is scary, but if it’s in the past and he’s not losing more blood then it’s not an issue (yet).
    the arthritic build up of calcium might have it’s roots in a hairline fracture of one or more vertebrae.

    and now for the humor portion of the program:
    [silly] I have no doubt that it’s a subluxation of the meridians and can best be helped by Zen Feng shuei chiropractic.

  20. OleanderTea

     /  December 6, 2010

    How about setting the guy up with some epidural and/or soft-tissue injections of cortisone and/or local anesthetic (after doing appropirate imaging studies, of course)? Obviously epidurals are limited but a series could well bring him relief.

    (Insert “I am not an MD, just a chick with chronic pain” statement here.)

  21. Robert S.

     /  December 10, 2010

    Re: Oleander ^^^ I’m not an MD either, but am a bloke with chronic pain.

    It sounds like he is currently dependent on NSAIDs at clearly dangerous doses to get through the day. I know my life was significantly improved when I was switched from NSAIDs +Tricyclics to a relatively low dose of methadone (are there any longer acting/slower on/offset opioids?) . Starting with an opioid that is of shorter action and finding if it gives better relief, then switching to a longer acting drug with less abuse potential while surgical options are explored seems like a fairly conservative approach. Until the pain is managed, I don’t see how anything else can go forward with any chance of success.

  22. SurgPA

     /  December 11, 2010

    Pal,
    I’m late to this party, intrigued by the scenario and your clinical conundrums in general; keep’em coming.

    I’ll side-step the medical disease workup of anorexia, bleeding disorders, GI bleeds (although a former drinker with anorexia, “bleeding disorder” prior GI bleed and heavy NSAID use has a broad differential to sort through.) Similarly, I won’t rehash the narcotic vs non-narcotic discussion, although am I the only one who thought the “V” med was valium? Anxiolytic and antispasmodic – I’ve seen this used before for paraspinal muscle pain. I don’t think narcotics are out of the question for this patient, although my bias is to first try to “fix” the underlying problem.

    Toward that end, I want to know more about what aspect bothers him the most and what surgeries were previously offered. Is the radicular (arm) pain the most bothersome? If so, a nerve root decompression could be very effective. Does the worst pain seem arthritic in nature? An interventional pain specialist might try a facet block for an arthropathy (assuming the “bleeding disorder” can be diagnosed and managed.) I don’t know how effective a C-spine fusion would be; I’ve never been convinced that non-radicular pain gets dramatically better with surgery, but I could be convinced by data.

    In particular, I’d want to know what his goal is. If he expects to be made whole and pain-free, you’re being set up for failure and a frustrating relationship. I’d want to clarify what I think are realistic goals of therapy, focusing on functional outcome (identify the experiences he can no longer do and wants to, and determine strategies to enable him to do those.) Obviously, chronic pain is depressing, so screening/treating depression is important.

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