DATE: May 9, 2019 TIME: 10:00

NAME: Wick, Byron Palmar

IN-HOSPITAL CHRONIC PAIN CONSULT SERVICE

Thank you for the consult, CC note.

Chart, SCM, and Netcare reviewed. Patient interviewed and examined.

REASON FOR ADMISSION/HPI:

Presented to the Emergency Department with confusion and myoclonic jerks in the context of
an elevated creatinine 1384 and urea 59. Query seizure. His symptoms resolved with a
treatment of Ativan.

REASON FOR CONSULT:

51M longstanding chronic pain since age 11 with opioid use for chronic back pain. Seen by
ARCH who recommends CPS consult. Ongoing AKI that is improving.

PATIENT PROFILE/SURGICAL HISTORY

Past medical history significant for: chronic opioid use for traumatic back pain, Type 2 Diabetes,
Chronic Kidney Disease requiring dialysis, and a seizure disorder
Has had many broken bones and fractures in the past.

SOCIAL HISTORY
Byron is now retired. He lives in downtown with his son. His finances are from Alberta Works, but he
notes that this is insufficient.

SUBSTANCE USE
No Alcohol
No Illicit Substances
Cannabinoids daily: 3 g/daily; acquires cannabis from a dispensary

OPIOID RISK TOOL

0

DRUG ALLERGIES
NKA

CURRENT PAIN OR RELEVANT MEDS IN HOSPITAL MEDD = 80 mg

Hydromorphone 4 mg PO q6h
Today, asked for a breakthrough dose of hydromorphone 3 mg as pain was 6/10

PAIN OR RELEVANT MEDS AT HOME MEDD: 300 mg

Morphine contin 100 mg PO TID
Cannabinoids 3 g/daily
Allopurinol 300 mg Tablet
Gabapentin 300 mg TID
Nabilone 1 mg BID

PREVIOUS PAIN OR RELEVANT MEDICATION TRIALS (Netcare)

Tylenol 3 2016
Tylenol 4 2011- some early fills, 2013
Percocet 2011
Ergotamine/Caffeine 2011-2013
Arthrotec 75mg-200 mcg BID 20111
Baclofen 10 mg BID 2013, 2017
Cyclobenzaprine 10 mg BID 2011-2012, 2016-2017
Clonazepam 2mg BID prn 2013
Temazepam 30 mg qhs 2011
Zopiclone 7.5 mg qhs 2011-2016
Mirtazapine 15 mg qhs 2016-2017
Quetiapine 25 mg qhs 2017-2018

OTHER TREATMENT MODALITIES

Phone consultation with Dr. Chatha and Chronic Pain Center (Dr. Finley) on February 20, 2019
Seen at the FMC Neurosurgery Spine Triage Clinic in 2013

LABS
May 8, 2019
Sodium 143
Potassium 4.7
Chloride 105
Carbon Dioxide Content 21
Anion Gap 17
GFR 14
Creatinine 395
May 3, 2019
PH Venous 7.42
PCO2 Venous 48
PO2 Venous 53
Base Excess 6
HCO3 Calculated Venous 31
O2 Sat Calculated Venous 88
O2 Sat Measured Venous 87
Total Hemoglobin 86
Hematocrit 0.260
Carboxyhemoglobin 1.5
Methemoglobin 0.5
Barometric Pressure 670
Sodium 134
Potassium 4.5
Chloride 95
Lactate, Blood Gas 0.5
Glucose 5.6
Ionized Calcium 0.97
URINE DRUG SCREEN (UDS)
No urine drug screen ordered in hospital admission

ECG
Sinus tachycardia
Right Bundle Branch Block
Left Anterior Fascicular Block
Bifascicular Block
Prolonged QtC 471

DIAGNOSTIC IMAGING
May 6, 2016 PLC Echo – No hemodynamically significant valvular disease
May 4, 2019 Renal Ultrasound – Echogenic renal parenchyma is compatible with nonspecific medical
renal disease; no evidence of hydronephrosis
May 3, 2019 GR Chest 1 Projectoin – Well-Positioned Right Internal Jugular Central Line
May 3, 2019 CT Head – No acute intracranial process
Dec 7, 2017 Chest PA and Lateral – no acute intrathoracic abnormality
Oct 17, 2017 Cervical Spine X-Ray – L4-5 and L5-S1 moderate to severe spondyloarthropathy. C5-6 and
C6-7 severe spondyloarthropathy
June 12, 2017 Abdomen US – Abnormal dilatation of the common bile duct, measuring up to 9 mm for a
patient of this age; gallbladder is underdistened; no gallstones are seen.

PAIN HISTORY
ONSET: Pain began at age 11
LOCATION: Back, neck and left arm
DURATION: Pain is worse during the morning. Morphine usually helps the pain to subside within
30 minutes, and helps reduce pain for about 3-4 hours.
CHARACTER: Pain is a throbbing constant pain
AGGRAVATING: Pain is worse with lying down and minimal movement.
ALLEVIATING: Exercise and narcotics make pain better
RADIATION: nil
TIMING OF PAIN: Pain is worse in the morning after waking up.
SEVERITY: In the morning, pain is 8/10; after medication pain is 2-3/10
SLEEP/ACTIVITY LIMITATIONS/APPETITE: Notes that cannabis and narcotics is helpful for
limiting pain.
PREVIOUS THINGS TRIED: Cannabis and morphine only since age 11
COPING ABILITY/CONFOUNDING FACTORS: Believes that he is coping well; he is motivated to
limit narcotic use but would like to do that on his own. Patient takes anywhere from 0mg to
300mg of morphine contin daily, depending on his symptoms. At times, he abstains from taking
morphine for a few days consecutively if pain is not significant.

EXAM
Appears well; alert and oriented.
Noted that he was having difficulty sitting still, switching positions constantly. Slight tremors in arms
were noted.

IMPRESSION
Chronic Team Assessed Patient on May 9, 2019
51 year-old male with chronic opioid dependence following traumatic back injury at age 11, likely mixed
nociceptive and neuropathic pain.

RECOMMENDATIONS

1. To be reviewed and implemented by patient’s attending physician.

2. Patient’s opioid consumption has reduced drastically since hospital admission (from 300mg
down to 80mg). As a result, we would like to continue with the current hydromorphone
schedule 4 mg PO q6h. Patient has contemplated tapering his narcotic intake and would suggest
that the family physician pursue this further in the community; recommend tapering opioids by
10% q1-2 weeks. We suggest continuing with short-acting hydromorphone due to renal
considerations. We would also recommend utilizing only short-acting opioids due to patient’s
fluctuating pain severity and the fact that patient does not require opioids on a daily basis.

3. Patient could consider restarting gabapentin as renal function improves. post-admission:

maximum dose of gabapentin is 700 mg daily single dose per his current creatinine clearance.
4. We would not recommend patient to restart Nabilone post-admission due to his excessive
cannabinoids intake.
5. Patient should be sent home with Nalaxone kit as well as bowel routine.

6. Patient would benefit from ongoing chronic pain self-management education. I have provided
information to:
a. Online Chronic Pain Management Lectures
https://www.albertahealthservices.ca/services/Page2790.aspx
b. Online video Explaining Pain
https://www.albertahealthservices.ca/services/Page10887.aspx
c. Alberta Healthy Living Program for self – referral to programs such as BCBH Chronic Pain
and Pacing for People for Chronic Pain
https://www.albertahealthservices.ca/info/page13984.aspx

7. I have provided patient information regarding opioid safety http://www.cpsa.ca/wp-

content/uploads/2017/08/opioid-safety_chronic_pain.pdf

8. Upon discharge home, would recommend harm reduction strategies including:

a. Maximizing non-pharmacological therapies and non-opioid pharmacotherapy
b. Opioid taper to lowest effective dose, may decrease by 5 – 10% every 1 to 2 weeks
c. Blister packing of medications
d. Limited dispensing at GPs discretion
e. One prescriber with opioid agreement
f. One pharmacy
g. Random urine drug screens
h. Take home Naloxone/Narcan Kit

9. Our service has no additional recommendations at this time, CPCS signing off. Please re-consult
as needed.

Thank you for involving us in this patient’s care.

Vaneet Randhawa CC3
Chronic Pain Consult Service

IMPORTANT INFORMATION

1. The Chronic Pain Consult Service (CPCS) recommendations are applicable to an inpatient stay at
1 of the 4 adult, acute care sites only. Once the patient is discharged, he/she is no longer
followed by the consult service.

2. CPCS suggestions in hospital may have been fully or partially implemented based on the
discretion of the attending physician and the patient’s needs at the time of stay. Please review
the recommendations once your patient returns to your care in the community.

3. If your patient requires a referral to the Chronic Pain Program at Richmond Road Diagnostic and
Treatment Centre, please review the Chronic Pain Services, Alberta Health Services website for
referral guidelines and forms.

4. For further guidance, please review the College of Physicians and Surgeons of Alberta (CPSA)
Standard of Practice for Prescribing Drugs with Potential for Misuse or Diversion:
http://www.cpsa.ca/standardspractice/prescribing-drugs-misuse-diversion/ and the associated
Advice to the Profession: http://www.cpsa.ca/wp-content/uploads/2017/05/AP_Prescribing-
Drugs-with-Potential-for-Misuse-or-Diversion.pdf.

5. The Chronic Pain Centre Website now includes Opioid Tapering Advice.  Please take a look and
bookmark us at:  http://www.albertahealthservices.ca/info/Page10891.aspx. See all our services
on our Main Webpage:  http://www.albertahealthservices.ca/services/Page10887.aspx.