Opioids in Chronic Pain

Abstract

Mr. Walter is a 55-year-old man with chronic low back pain. He underwent three back surgeries—including a fusion procedure, epidural steroid injections, facet blocks, and numerous medication trials—without benefit. He is a chef and restaurant owner, but his pain has prevented him from cooking in the restaurant or spending more than about 2 hours a day at work. He had been treated with nonsteroidal analgesics, but developed anemia from gastric ulcers. A trial of tramadol was unsuccessful. Mr. Walter’s examination revealed pain with postural changes and restricted motion in his lumbar spine. He had no leg weakness, reflex changes, or numbness. His doctor diagnosed mechanical back pain and, after ensuring no history of drug or alcohol abuse, treated him with short-acting hydrocodone. Mr. Walter was instructed to take hydrocodone only when his pain was debilitating, and was given 30 pills. Mr. Walter called the clinic after 1 week, reporting good results from the hydrocodone, with mild constipation controlled by adding prune juice to breakfast and no cognitive effects. He requested a medication refill. The partner of Mr. Walter’s treating physician authorized four refills. Mr. Walter returned to the clinic in 1 month and reported great satisfaction with his medication. He reported he could now grade his pain with a score of 6, on a scale of 1–10, instead of 9, and that he was sleeping better at night because his pain diminished and was able to spend 6 hours a day at the restaurant. He had even restarted cooking for some meals. In addition, he had resumed his stretching and flexion exercise program, now that his pain was better controlled. Although encouraged by this good report, Mr. Walter’s doctor was surprised to see that in 1 month, Mr. Walter had used 150 tablets. The doctor angrily asked why Mr. Walter was using the medication so frequently, reminding Mr. Walter that he was instructed to use hydrocodone only for severe pain. Mr. Walter replied that his pain was always severe, and hydrocodone effectively relieved his pain, but only for approximately 4 hours. Therefore, Mr. Walter was taking hydrocodone four times daily. The doctor discontinued hydrocodone and requested consultation at a drug abuse facility.