Pain control in patient with GI bleed, alcoholic

[sprtsmeddoc]

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How would you manage arthritic joint pain in this patient?

 

[Quito]

I do addiction medicine and pain and use gabapentin to decrease pain, anxiety, and alcohol cravings. The use for anxiety and alcohol cravings is off-label.


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[clubdeac]

Celebrex and Gabapentin are a miraculous combination in my hands 😉 make sure to add protonix. Or just go the turmeric route

 

[lobelsteve]

Ice, heat, topicals. Injection.

 

[Ducttape]

If he keeps drinking.... he will go into hepatic encephalopathy...

no, that’s too cynical.

if he has had a GI bleed, there’s a good chance he has esophageal varices and end stage liver dx. Options are limited.

I always recommend gentle water based exercise and CBT, but if end stage, consider palliative care referral and they can consider end of life treatments...

 

[sprtsmeddoc]

Attending recommended topical NSAID, said there is minimal absorption so not worried about exacerbating GI bleed. Otherwise, he said "refer to pain management, there are specialists for that" Which I'm assuming he means for opioids. Didn't know, in this complicated case, what else could you do besides opioids. Gabapentin can help with arthritis pain? You'd be ok with steroid injection in this case?

 

[clubdeac]

So you’rea resident? Or a patient

 

[sprtsmeddoc]

So you’rea resident? Or a patient

Medical student.


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[lobelsteve]

opiates essentially contraindicated for OA pain in an alcoholic. Sounds like attending wants to dump patient. Needs education.

 

[Timeoutofmind]

Attending recommended topical NSAID, said there is minimal absorption so not worried about exacerbating GI bleed. Otherwise, he said "refer to pain management, there are specialists for that" Which I'm assuming he means for opioids. Didn't know, in this complicated case, what else could you do besides opioids. Gabapentin can help with arthritis pain? You'd be ok with steroid injection in this case?

Topical absorption around 5%
I wouldnt do that in a GI bleeder
I would do ketamine gel instead (has some efficacy in nociceptive as well as neuropathic pain)

 

[kstarm]

Addiction treated first, then pain management. It never works the other way around (outside of acute injury). The number of patients that have improvement in their pain once their addiction is stabilized without any other treatment is high in my experience. Similar if unstable mental health. Agree with gabapentin to help with cravings. The messaging should be treat ETOH before or while we work on pain management.

 

[Bsb2015]

I do addiction medicine and pain and use gabapentin to decrease pain, anxiety, and alcohol cravings. The use for anxiety and alcohol cravings is off-label.


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What's your second "go to" if the patient says the Gabapentin isn't working for pain or cravings? Lyrica? Topamax?

 

[callmeanesthesia]

What's your second "go to" if the patient says the Gabapentin isn't working for pain or cravings? Lyrica? Topamax?

Tizanidine.

 

[SommeRiver]

Baclofen

 

[soccrwz]

topirimate, used for ETOH cravings as well

 

[clubdeac]

Low dose naltrexone

 

[joshmir]

I have heard buprenorphine can reduce alcohol cravings

But has issues with liver disease

Just spitballing about a possible role for Butrans? hard to abuse, could titrate to effect Rx'ing one patch at a time (ie (do not fill until __ date so they could only get one per week)

 

[jonnylingo]

Cymbalta
CBT
low impact exercises

 

[Ducttape]

cymbalta may be linked to worsening liver disease, possibly causing liver disease. probably best to avoid.

CBT, exercise. i was considering suggesting butrans. there is stil some hepatic concerns and would be a no go for me if he was still drinking - unless he is palliative care only.

 

[Orin]

The question is about the risk/benefit for this individual.

SNRI, Baclofen, gabapentinoids are a reasonable start and may treat the alcoholism in addition to the pain.
CBT/PT/TENS/etc won't hurt and could help

Depending on the joint, there are ablative interventions that can be done without steroids.

Topical diclofenac is reasonable, but the efficacy can be very limited. The GI bleeding risks are normally overstated and are similar to vehicle

Adverse Effects (AEs) of Topical NSAIDs in Older Adults with Osteoarthritis (OA): a Systematic Review of the Literature - PMC

To systematically review the literature on reported adverse effects (AEs) associated with topical NSAID use in older adults with osteoarthritis (OA). A systematic search of Medline (1950 to November 2009), Scopus, Embase, Web of Science, Cochrane ...

www.ncbi.nlm.nih.gov

I am a fan of buprenorphine in this population but that requires me to have more faith/trust in them

 

[Baron Samedi]

cymbalta may be linked to worsening liver disease, possibly causing liver disease. probably best to avoid.

Serotonergic medications also lead to platelet dysfunction. I would exercise caution in using on patients with active GI bleeding or other significant bleeding risks.

 

[painfree23]

Serotonergic medications also lead to platelet dysfunction. I would exercise caution in using on patients with active GI bleeding or other significant bleeding risks.

Lol. So what do you tell tour alcoholic patients to do? Never move?

 

[Baron Samedi]

Lol. So what do you tell tour alcoholic patients to do? Never move?

What? I was talking about serotonergic medications.

 

[painfree23]

What? I was talking about serotonergic medications.

Ok, your alcoholics with depression on serotonergic meds?

 

[soccrwz]

R/B discussion, liver dysfunction c/b esophageal varices and getting erosion 2/2 to chronic NSAID use is higher risk. Garlic also causes plate dysfunction, is it clinically significant to tell them to not eat garlic bread, I will leave that to the researchers. Discuss with patient, and hepatologist, document clinic necessity, and R/B/A discussion regarding SSRI, or have a psychiatrist weigh in.

 

[dhcofc]

A true alcoholic may be too high risk to prescribe medications to that could have serious side effects. Why put a target on yourself if they happen to develop fatal or serious side effects? It’s not my fault they’ve drank themselves into a situation where many drugs are a double edge sword.

I think we forget that sometimes it’s okay to say we really don’t have any reasonable options likely to help.

 

[NJPAIN]

A true alcoholic may be too high risk to prescribe medications to that could have serious side effects. Why put a target on yourself if they Happen to develop fate but serious side effects? It’s not my fault they’ve drank themselves into a situation where many drugs are a double edge sword. I think we forget that sometimes it’s okay to say we really don’t have any reasonable options likely to help.

Amen.


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[painfree23]

Amen.


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what if you get targeted for undertreating pain?

 

[Ducttape]

"I have nothing to add to the care of this patient. a referral to the University Palliative Center was generated"

 

[dhcofc]

what if you get targeted for undertreating pain?

I see patient once. Nothing reasonable to offer as far as medications because risk outweighs benefit in uncontrolled alcoholic. See PCP. Hard to argue with that.

 

[Baron Samedi]

what if you get targeted for undertreating pain?

There is not a single procedure or treatment that we, as a specialty, offer that isn't elective.

 

[NJPAIN]

what if you get targeted for undertreating pain?

I think I can defend myself against an accusation of under-treatment easier than I can defend against a malpractice suit for some catastrophic complication resulting from treatment in this train wreck.


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[Aether2000]

There are 360 joints in the human body, so you could inject each of them with 1/3mg depomedrol every month.