Vivitrol and (legit) acute pain

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WVUPharm2007

WVUPharm2007

imagine sisyphus happy
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Time for a moral/clinical discussion...yippee...

Ah, Vivitrol. You block the mu receptor for months at a time. How recovering addicts must love you.

Anyway...dude comes in...admitted...legit pain from trauma. Former Heroin addict...claims he's been clean for months...tox screen actually agrees. Doc calls me...the old wtf do I do thing. There are no guidelines or gold standards for this situation. You can't just give an opioid and expect it to work great. I go with a recomendation of IV Toradol...doesn't do ****...dude was claiming 10 on the pain scale...it only brought it down to an 8 or so...and given the Dx of acute hepatits...I don't really doubt him...

...now...the dude ADAMENTLY refuses to be given an opioid. He says he's made it too far to just take another opioid when it's not even his fault for being around the stuff. I kinda see his point. Now...naltrexone is a COMPETITIVE antagonist at mu...so now my thought is that perhaps we could give a drug that has a higher affinity for mu than naltrexone...my first thought is buprenorphine...when I was at WVU, they used it to "rescue" patients from withdrawal symptoms. Hmm...for a recovering addict...it might be ideal in this situation...

So...pretty much out of options...we go with the Buprenex 0.3mg IV q4h PRN pain if Toradol ineffective.

Now this leaves me with an array of things to consider...how f'ing ethical is it to give the guy Buprenex...it isn't a total agonist anyway...kinda a grey area. I also wonder wtf I'm going to do in a few days because you can only give Toradol for 3 days or so...and I also wonder how effective for PAIN the addition of Buprenex is going to be...

Ah...fun...I'm going to call here in a few and see what happened.
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Stupid question from pre-vet peanut gallery -- what are your thoughts/why or why not for these as adjuncts or part of a balanced analgesia plan?
- IV lidocaine CRI
- ketamine
- alpha-2 agonist
 
these guys who are still awake are tough.

One thing that I've heard from ICU nurses, and looked up a little bit, is that opiate addicts (esp. heroin) need insane amounts fentanyl - but much less morphine, for pain control. Something about the receptors changing conformation.


Ketamine could be an option. I've seen clonidine used in vet medicine here, but not people. Precedex? Also, what about a nerve block?
 
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Buprenex worked. Pt went from 10 pain scale, cringing in fetal position to 4 pain scale, walking around with family within 30 minutes of the injection. LMAO...I was breaking out the receptor affinity charts and ****...

"I am so smart, I am so smart, S-M-R-T....I mean S-M-A-R-T." - Homer J. Simpson
 
WVUPharm2007 said:
Buprenex worked. Pt went from 10 pain scale, cringing in fetal position to 4 pain scale, walking around with family within 30 minutes of the injection. LMAO...I was breaking out the receptor affinity charts and ****...

"I am so smart, I am so smart, S-M-R-T....I mean S-M-A-R-T." - Homer J. Simpson
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It's that 45 caliber thing again. That's why it's great to be a pharmacist. You saved this guy from hell when his doctors had not the slightest clue....
 
so do you get a lot of issues that come up in the grey area? that's what i've heard from some professors in pharmacy practice. they say pharmacists just have to make their own judgment because it won't be written clearly anywhere.
 
crazybob said:
so do you get a lot of issues that come up in the grey area? that's what i've heard from some professors in pharmacy practice. they say pharmacists just have to make their own judgment because it won't be written clearly anywhere.
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Usually, there are guidelines, expert opinions, or even case studies available. Usually in situations where there is no standard, there is an idea of what to do...or the choice is kinda obvious...like the first thing we tried was the strongest NSAID we had lying around - Toradol. That was the obvious choice for this patient...and I think everyone would agree...even though if you check resources or google the problem, nobody spells that one out for you. But it's the expected conclusion any educated clinician would arrive at, IMO. Now when THAT doesn't work...that's when the real freestylin' goes down. And those situations don't come around too, too often...thankfully, to be honest...basing things off of evidence is infinitely better than inventing a hillbilly-rigged, educated guess-based solution...
 
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WVUPharm2007 said:
Usually, there are guidelines or expert opinions available. USually, there is an idea of what to do...or the choice is kinda obvious...like the first thing we tried was the strongest NSAID we had lying around - Toradol. That was the obvious choice for this patient...and I think everyone in the field would agree...even though if you check resources or google the problem, nobody spells that one out for you. But it's the expected conclusion an educated clinican would arrive at. Now when THAT doesn't work...that's when the real freestylin' goes down. And those situations don't come around too, too often...thankfully, to be honest...basing things off of evidence is infinitely better than inventing a hillbilly-rigged, educated guess-based solution...
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That's crap. Necessity is the mother of invention. It made perfect pharmacological sense. No you know why we learn all of that pharmacology.

When Capoten (the first ACEI) was introduced in 1981, it was approved only for hypertension. I was still in school and was very friendly with Squibb rep. I got the entire training binder, about 500 pages with detailed information about the pharmacology and all the studies they had at the time. I went over everything and the first thing I said was "what a great drug for heart failure." There were very few if any studies at that time about ACEI's and CHF. But is you know your stuff, it's as clear as day....
 
Why would you expect to get respect or admiration from the patient if you never see them? Perhaps the attending told him about your role but that's certainly not a given.

Pharmacists as drug consultants should be utilized more, but in terms of ego stroking you picked the worst "medical specialty." You have to talk to patients to get that. Similar story for many other esoteric consultants like radiologists or pathologists.
 
meister said:
Why would you expect to get respect or admiration from the patient if you never see them? Perhaps the attending told him about your role but that's certainly not a given.

Pharmacists as drug consultants should be utilized more, but in terms of ego stroking you picked the worst "medical specialty." You have to talk to patients to get that. Similar story for many other esoteric consultants like radiologists or pathologists.
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Honestly, I really don't care about prestige. If I did, I wouldn't be a pharmacist...and I wouldn't live in a place called "Independence Hill Mobile Home Park".
 
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Fair enough, but seriously, write that **** up as a case study along with the attending. Dealing with acute pain in recovering opioid addicts is a difficult situation and you could help a lot of clinicians and patients.
 
meister said:
Fair enough, but seriously, write that **** up as a case study along with the attending. Dealing with acute pain in recovering opioid addicts is a difficult situation and you could help a lot of clinicians and patients.
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If you Google "Vivitrol acute pain" this thread is the second thing that pops up...
 
Hi there WVUpharm- very exciting stuff, I haven't seen anyone really address this issue of acute severe pain control in IM naltrexone (vivitrol) patients authoritatively anywhere in the literature yet. I'm curious about your Vivitrol patient with the acute pain. I'm an addiction neuropsychopharmacologist (a psychiatrist) at Yale, I'm helping some colleagues come up with a protocol for treating acute severe pain (and other forms of pain) in Vivitrol treated patients before they roll out a major IM naltrexone program at the VA. I've treated a number of patients with Vivitrol but they've never had acute severe pain or trauma during treatment. I've had some patients on buprenorphine have to deal with the issue, but never unexpectedly (planned surgeries, births, etc.). I'm curious about a couple things, but let me start with this; I'm looking at a binding affinity chart for opioids at the mu receptor (from the book Opioids in Medicine by Enno Freye), and it's showing a slightly higher affnity (smaller Kd) for naltrexone versus buprenorphine (.4 nmol/l vs .6 nmol/l)... so I'm curious if that is correct or if you have a better reference for the actual Kds? Is the actual Kd at mu (MOR) lower for bupe than naltrexone? Or were you able to get the concentration of buprenorphine high enough rapidly to outcompete for the mu receptor even though naltrexone has a slightly higher affinity at mu? Buprenorphine has good analgesic effect in an opioid naive person (or potentially in a naltrexone treated former opioid addict, as naltrexone treatment seems to reverse or reset tolerance over time). Do you think it's possible that analgesia could have been mediated through other opioid receptors in this patient, like delta, kappa, or the orphanin/nociceptin receptor? I believe bupe is a nociceptin receptor agonist or partial agonist and so is its metabolite...???
 
I just wanted to add this update to my question/post above: I used this public database PDSP (http://pdsp.med.unc.edu) to look up binding affinities... It shows some published research results showing naltrexone with higher binding affinity than bupe at the MOR, and some just the opposite, with higher affinity values for bupe than naltrexone... Can anyone clarify? Does bupe really have a higher affinity for the MOR than naltrexone????
 
Necro bump!

Although I'm glad because I didn't see this the first time and it's very interesting. Good job, WVU.
 
Nooooo! How did I miss this? I could have been brought to New England for a day of eating crumpets and lobster or whatever the hell it is they do up there in exchange for my hillrigged opiate treatment strategies. Crap.


I wonder how this turned out.
 
We had one of these a couple weeks ago. We did ketorolac and lorazepam.
 
WVUPharm2007 said:
Nooooo! How did I miss this? I could have been brought to New England for a day of eating crumpets and lobster or whatever the hell it is they do up there in exchange for my hillrigged opiate treatment strategies. Crap.


I wonder how this turned out.
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This is one of the best things I've seen on SDN. Particularly the trailer park comment haha.
 
good job WVU, good job thinking about the pharmacology behind it all too
 
WVUPharm2007 said:
Nooooo! How did I miss this? I could have been brought to New England for a day of eating crumpets and lobster or whatever the hell it is they do up there in exchange for my hillrigged opiate treatment strategies. Crap.


I wonder how this turned out.
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We eat a lot of pizza in fancy New Haven. We do have lots of amazing restaurants too, but I can't tell you the last time I ate lobster. Definitely not at a place near Yale. The ridiculous number of food carts more than makes up for it.


If you're really curious, I can see if that protocol was ever implemented at YNHH... not if it was done at the VA though.
 
I've been told that new haven pizza is the shizzle.
 
ucrx said:
We eat a lot of pizza in fancy New Haven. We do have lots of amazing restaurants too, but I can't tell you the last time I ate lobster. Definitely not at a place near Yale. The ridiculous number of food carts more than makes up for it.


If you're really curious, I can see if that protocol was ever implemented at YNHH... not if it was done at the VA though.
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I miss those food carts. The Korean guy is the man.

njac said:
I've been told that new haven pizza is the shizzle.
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New Haven has delicious pizza...can't beat the white/clam combo.
 
"Healthy Chinese food" right?
 
Looks like it worked pretty well since they ordered it 3 more times before transferring the patient to one of the larger hospitals in the network.

Only different thing we did was we went with Buprenorphine 2 mg PO.
 
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WVUPharm2007 said:
I used to be all smart and useful and stuff. Now I count by 5s and take the trash out for a living.

Mike -- A Cautionary Tale.
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Well, the trade off is, life is more stressful when you are smart and continuously frustrated by stupidity in the world....it's much easier just to count & take out trash.
 
If the patient was clean for several months couldn't a few doses of bupe put them back into withdrawal just as if they took an opiate/relapsed ?
 
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