Thread by @SaraJPharmD

Ortho rounds last Wednesday- "angry/drug-seeking patient refusing PT" and had just "fired his RN for not caring about his pain."
A (somewhat verbose) patient interaction story + clinical pearls about opioid metabolism:
1/n
ncbi.nlm.nih.gov/pmc/articles/P…

POD1 elective TKA-

Surgeon: How is everything going?

Patient (visibly tense, tearful, diaphoretic): Terrible!! This is the worst experience of my LIFE- I have been in so much pain and nobody cares enough to even try to help me!

2/n

Surgeon: Well you just had a major surgery, you're gonna have some pain...

Patient: (visibly shuts down, stops making eye contact/participating in conversation)

Surgeon: ...well we'll work on it but you have to get moving today, ok?

Patient:

Surgeon: Ok then.

3/n

As the pharmacist on service I:

1) Got orders for maximal multimodal/nonopioid therapies entered and expedited, in concert with patient's "newly hired" RN

4/n

2) Assessed opioid orders- pt was a younger male with no known pre-existing opioid tolerance. Had been ordered oxy 5-10mg PO q4hprn + morphine 5-10mg SL q4hprn BTP per routine opioid naive order set, APAP ATC. Looks like a perfectly reasonable starting point.

5/n

3) Waited for new meds to be passed, then went into room to talk to patient.

Me: Hi [pt's preferred name], my name is Sara. I'm here to listen to you about your pain.

Patient: I just can't believe how much this hurts. Like, I'm not stupid I know there should be some pain...

Patient continued: ... but I don't think I should be laying here crying in pain all night unable to do anything and nobody can do anything about it...I'm completely regretting this, I didn't have to come here you know!

Me: I agree. I'm really sorry you've been suffering.

7/n

Patient: Like the oxy seems to make it tolerable for a while but the morphine does nothing! Well it works for about 15 mins then it's like it never happened, and they tell me they can't do anything for another 2 hours! No one's listening to me!

8/n

Me: I'm really sorry this has been so awful, and I'm most sorry you haven't felt heard.
I want you to know that we're listening, and we've made a lot of adjs, and we're going to do everything we can to get you more comfortable.

Pt (visibly starting to relax): ok...thank you.

Me: (does some more listening, validating, taking ownership, educating on the value of multimodals, explains how the medicines he was given were just a starting point, and that while they work well for many, they will NOT work well for everyone)

10/n

The whole convo took <10mins and seemed to go a long way with the patient.

11/n

1st clinical pearl here is clearly the value of therapeutic listening and taking ownership when something goes poorly for the patient.

Don't forget that non-pharm interventions like edu and CBT are effective analgesics supported by current guidelines.
doi.org/10.1016/j.jpai…

But listening to the patient describe how the medications were working (or not) also gave me valuable insight into another potential opportunity here- altered drug metabolism.

13/n

Recall that opioids are a heterogeneous group of mu receptor agonists ranging from naturally occurring to purely synthetic, and that each drug in this class has a unique constellation of metabolic pathways, I.e. Phase I vs Phase II, active vs inactive metabolites, etc.

Also recall the vast nature of how pharmacogenomics alters these pathways, not to mention pain perception in general. Some refs below and all speak to how LITTLE is well-understood at present.

doi.org/10.2147/PGPM.S…
doi.org/10.1093/pm/pnw…
doi.org/10.2217/pgs-20…

15/n

Available evidence suggests that large swaths of the general population exhibit "non-normal" variants of genes involved in these metabolic enzymes. Many significant clinical implications exist:

As one article puts it: "These differences reinforce the fact that individual patients vary significantly in their response to the “universal” doses of opioids that are used in practice where one dose of medicine can be ineffective to one person and lethal to another."

And guess what? WE DON'T KNOW who's a poor or rapid metabolizer at the enzyme patient pertinent to the drugs we're using the VAST MAJORITY of the time.
Furthermore, we sometimes need reminded that we never really know what another human being is feeling and going through.

18/n

So what should we do? My strategy:
1) Pick a starting point that is thoughtful based on what we know
2) Monitor (=LISTEN)
3) Augment when we get new info
If drug not lasting anywhere near its "usual" duration of action ➡ utilize a different metabolic pathway ✅ before ⬆dose

For this pt, I changed his breakthrough regimen from SL morphine 10mg to SL oxy 5mg. Slightly lower equialgesic opioid dose yet it worked significantly better for him, in his assessment.

20/n

Between changing the BTP opioid to one with a different metabolic pathway (one that we knew worked better for him), maximizing non-opioid multimodals, and listening, we were able to help him achieve better analgesia w/ smaller prescribed opioid doses than Plan A.

21/n

He also ultimately voiced a positive experience and gratitude to his caregivers.

P.S. Surgeons- I'm not criticizing you for not having time or feeling equipped to have these conversations and make these adjustments. Partner with team members who can for best results💪

Thank you for joining me on this lengthy #medtweetorial. Hope the food for thought was worth the read!

23/23

#PeriopClinicalPharmacist #periopcare #multimodalanalgesia #teamworkmakesthedreamwork