Chronic Disease

1 In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:
– acute complications of the chronic disease (e.g., diabetic ketoacidosis). Compression # in Osteoporosis
– acute exacerbations of the disease (e.g., asthma exacerbation, acute arthritis). COPDE
– a new, unrelated condition. MI in a pt with panic attacks

2 Regularly reassess adherence (compliance) to the treatment plan (including medications).

• DM – Q3m f/u
• HTN – Q6mo f/u
• Hypothyroidism – Q3-6mo etc

3 In patients with chronic disease:
a) Actively inquire about pain. Often a predominant symptom in chronic dz
b) Treat appropriately by:
– titrating medication to the patient’s pain.
– taking into account other treatments and conditions (e.g., watching for interactions). 
– considering non-pharmacologic treatment and adjuvant therapies: CBT, PT, OT, MT

Determine cause of pain:

• cancer vs non-cancer pain
  • Tend to use opioid (Hydromorphone) in cancer pt (no max dose)
  • Target end points: pain reduction >=30% or improved function
  • Max dose of Morphine =<200mg/d for Tx chronic pain
  • Opioid titration: add all the breakthrough and add to the regular
    • Breakthrough = 10% of daily dose Q1h
    • Switching opioids = decrease 25% daily dose, convert, add 10% breakthrough
    • Transdermal fentanyl for stable pain / dose: decreased nausea, constipation, metabolites
• somatic – deep, aching, stabbing, worse with movement
  • Tend to respond to Tylenol / NSAIDs
• Visceral – deep aching / cramping, squeezing
• neuropathic – Burning, tingling, lancinating along a peripheral nerve
  • Tend to respond to TCA / anticonvulsant
• Tx: use the analgestic ladder: Tylenol, NSAIDs, Opioids + adjuncts, nerve blocks
• Adjuncts: Dexamethasone, Topical anesthetic, TCA – Amitriptyline, Anticonvulsant: Gabapentin

Cannabis for chronic noncancer pain

• indication: Refractory severe neuropathic pain
• Contraindication: <25yo, family hx of psychosis, Hx of cannabis/substance disorder, CV/Resp dz, pregnant
• No driving 3-4 hr after smoking, 6hr after ingestion, 8 hr after a high
• Max dose: 1 inhalation qid
• Discontinue if inadequate pain relief, s/e, addiction/diversion

4 In patients with chronic disease, actively inquire about:
– the psychological impact of diagnosis and treatment.
– functional impairment.
– underlying depression or risk of suicide.
– underlying substance abuse.

5 Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan.

Strategies to Improve Adherence:

• Regularly scheduled visits
• Blister pack
• Long-acting and Combined (decrease # pills) medications