Brad Stevens Acute shoulder Syndrome

1. Brad Stevens Acute shoulder Syndrome With thanks to Dr. Launette Rieb

2. Objectives At the end of this session our hope is that attendees will be able to: • Recognize addiction in the context of managing an acute injury that transitions to a chronic pain disorder. • Take an active role in the perioperative management of pain for a patient with the disease of opioid addiction. • Communicate more effectively with patients comorbid with addiction and pain, their families, and specialists involved in their care. And perhaps more importantly: • Facilitate case-based sessions like this one even more effectively than they do at present. (The subtext for the day, after all, is becoming a better peer-trainer.)

3. Case of Brad StevensAcute shoulder syndrome • 38 year old single man. • Facilities manager, Golf and Tennis Club • Moved to your community five years ago for the job. • Became your patient soon after—ER visit for a minor laceration, right cheek. Struck by his doubles partner. Presented as fit and well adjusted. • Rarely sees the doctor. • Excellent tennis player.

4. Case of Brad StevensAcute shoulder syndrome Acute shoulder injury. • May long weekend. Saturday. • Busy at the Club—two wedding receptions and a golf tournament. • Helping staff to set up for a banquet—pulled on a cart loaded with stacking chair. Didn’t realize the cart was stuck. Injury: • Acute right shoulder pain. Movement excruciating. • Applied ice. • Worse in the morning—unable to raise his arm. Incapacitated.

5. Case of Brad StevensAcute shoulder syndrome Presentation at your office. • Tuesday afternoon (post injury day # 3). • Additional history volunteered by the patient: • sleep disrupted by pain • taking Advil • has to work—busy season, small staff What would you ask to gain a better understanding of the injury and factors contributing to the pain?

6. Case of Brad StevensAcute shoulder syndrome Initial visit: • Physical findings: • [What do you expect to find?] • Investigations? • Advice?

7. Case of Brad StevensAcute shoulder syndrome Two weeks later. A Thursday. • Brad has been following advice religiously—avoiding load strain on the shoulder. ROM drills. Taking Advil. • Pain at rest worse than ever. • Unable to sleep. • Another very busy weekend upcoming at work. • A friend had provided two Percocet. Was at least able to sleep. • How will you respond?

8. Case of Brad StevensShoulder syndrome—9 months later Now mid-February. In the interim: • Pain and stiffness have persisted despite conservative treatment. • Stopped work in mid-July. • Expedited orthopedic assessment through WorkSafe • MRI 3 months earlier showed partial tear of supraspinatus tendon • At the time the surgeon offered Brad a choice of continued conservative approach vs. arthroscopic repair—based on your advice, he initially opted to wait. • Surgery now three days away.

9. Case of Brad StevensShoulder syndrome—9 months later • Brad is uneasy. It’s clear he has something to tell you. • He understands there may be a lot of pain postoperatively. • When he was 21 he fractured his ankle—he’d been out drinking with friends, the grass was wet, and he went over on his ankle. • The ankle was repaired surgically. • He was given pain killers and had trouble stopping them. [Group discussion. Additional history. What questions would you ask?]

10. Case of Brad StevensShoulder syndrome—9 months later Specific questions for Brad at this point: • What was the pain killer he was given before? • How many did he take per day? • How long did he remain on them? • Did he administer them in any way other than swallowing? Chewing, shooting, or snorting? • Did he take them to alleviate withdrawal symptoms only (physical dependence) or did he also take them to relieve anxiety, cope with life generally, or just feel good/get high? • Did he suffer consequences for acquiring, using, or recovery? • How did he stop—rehab program, cold turkey, doctor refused to continue? • Did he combine with alcohol or other drugs?

11. Case of Brad StevensShoulder syndrome—9 months later In response to your specific questions, Brad discloses: • He became severely addicted to pain killers—primarily Percocet. • He obtained them from many doctors and bought them on the street. • He stole money from his parents and friends. • Eventually his parents funded his attendance at a 28 day residential program in Ontario. • He attended NA for five years. • [How do you manage his perioperative analgesia?]

12. Case of Brad StevensShoulder syndrome, opioid addiction • Affirm Brad’s diagnosis of opioid addiction in clear, nonjudgmental terms. • Advise that it is crucial to manage his postoperative pain and his addiction concurrently. That is challenging, but manageable. • Advise that he must allow you to inform and assist his surgeon and anesthesiologist.

13. Case of Brad StevensShoulder syndrome, perioperative analgesia Perioperative analgesia in the context of opioid addiction: First line: • Consult an anesthesiologist with a view to local or regional; maximal dose NSAIDS and acetaminophen. TCA or trazodone for sleep. • Avoid opioids. Backup: Opioid analgesic with tight dispensing and predetermined sunset clause (the duration you would expect for someone without addiction).

14. Case of Brad StevensShoulder syndrome, treating addiction • It is important to actively plan for the challenge of tapering and stopping opioids. That includes: • A commitment to a preset schedule. • Re-engagement in recovery: sponsor, meetings, monitoring (regular visits, urine drug screens, pill counts) • Be very specific about recovery activities • See weekly at first, and regularly thereafter