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SUMMER 2017
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D
uring surgery, Max was given
medication that included opioids
and then a small amount of Vicodin to
relieve his post-surgical pain. Less than
a month later, he was dead from a
heroin overdose.
There is no guarantee that this story
would have ended well no matter
what was done, but there are some
interventions that might have improved
the chances for a better outcome.
Max had been treated for his opiate
addiction with buprenorphine/naloxone
(Suboxone) and tapered off the drug
after a year. Buprenorphine, in addition
to methadone, are opiate agonists
that suppress drug cravings in opioid
addicted individuals. Max had been
using prescription opiates as a teenager
and later moved on to heroin. In young
people, the brain’s executive function,
i.e., the ability to make good decisions,
is not fully developed until the mid- to
late-20’s. The effects of opiate addiction
on the developing brain can be more
profound and long-lasting. In such
a case it may have been desirable to
keep him on the buprenorphine for a
longer period of time, possibly for many
years, along with intensive psychosocial
support. This support can be provided
through 12-step programs such as
Narcotics Anonymous, individual
therapy, or both.
There is a stigma attached to treatment
with opioid agonists and patients are
often eager to get off as soon as possible.
This is often not a good idea. Sometimes
it is better to stay on agonist therapy for
longer periods of time, combined with
the intensive psychosocial support, so
that the brain can be retrained to cope
with triggers, stress, and pain in ways
that do not include abusing opiates.
The psychosocial interventions can be
continued indefinitely, as addiction is
a lifelong condition and relapses can
occur after decades of abstinence.
When Max had his car accident,
he undoubtedly was in real pain that
required treatment. It would have
been ideal if he could have been treated
with non-opioid analgesics or non-
pharmacologic measures. In his case,
opioids were deemed necessary and
the physician stated that he gave him a
“small amount of Vicodin.” Individuals
with opiate addiction often have a lower
tolerance to pain and may need higher,
not lower doses of opioids to control
their pain. Max may have sought out
illicit opioids, including heroin
(cheaper than prescription opioids
and very effective as an analgesic)
and begun habitual use as a result of
his pre-existing addiction. Consultation
with an addiction medicine specialist
would have been appropriate. Max
could have been evaluated for:
1) slow taper of his opioids under
close supervision; 2) reinstitution of
buprenorphine or methadone therapy
and/or 3) psychosocial support.
Families should seek out help as well,
as they are key factors in helping
individuals with addiction to achieve
and sustain recovery. Hindsight, of
course, is always 20/20.
LEGAL DRUGS
The Impact Of Prescription Pain Pill Addiction
Jonathan Samuels, MD,
director of addiction medicine at SBH, wrote the following article in
response to a story that appeared on NPR’s Morning Edition about Max, a young man who had
kicked an addiction to prescription pain pills before breaking his hand in an automobile accident.
ADDICTION MEDICINE
RADIOLOGY
O
ften during the course
of my day as an
interventional radiologist, I’ll
take the time to explain arteries
and veins at their most basic
level. Arteries are blood vessels,
carrying blood away from the
heart to various tissues. In
arteries the blood is propelled
by the pumping of the heart.
Veins are a bit less intuitive to
understand. For the most part, pressure
and movement of blood in the veins is
not subject to the pumping of the heart.
Blood travels through the veins primarily
by local pressure changes around
the vein (e.g., muscles contracting
around veins of arms and legs during
movement). This action works in
combination with valves in the veins
allowing flow only towards the heart and
blocking flow in the opposite direction.
Disruption in the normal flow of blood
through the veins and the subsequent
build-up of static blood in veins can
lead to varicose veins, varicoceles in
men, and pelvic venous congestion
syndrome in women. Pelvic pain is a
very common complaint with estimates
of up to a third of women experiencing
it at some point in their lives. Pelvic
congestion syndrome (PCS) is an
underdiagnosed and undertreated cause
of female pelvic pain.
The classic presentation of PCS is that
of a multiparous woman complaining
of dull aching pelvic pain persisting for
more than six months. Exacerbating
factors include prolonged standing,
menstruation, and sexual activity.
Given that the pain of PCS is due to
engorgement of pelvic veins, it should
make sense that activities leading to
increased blood flow to the pelvis would
exacerbate the symptoms. Patients are
usually parous since pregnancy increases
pelvic vein capacity by 60 percent during
which time the venous distension might
leave pelvic veins incompetent. There
may be associated varicose veins of the
vulva, perineum, and lower extremities.
After history and physical exam (ovarian
point tenderness and a history of
postcoital pain is 94 percent sensitive
and 77 percent specific for PCS),
ultrasound should be the first line
imaging study for PCS. Ultrasound may
identify enlarged pelvic veins and reflux
with Valsalva maneuver. CT and/or
MRI may also be of benefit if coexisting
pathology such as compressive tumors
are suspected.
Historically, PCS was treated
medically with limited effect using
medroxyprogesterone acetate (Provera)
or the GnRH agonist Goserelin. More
recently, transcatheter therapy has
increasingly become the first line of
treatment. Typically the treatment
involves embolization of the ovarian
veins with coils and/or sclerosant
medication. Occasionally, the internal
iliac vein branches of the pelvis are also
embolized. By embolizing the enlarged
and incompetent veins responsible for
pelvic pain, alternative collateral veins
with competent valves take over and
pain is relieved as the pelvic blood
can return to the heart more easily
from the pelvis following embolization.
The few studies published regarding
response to treatment of PCS by
transcatheter embolization have reported
anywhere from 60 to 100 percent of
patients reporting clinical benefit from
the procedure.
The procedure is generally done with IV
moderate sedation and patients generally
go home the day of the procedure.
Depending on the anatomy of the
patient, the procedure can be done with
access at either the neck or groin. The
procedure will then usually take one to
two hours.
There may be crampy pelvic pain
following the procedure for a few
days with most women recovering
in one week or so. Reduction in pelvic
pain typically occurs after two to
three weeks.
Pelvic Congestion Syndrome (PCS):
Underdiagnosed and Undertreated
By B. Bobby Chiong, MD, Chair, Department of Radiology
