Undetected Ultracet™ dependence in an adolescent with nonmalignant back pain.

Addiction to painkillers or other substances in pediatric and adolescent cases of noncancer chronic pain is an understudied phenomenon, even amidst documented increases in rates of prescription opioid use and misuse. Case studies can inform the training of clinicians in ethically negotiating a balance between optimizing analgesia and mitigating risk of aberrant drug-taking behaviors. This report discusses an 18-year-old woman with idiopathic scoliosis and clinical depression secondary to undertreated refractory chronic back pain who underwent surgery to correct pseudoarthrosis after a prior spinal instrumentation operation. This intervention in conjunction with a course of patient-controlled analgesia, hydromorphone, and outpatient tramadol, naproxen, methadone, and gabapentin was successful in addressing her long-standing lumbar pain. The patient, however, continued to complain to her pain management team of postsurgical discomfort and insisted on being prescribed Ultracet™ (acetaminophen-tramadol) rather than generic tramadol. The patient's eventual disclosure of severe withdrawal discomfort and history of covert abuse of Ultracet™ is discussed with respect to key warning signs, gaps, and contingencies in the screening, surgical, and pain management processes.

Balancing Knowledge Among Resident Specialties: Lecture-Based Training and the OUCH Card to Treat Children's Pain.

BACKGROUND: There are well-established deficiencies in residents' knowledge of acute-pain assessment and treatment in hospitalized children. METHODS: Among residents in 3 specialties (anesthesiology, orthopedics, and pediatrics), we investigated whether a pediatric pain management (PPM) curriculum that offered a lecture combined with a demonstration of how to use the OUCH card would yield higher performance on a subsequent PPM knowledge assessment. The OUCH card was created as a portable reference tool for trainees to provide analgesic dosing information, pain-assessment tools, and treatment of opioid-induced adverse effects. There was an initial convenience sample of 60 residents randomized to Form A or B of the pretest. From this, 39 residents (15 anesthesiology, 13 orthopedic, 11 pediatric) completed a PPM knowledge posttest approximately 4 weeks after the pretest, PPM lecture, and OUCH card instruction. RESULTS: Using a repeated measure design, the interaction of resident specialty and pretest to posttest scores was significant (P  =  .01) along with the covariate of residency year (P  =  .026). CONCLUSIONS: These preliminary data based on a convenience sample of residents suggest that PPM training along with use of the OUCH card may help to reduce knowledge differences among residents. Faculty whose clinical practice includes children with acute pain should consider including learning or performance aids like the OUCH card in education and clinical care for its potential benefit in resident learning.