Post on 13-Aug-2020
Joshua D. Dion MSN, APRNJoshua D. Dion MSN, APRN--BC, ACNPBC, ACNP
Pain Management in Primary Care: Pain Management in Primary Care:
Patient Selection, Analgesics, and Patient Selection, Analgesics, and
Compliance Monitoring. Compliance Monitoring.
ObjectivesObjectives
•• Background and Significance of Chronic PainBackground and Significance of Chronic Pain•• Pharmacology for Pain Management.Pharmacology for Pain Management.•• Proper Patient Selection, Compliance Monitoring, and Proper Patient Selection, Compliance Monitoring, and
Treatment Agreements Treatment Agreements •• Case Studies.Case Studies.
DisclosuresDisclosures
•• NONENONE
What is Pain?What is Pain?
•• International Association for the International Association for the Study of Pain DefinitionStudy of Pain Definition:: An unpleasant An unpleasant sensory and emotional experience associated sensory and emotional experience associated with actual or potential tissue damage, or with actual or potential tissue damage, or described in terms of such damagedescribed in terms of such damage
•• Margo Margo McCafferyMcCaffery’’ss DefinitionDefinition: : ““Pain is Pain is whatever the experiencing person says it is, whatever the experiencing person says it is, existing whenever the experiencing person says existing whenever the experiencing person says it doesit does””..
TYPES OF PAINTYPES OF PAIN
Duration Cause LocationAcute Nociceptive Somatic
Chronic Neuropathic Visceral
Duration Cause LocationAcute Nociceptive Somatic
Chronic Neuropathic Visceral
DurationDuration
Acute painAcute pain Chronic painChronic pain
– Relatively brief duration
– Etiology known
– Pain proportionate to damage
– ~ Transient objective signs
– Anxiety, anger, fear common
– Longer duration
– Etiology ~ unknown
– Pain ~disproportionate
– Often no objective sign
– Depression is common
Background & SignificanceBackground & Significance
•• According to the Institute of Medicine Report on According to the Institute of Medicine Report on Relieving Pain in America 2011:Relieving Pain in America 2011:
•• Chronic pain affects > 100 million Americans Chronic pain affects > 100 million Americans –– 35% to 50% of adults 35% to 50% of adults –– $560 to 635 billion per year in healthcare costs $560 to 635 billion per year in healthcare costs
and lost productivity.and lost productivity.–– Chronic pain will continue to rise as a result Chronic pain will continue to rise as a result
of: age, obesity, advances in medicine, poor of: age, obesity, advances in medicine, poor management of surgical pain, recognition of management of surgical pain, recognition of the disease. the disease.
Lower Back PainLower Back Pain
•• The financial burdens to the patient, the healthcare The financial burdens to the patient, the healthcare system, and society are immense. system, and society are immense.
•• Low back pain is the leading cause of disability for Low back pain is the leading cause of disability for Americans under 45 years of age.Americans under 45 years of age.
•• Lower back pain is one of the primary reasons for Lower back pain is one of the primary reasons for patients to seek healthcare.patients to seek healthcare.
Consequences of Unrelieved PainConsequences of Unrelieved Pain
Physical stress, emotional distress, & sufferingPhysical stress, emotional distress, & suffering
Insomnia Insomnia
Immobility & deImmobility & de--conditioning conditioning
Impaired hormonal & immune functionImpaired hormonal & immune function
AtelectasisAtelectasis, hypoxia, & increase cardiac workload, hypoxia, & increase cardiac workload
Increases morbidity and mortality Increases morbidity and mortality
Sensitization & Sensitization & neuroplasticityneuroplasticity
Assessing the BodyAssessing the Body
•• Comprehensive pain assessmentComprehensive pain assessment•• Examination of affected body Examination of affected body part(spart(s))•• SymmetrySymmetry•• Effect of medications (desired / undesired)Effect of medications (desired / undesired)•• ROM, Strength, FunctioningROM, Strength, Functioning•• General healthGeneral health•• Review of SystemsReview of Systems
Assessing the MindAssessing the Mind
•• Emotional state Emotional state (sad, mad, scared, (sad, mad, scared, frustrated)frustrated)–– Stress / distress levelStress / distress level
•• Memory, concentration Memory, concentration (MMSE)(MMSE)
•• CognitionsCognitions–– Self doubts, learned helplessnessSelf doubts, learned helplessness–– Rumination, selfRumination, self--pitypity–– Distortions, Distortions, catastrophizingcatastrophizing–– AcceptanceAcceptance
Assessing Social InteractionsAssessing Social Interactions
•• Impact of pain on activities (meaningful, Impact of pain on activities (meaningful, pleasurable)pleasurable)
•• Relationships with family members / friendsRelationships with family members / friends
•• Abusive relationships? Abusive relationships?
•• Assistance given / received from othersAssistance given / received from others
•• Use of alcohol, drugs, tobaccoUse of alcohol, drugs, tobacco
•• Talk with patient and Talk with patient and S.O.S.O.’’ss
•• Self awareness re: therapeutic relationshipSelf awareness re: therapeutic relationship
Targeting the Body:Targeting the Body:Selected techniquesSelected techniques
•• MedicationsMedications•• Invasive proceduresInvasive procedures
–– Nerve blocks / Nerve blocks / neuroblationneuroblation
–– Implanted devicesImplanted devices
•• AcupunctureAcupuncture•• Massage / Massage /
manipulationmanipulation
• Apply heat / ice• Avoid pain triggers
• environmental, • dietary, • overexertion
• Exercise• Positioning• Sleep Hygeine
Targeting the BodyTargeting the Body
•• FixFix treatable causes of the paintreatable causes of the pain–– CureCure--directeddirected–– Block or damage malfunctioning nervesBlock or damage malfunctioning nerves
•• Strengthen defenses to dampen painStrengthen defenses to dampen pain–– Increase endorphin production / releaseIncrease endorphin production / release
•• Prevent Pain FlaresPrevent Pain Flares–– Avoid factors that exacerbate painAvoid factors that exacerbate pain–– Promote wellness and develop strengthPromote wellness and develop strength
Targeting the Body:Targeting the Body:Principle of balance Principle of balance
•• Balanced approach to analgesicsBalanced approach to analgesics
–– Drug class selectionDrug class selection
–– Concerns of effect vs. side effectConcerns of effect vs. side effect
–– Therapeutic vs. Legal concernsTherapeutic vs. Legal concerns
–– Consensus statements vs. MediaConsensus statements vs. Media
•• Balance pain reduction & Balance pain reduction &
functioningfunctioning
Pain Treatment ContinuumPain Treatment Continuum
Diagnosis
Physical TherapyOTC Pain Medications
Pain Treatment ContinuumPain Treatment Continuum
Diagnosis
First-TierPain Therapies
NSAIDsTENSPsychological TherapyNerve Blocks
Physical TherapyOTC Pain Medications
Pain Treatment ContinuumPain Treatment Continuum
Diagnosis
First-TierPain Therapies
Second-TierPain Therapies
NSAIDsTENSPsychological TherapyNerve Blocks
OpioidsNeurolysisThermal Procedures
Physical TherapyOTC Pain Medications
Pain Treatment ContinuumPain Treatment Continuum
Diagnosis
First-TierPain Therapies
Second-TierPain Therapies
AdvancedPain Therapies
NSAIDsTENSPsychological TherapyNerve Blocks
NeurostimulationImplantable Drug PumpsSurgical InterventionNeuroablation
OpioidsNeurolysisThermal Procedures
Physical TherapyOTC Pain Medications
Principles for Using AnalgesicsPrinciples for Using Analgesics
•• By the Step (WHO ladder)By the Step (WHO ladder)
•• By the ClockBy the Clock
•• Adequately trial each drug Adequately trial each drug
•• Stay low and go slowStay low and go slow
NonNon--OpioidsOpioids / / NSAIDsNSAIDs
•• BenefitsBenefits–– Good for mild painGood for mild pain–– Helps sore, aching painHelps sore, aching pain–– Treats inflammationTreats inflammation–– Treats feverTreats fever–– Many productsMany products–– Available in many routesAvailable in many routes–– Not habit formingNot habit forming
•• Risks / Risks / problemsproblems–– Ceiling effectCeiling effect–– May delay healingMay delay healing–– GI toxicityGI toxicity–– Renal toxicityRenal toxicity–– Hepatic toxicityHepatic toxicity–– Asthma, HTN Asthma, HTN
warningwarning
Commonly Used Commonly Used NSAIDsNSAIDs
Drug Dosing Strengths mg
Dosing Frequency
Maximum Daily Dose
Ibuprofen 100,200,400,600, 800
300 to 800 mg tidto qid prn
3200 mg
Naprosyn 250, 375,500 250 to 500 mg bid to tid
1500 mg
Relafen 500, 750 1000 mg qd to bid 2000 mg
Diclofenac 25,50,75 DR100 ER
50 mg bid to tid100 mg qd to bid
200 mg
Mobic 7.5, 15 7.5 mg bid15 mg qd
15 mg
Celebrex 100,200 100 to 200 mg qdto bid
400 mg
NonNon--OpioidsOpioids/ Skeletal Muscle / Skeletal Muscle RelaxantsRelaxants•• BenefitsBenefits--Helps muscle Helps muscle
spasm/tension.spasm/tension.--Helps pain.Helps pain.--Many Products Many Products
available.available.--Not habit forming.Not habit forming.
•• RisksRisks--Hepatic toxicityHepatic toxicity--SedationSedation--SyncopeSyncope--HypotensionHypotension--AnticholinergicAnticholinergic
effectseffects
Commonly USED Commonly USED SMRsSMRs
Drug Dosing Strengths mg
Dosing Frequency
Maximum Daily Dose.
Robaxin 500,750 1000 mg qid 8000 mg qd
Baclofen 10,20 20 to 80 mg qdin divided doses. 80 mg qd
Zanaflex 2,4 tablet2,4,6 capsule
8 mg q6 to q8 prn
Max 3 doses in 24h
Skelaxin 800 Tid to qid prn Not defined
Flexeril 5,10 5 to 10 mg tid 30 mg qd
Other Medications for PainOther Medications for Pain
Drug Class Indication Dosing Frequency
Maximum Recommend Dose
Gabapentin Seizure Disorder. Other Neurologics
Neuropathic Pain
300 to 1200 mg tid 3600 mg qd
Lyrica®®Seizure Disorder, Other Neurologics, Fibromyalgia
Fibromyalgia Neuropathic Pain
100 to 300 mg bid to tid
450 mg qd-FMS600 mg qdNeuropathic Pain
Amitriptyline TCA Pain, chronic 0.1 mg kg qhs 150 mg qd
Cymbalta®®
Fibromyalgia, Neuropathic Pain, diabetic Musculoskeletal Pain, Chronic
60 to 120 mg qd
60 mg qd for FMS and Musculoskeletal.120 mg qd for Neuropathic
Tramadol Opiods, other anlagesics
Acute/chronic moderate to severe pain
50 to 100 mg q4 to 6 prn 400 mg qd
Opioid Benefits: Opioid Benefits:
•• Highly effective, sometime the only effective RxHighly effective, sometime the only effective Rx
•• Promotes healingPromotes healing
•• Improves mood Improves mood
•• Products with low or Products with low or ““nono”” ceilingceiling
•• Accumulation ~ occur Accumulation ~ occur
•• Pure agonists have no known endPure agonists have no known end--organ damageorgan damage
OpioidsOpioids: Potential Problems: Potential Problems
•• Risks Risks –– AddictionAddiction–– Physical Physical
dependence dependence –– ToleranceTolerance–– Safety concerns Safety concerns
(driving)(driving)–– Drug interactionsDrug interactions
•• Side effectsSide effects–– Respiratory depressionRespiratory depression–– SedationSedation–– Nausea / vomitingNausea / vomiting–– Urinary retentionUrinary retention–– Hormonal changesHormonal changes–– Sexual dysfunctionSexual dysfunction–– ConstipationConstipation
A Range of ProductsA Range of Products
•• Weak or Mixed Weak or Mixed OpioidsOpioids–– CodeineCodeine–– PropoxyphenePropoxyphene–– TramadolTramadol–– PentazocinePentazocine–– NalbuphineNalbuphine
•• Strong Strong OpioidsOpioids–– HydrocodoneHydrocodone–– OxycodoneOxycodone–– MorphineMorphine–– LevorphanolLevorphanol–– HydromorphoneHydromorphone–– FentanylFentanyl–– OxymorphoneOxymorphone–– TapentadolTapentadol
Commonly Used SA Commonly Used SA OpioidsOpioids
Drug Dosing Strengths mg Dosing Frequency Maximum
Daily Dose
OxycodoneOxycodone/AcetaminophenAspirinIbuprofen
5,10,15,20,302 .5,5,7.5,10 325 to 650 4.8/ 325 5/400
5 to 30 mg q4 prn2.5 to 10 mg q4 to 6 prnq6 prnqd to qid prn
Not defined 4 grams Acet. In 24 hr. 12 per 24 hr. 4 per 24 hr.
Hydrocodone/AcetaminophenIbuprofen
2.5,5,7.5,10300 to 700 mg 200
2.5 to 10 mg q4 to 6 prnq4 to 6 h prn
4 grams Acet. in 24 hr.Max 5 qd
Hydromorphone 2,4,8 2-8 mg q3 to 4 prn Not defined
Morphine IR 15,30 10-30 mg q3 to 4 prn Not defined
Nucynta 50,75,100 50 to 100 mg q4 to 6 prn Not defined
LongLong--Acting Acting OpioidsOpioids Currently AvailableCurrently Available
DrugDrug Dosing Dosing IntervalInterval
Available Available StrengthsStrengths AdministrationAdministration BolusBolus Ceiling Ceiling
dosedose
KADIANKADIAN®®q12hrq12hrq24hrq24hr
20, 30, 50, 60, 20, 30, 50, 60, 100 mg100 mg
Capsule, Capsule, Sprinkle, Sprinkle, GG--TubeTube
NoNo ––
AVINZAAVINZA®® q24hrq24hr 30, 60, 90, 30, 60, 90, 120 mg120 mg
Capsule, Capsule, SprinkleSprinkle YesYes 1600 1600
mg/daymg/day
OxyContinOxyContin®® q12hrq12hr 10, 20, 40, 80, 10, 20, 40, 80, 160 mg160 mg TabletTablet YesYes ––
MS MS ContinContin®®q8hrq8hrq12hrq12hr
15, 30, 60, 15, 30, 60, 100, 200 mg100, 200 mg TabletTablet NoNo ––
DuragesicDuragesic®®q48 hrq48 hrq72hrq72hr
12, 25, 50, 75, 12, 25, 50, 75, 100 mcg/hr100 mcg/hr
TransdermalTransdermalPatchPatch NoNo ––
LongLong--Acting Acting OpioidsOpioids (continued)(continued)
OpanaOpana ERER®® Q 12hrQ 12hr 5, 10, 20, 405, 10, 20, 40 TabletTablet NoNo --
ExalgoExalgo ®® Q 24 Q 24 hrhr 8,12,16 mg8,12,16 mg TabletTablet NoNo --
ButransButrans®® Q Q weekweek
5, 10, 20 5, 10, 20 mcg/hrmcg/hr
TransdermalTransdermalPatchPatch NoNo --
NucyntaNucynta ERER®® Q 12 Q 12 hrhr
50,100,150,50,100,150,200, 250200, 250
TabletTablet NoNo --
Products to avoid Products to avoid (or use cautiously)(or use cautiously)
•• DO NOT USE PLACEBOSDO NOT USE PLACEBOS
•• AvoidAvoid–– Demerol Demerol
•• Use Cautiously Use Cautiously –– CodeineCodeine
–– TramadolTramadol
–– Agonist/antagonist drugsAgonist/antagonist drugs
–– MethadoneMethadone
Risk Evaluation and Mitigation Risk Evaluation and Mitigation Strategy (REMS)Strategy (REMS)
••ProsPros•• Address the potential Address the potential
problems associated with problems associated with prescribing prescribing opioidsopioids(physicians, NP(physicians, NP’’s, and s, and PAPA’’ss).).
•• Education on proper Education on proper patient selection and patient selection and tools for patient tools for patient education.education.
•• Paid for by Paid for by Pharmaceutical Pharmaceutical manufacturersmanufacturers. .
PolypharmacyPolypharmacy
•• For predictable/steady painFor predictable/steady pain–– Provide estimated need in LA medsProvide estimated need in LA meds–– Have 10Have 10--25% of daily dose for 25% of daily dose for
breakthrough pain episodesbreakthrough pain episodes
•• One drug per classOne drug per class (exc. LA / SR MS)(exc. LA / SR MS)
•• Different metabolism / excretion Different metabolism / excretion •• Different toxicity / Side effect Different toxicity / Side effect
profileprofile•• Better than irrational Better than irrational polypharmaciapolypharmacia
•• Descending Inhibitory PathwaysDescending Inhibitory Pathways–– OpioidsOpioids–– Selective Selective norepinephrinenorepinephrine reuptake reuptake
inhibitors (inhibitors (SNRIsSNRIs))–– Selective serotonin reuptake Selective serotonin reuptake
inhibitors (inhibitors (SSRIsSSRIs) ) –– TramadolTramadol–– TricyclicTricyclic antidepressantsantidepressants
•• Peripheral PathwaysPeripheral Pathways•• Voltage D. NaVoltage D. Na++ ChannelsChannels
–– TricyclicTricyclic antidepressants antidepressants –– AnticonvulsantsAnticonvulsants
•• CarbamazepineCarbamazepine•• OxycarbazepineOxycarbazepine•• PhenytoinPhenytoin•• LamotrigineLamotrigine
–– LidcLidcocaineocaine–– MexiletineMexiletine
•• Spinal PathwaysSpinal Pathways–– NN--type Catype Ca++++ Channels Channels
•• GabapentinGabapentin•• LamotrigineLamotrigine•• LevetiracetamLevetiracetam•• OxycarbazepineOxycarbazepine•• CarbamazepineCarbamazepine•• PregabalinPregabalin
–– NMDA receptorsNMDA receptors•• DextromethorphanDextromethorphan•• KetamineKetamine•• Methadone Methadone
CoCo--AnalgesicsAnalgesics
Questions on Pharmacology?Questions on Pharmacology?
Screening of Pain Management Screening of Pain Management ReferralsReferrals•• Require referral from current treating Require referral from current treating
provider, regardless of insurance plan.provider, regardless of insurance plan.•• Require 3 to 6 months of office notes and Require 3 to 6 months of office notes and
all pertinent diagnostics pertaining to the all pertinent diagnostics pertaining to the condition.condition.
•• Require all notes from specialists and/or Require all notes from specialists and/or previous pain care providers.previous pain care providers.
•• Use caution accepting self pay patients.Use caution accepting self pay patients.
Risk Assessment for Opioid UseRisk Assessment for Opioid Use
•• ProsPros--Protects the patient, the Protects the patient, the
public, and your practice.public, and your practice.--Helps determine most Helps determine most
appropriate treatment appropriate treatment protocol.protocol.
--Compliance monitoring Compliance monitoring (frequency of pill counts (frequency of pill counts and UDS)and UDS)
•• ConsCons--Difficult to find a provider Difficult to find a provider
to screen patients.to screen patients.--Assessments can be open Assessments can be open
to interpretation.to interpretation.--Cost can be prohibitive for Cost can be prohibitive for
patients if not covered on patients if not covered on insurance plan.insurance plan.
--How to chose which How to chose which patients need to be patients need to be screened.screened.
High Risk: Likelihood of High Risk: Likelihood of Misusing Opioid Medications.Misusing Opioid Medications.•• May chose to use only nonMay chose to use only non--opioid medications opioid medications
and alternate treatment modalities.and alternate treatment modalities.•• If prescribing of If prescribing of opioidsopioids is initiated, use longer is initiated, use longer
acting products, smaller quantities, frequent acting products, smaller quantities, frequent visits, more frequent UDS, and random pill visits, more frequent UDS, and random pill counts.counts.
•• ReRe--screen if any signs of aberrant behaviors.screen if any signs of aberrant behaviors.•• Consider NA and/or AA servicesConsider NA and/or AA services if needed.if needed.•• Role of Methadone /Role of Methadone /SuboxoneSuboxone Clinics for Clinics for
detoxification.detoxification.
Low Risk: Unlikely to misuse Low Risk: Unlikely to misuse opioid medications.opioid medications.•• Set clear expectations for treatment with Set clear expectations for treatment with
opioidsopioids and sign treatment agreement.and sign treatment agreement.•• UDS on day of first RX to ensure UDS on day of first RX to ensure
compliance with current and/or reported compliance with current and/or reported medication regimen and to ensure no medication regimen and to ensure no other illicit or prescribed drugs are other illicit or prescribed drugs are present.present.
•• Perform random UDS and pill counts.Perform random UDS and pill counts.
Pain Treatment AgreementsPain Treatment Agreements
PositivesPositives--Clear expectationsClear expectations--Informed ConsentInformed Consent--DocumentationDocumentation--Patient safetyPatient safety--Safe Guarding Safe Guarding
PracticePractice
NegativesNegatives--Patient Perceptions Patient Perceptions
about agreementsabout agreements--Open to Open to
interpretation.interpretation.--Time and staff Time and staff
power needed to power needed to keep agreements keep agreements up to date.up to date.
Compliance Monitoring Compliance Monitoring
PositivesPositives•• Necessary to Necessary to
protect the patient, protect the patient, provider, and provider, and society.society.
•• Monitors Monitors adherence to adherence to treatment protocoltreatment protocol
NegativesNegatives•• CostCost•• StaffingStaffing•• TimeTime•• Patient complaintsPatient complaints
Laboratory InformationLaboratory Information
•• Know the cut off levels for a given drug.Know the cut off levels for a given drug.•• Know which drugs are screened for on a Know which drugs are screened for on a
standard panel and which need to be standard panel and which need to be added.added.
•• If using a commercial lab, ensure that If using a commercial lab, ensure that pricing information is available for a given pricing information is available for a given panel and add panel and add onsons..
•• Have a go to person to address problems Have a go to person to address problems or concerns.or concerns.
Toxicology Report ExamplesToxicology Report Examples
..
Multidisciplinary Pain CareMultidisciplinary Pain Care
•• Pros:Pros:•• Improved patient Improved patient
outcomesoutcomes•• Multifaceted approach Multifaceted approach
with less reliance on with less reliance on one modality.one modality.
•• Decreased long term Decreased long term cost for insurers.cost for insurers.
•• Difficulties:Difficulties:•• Overhead Costs.Overhead Costs.•• Coordination of care Coordination of care
incorporating multiple incorporating multiple specialties.specialties.
•• Patient compliance.Patient compliance.•• Buy in from insurers.Buy in from insurers.•• Support from referral Support from referral
sources.sources.
Case Study Acute Back PainCase Study Acute Back Pain
•• 38 38 yoyo male construction worker injured his lower male construction worker injured his lower back picking up a 100 pound bag of concrete back picking up a 100 pound bag of concrete mix x 3 days ago.mix x 3 days ago.
•• Reports feeling an initial burning sensation in his Reports feeling an initial burning sensation in his lower back that progressively became more lower back that progressively became more problematic as his work day progressed and problematic as his work day progressed and states it is now a constant ache.states it is now a constant ache.
•• Denies a Denies a radicularradicular component or any associated component or any associated symptoms.symptoms.
Case Study Acute (continued).Case Study Acute (continued).
•• Patient X has tried taking Tylenol and Patient X has tried taking Tylenol and using ice compresses with minimal using ice compresses with minimal benefit.benefit.
•• PE: 2 + lumbar PE: 2 + lumbar paraspnialparaspnial muscle tenderness muscle tenderness and spasm noted bilaterally. No lumbar and spasm noted bilaterally. No lumbar spinousspinousprocess tenderness, no SI joint tenderness, process tenderness, no SI joint tenderness, negative straight leg raise while sitting and negative straight leg raise while sitting and supine, ROM limited to pain in all plains of supine, ROM limited to pain in all plains of motion, motion, stretngthstretngth is 5/5 is 5/5 BLEsBLEs with flexion and with flexion and extension. Reflexes are 2+ patella and extension. Reflexes are 2+ patella and achillesachillesbilaterally.bilaterally.
Case Study Acute (continued)Case Study Acute (continued)
•• Assessment: Lumbar strainAssessment: Lumbar strain•• Plan: OTC Plan: OTC NSAIDsNSAIDs and course of PT with a and course of PT with a
focus on proper lifting techniques, focus on proper lifting techniques, postural exercises, and stretching, 40 postural exercises, and stretching, 40 pound weight restriction at work.pound weight restriction at work.
•• Outcome: Patient completed PT in 4 Outcome: Patient completed PT in 4 weeks and is performing HEP at home. No weeks and is performing HEP at home. No longer on NSAID and is back to full duty longer on NSAID and is back to full duty without restrictions.without restrictions.
Case Study: Chronic Back PainCase Study: Chronic Back Pain
•• 45 45 yoyo male with a c/o back pain x 3 years male with a c/o back pain x 3 years s/ps/p lifting injury at work. Reports lifting a lifting injury at work. Reports lifting a heavy object in a forward flexed position heavy object in a forward flexed position when he felt a popping sensation in his when he felt a popping sensation in his lower back and pain down into his RLE.lower back and pain down into his RLE.
•• Initially Presented to occupational health Initially Presented to occupational health and was referred for a course of PT, given and was referred for a course of PT, given a a medrolmedrol dose dose pakpak, and , and flexerilflexeril for his for his pain, with poor response and has been on pain, with poor response and has been on light duty since the injury.light duty since the injury.
Chronic Pain Case (continued)Chronic Pain Case (continued)
•• MRI of Lumbar spine revealed an L4MRI of Lumbar spine revealed an L4--5 5 HNP with NF narrowing on the right. HNP with NF narrowing on the right.
•• Patient did not want surgery or injections Patient did not want surgery or injections therefore was put on Percocet per PCP to therefore was put on Percocet per PCP to manage his symptoms medically. manage his symptoms medically.
•• Pain became more problematic and Pain became more problematic and medications were becoming less effective. medications were becoming less effective. PCP referred for Pain Management PCP referred for Pain Management Evaluation. Evaluation.
Chronic Pain Case (continued)Chronic Pain Case (continued)
•• PE: PE: Pain to palpation along lumbar Pain to palpation along lumbar paraspinalparaspinalmusculature bilaterally, no lumbar musculature bilaterally, no lumbar spinousspinousprocess tenderness or SI joint tenderness noted. process tenderness or SI joint tenderness noted. ROM limited with forward flexion and lateral ROM limited with forward flexion and lateral flexion to the right due to pain. SLR positive at flexion to the right due to pain. SLR positive at 45 degrees on the right. Strength 4+/5 in RLE 45 degrees on the right. Strength 4+/5 in RLE and 5/5 LLE. Reflexes and 5/5 LLE. Reflexes wnlwnl. Decreased sensation . Decreased sensation to light touch along the L5 to light touch along the L5 dermatomaldermatomaldistribution in the RLE as compared to the LLE.distribution in the RLE as compared to the LLE.
Chronic Pain Case (continued)Chronic Pain Case (continued)
•• Assessment:Assessment:•• 1. Lumbar HNP at L41. Lumbar HNP at L4--5 with a 5 with a radicularradicular
/neuropathic component to pain along L5 /neuropathic component to pain along L5 distribution.distribution.
•• 2. Opioid dependence: using # 6 10/325 mg 2. Opioid dependence: using # 6 10/325 mg PercoetPercoet per day. per day.
•• 3. Alternate medications: May benefit from trial 3. Alternate medications: May benefit from trial of of GabapentinGabapentin for for radicularradicular pain.pain.
•• 4. Needs another course of PT for strengthening 4. Needs another course of PT for strengthening of RLE.of RLE.
Chronic Pain Case (continued)Chronic Pain Case (continued)
•• Plan:Plan:•• 1. Obtain EMG of RLE to R/O a 1. Obtain EMG of RLE to R/O a radiculopathyradiculopathy..•• 2. Change opioid regimen to 2. Change opioid regimen to RoxicodoneRoxicodone 15 mg 15 mg
tidtid prnprn to eliminate long term Tylenol use, to eliminate long term Tylenol use, decrease frequency of dosing, and lower total decrease frequency of dosing, and lower total daily dose of opioid. daily dose of opioid.
•• 3. Add 3. Add NeurontinNeurontin to medication regimen for to medication regimen for neuropathic component.neuropathic component.
•• 4. Course of PT.4. Course of PT.•• 5. Consider interventional options if above fails5. Consider interventional options if above fails
Chronic Pain Case (continued)Chronic Pain Case (continued)
•• OutcomeOutcome: EMG showed a slight right sided L5 : EMG showed a slight right sided L5 radiculopathyradiculopathy. . NeurontinNeurontin was titrated to 1800 mg/day was titrated to 1800 mg/day and patient was able to decrease and patient was able to decrease RoxicodoneRoxicodone frequency frequency to bid to bid prnprn, taking at end of work day., taking at end of work day.
•• Patient did well in PT and was able to increase his hours Patient did well in PT and was able to increase his hours from 24 to 32 hours per week and his lifting capacity from 24 to 32 hours per week and his lifting capacity was increased from 10 to 25 pounds.was increased from 10 to 25 pounds.
•• Patient wishes to forego surgery or procedures at this Patient wishes to forego surgery or procedures at this time.time.
QUESTIONS &QUESTIONS &SUGGESTIONSSUGGESTIONS
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