Pain Management in Primary Care: Patient Selection...

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


Diagnosis

First-TierPain Therapies

NSAIDsTENSPsychological TherapyNerve Blocks



Diagnosis


Second-TierPain Therapies


OpioidsNeurolysisThermal Procedures



Diagnosis


Second-TierPain Therapies

AdvancedPain Therapies


NeurostimulationImplantable Drug PumpsSurgical InterventionNeuroablation

OpioidsNeurolysisThermal Procedures


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.


•• 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.


•• 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.


•• 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


•• 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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Pain Management in Primary Care: Patient Selection...

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