RE: Chronic Low Back Pain and Drug-Seeking Behavior

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If your patient, do pressure sensitive quantification on the low back and repeat again in several minutes. Compare readingsCheck for and correct the misalignments including the pelvis for rotation. Bob W. Pfeiffer, D.C., D.A.B.C.O.Lee Pfeiffer, R.N., B.S.46 N.E. Mt. Hebron Dr. (no USPS mail)P.O. Box 606 Pendleton, OR 97801drbob@...leernbs@...541-276-2550 All people smile in the same language From: [mailto: ] On Behalf Of Sharron FuchsSent: Tuesday, January 10, 2012 11:29 AM Subject: Chronic Low Back Pain and Drug-Seeking Behavior FYI. ‘The challenges of using opioids are even more intense in a drug-seeking patient, and frustration with the management of these cases can contribute to physician burnout. There is clearly some evidence of burnout on display in the current discussion, and this is not unusual. Over half of physicians report burnout in some studies, and the profession of medicine itself has a poor history of taking care its providers.[8]’ I believe we can suffer from ‘burnout’ with chronic pain patients too. s. fuchs dcChronic Low Back Pain and Drug-Seeking Behavior P. Vega, MDCME Released: 12/28/2011; Valid for credit through 12/28/2012Case Presentation is a 47-year-old woman and a new patient to your clinic. Her chief complaint has been recorded by your medical assistant as " low back pain. " When you enter the room, the patient is lying on the examination table and moaning. She says, " Oh, doctor, thank goodness you're here. I've been in agony for the last 2 weeks, and I have heard that you're the best. " She proceeds to explain that she has had chronic low back pain since a motor vehicle accident 6 years ago. She has been treated in multiple centers in 2 different states but moved to your area several weeks ago. She has run out of multiple analgesic medications over that time and has experienced severe low back pain, which limits her to walking inside the house only and prevents her from some activities of daily living such as cooking and cleaning.The patient has an extensive and disorganized file of some of her past medical records with her. You find an MRI report from 4 years ago demonstrating disc bulges of 1-4 mm between L2 and S1 and mild facet arthropathy of the lumbar spine. There is a physical therapy note from last year. Mostly, the file contains many copies of prescription medication handouts, including ibuprofen, hydrocodone/acetaminophen, oxycodone/acetaminophen, dilaudid, carisoprodol, alprazolam, baclofen, fentanyl transdermal, and long-acting morphine and oxycodone. The dates of these prescriptions are mixed over the last 5 years.You ask the patient what she was taking most recently, and she says that the combination of long-acting oxycodone, dilaudid, carisoprodol, and alprazolam had been the most helpful for her. She took all medications on a schedule even though dilaudid and carisoprodol were written for breakthrough pain, and she says that ibuprofen and acetaminophen did " less than nothing for me. " She shows you a progress note from her previous primary care physician. It is 1 year old and does note refilling long-acting oxycodone and dilaudid. It also mentions the need for a consultation from pain management, which the patient says she did 9 months ago. According to her, the specialists added alprazolam to her regimen.Physical ExaminationThe patient's physical examination reveals tenderness over the lumbar spine and approximately 30% decrease in the active range of motion of the lumbar spine in all directions. A thorough neurological evaluation is completely normal.The patient wants a refill of long-acting oxycodone, dilaudid, carisoprodol, and alprazolam.Discussion QuestionWhat are the next steps in the care of this patient? Please explain your answer(s).Do you encounter similar patients in your practice? If so, how often? Please share your experiences with similar clinical scenarios.Case Discussion: Pain Control ControversyCommunity CME activities are developed in part from discussions by physicians in Medscape Physician Connect. View the complete discussion in Physician Connect (physicians only; click here to learn more).This case obviously drew a lot of interest, and, as mentioned in comment # 19, it says as much about our profession and its current challenges as it does about the care of chronic pain patients. The discussion was not only interesting in terms of the collective reasoning regarding the diagnosis and management of this admittedly difficult case, but it was remarkable for its passion and candor as well.While there were many thoughts on the next steps in 's care, there emerged a consensus that simply acquiescing to her current requests without trying to do something more is unacceptable. Overall, the forum embraced the idea of interdisciplinary care for . Randomized trials have demonstrated that programs that employ multiple care providers can improve chronic pain and disability compared with standard care in pain management practices alone, and such interdisciplinary management can actually reduce overall healthcare utilization and the cost of care.[1,2] Use of NonnarcoticsIn terms of medical therapy, several comments (# 14, 24, 34, and 46, for example) suggested the consideration of nonnarcotic prescription options for . In a randomized trial, duloxetine at doses of 60-120 mg daily was demonstrated to improve pain and function compared with placebo among a cohort of adults with nonneuropathic chronic low back pain.[3] In an uncontrolled extension of this trial, there was some augmentation of the therapeutic effects of duloxetine through 41 weeks of treatment.[4] Duloxetine was not associated with any important serious adverse events during the treatment period.Pregabalin has also been demonstrated to improve chronic pain, but most of the randomized trials of pregabalin have been limited to neuropathic pain such as postherpetic neuralgia and painful diabetic neuropathy. In one trial, the combination of pregabalin with celecoxib was more effective compared with either drug alone in a cohort of adults with chronic low back pain due to various etiologies.[5] Moreover, the combination of celecoxib and pregabalin after spinal fusion surgery has been demonstrated to reduce pain and the need for postoperative narcotics.[6] Novel Treatments and Coordination of CareCan other novel treatments be employed to treat more effectively, as suggested in comments # 38 and 40? Absolutely. The staggering number of complementary and alternative therapies suggests that a single physician may have difficulty in understanding them all. To maintain the most efficacious and, in particular, safe regimen combining traditional medicine and alternative care, the physician should partner with providers with expertise in these fields. Moreover, these providers should communicate regularly during 's care to ensure that the goals of treatment are being met and that she is not in danger of iatrogenic complications.All of this requires a significant amount of effort on the parts of both and her team of providers.Barriers to Prescribing OpioidsPhysicians cite multiple barriers to prescribing opioids for chronic pain, including[7]:The potential to harm patients;Difficulty in measuring pain as a guide to prescribing;Lack of education regarding the use of opioids in pain management; andStigma associated with opioid prescribing.The current discussion adds the threat of bureaucratic oversight from the DEA or physicians' rating systems to this list, as evidenced in comment # 22 and 29.Drug-Seeking Patients and Burned Out PhysiciansThe challenges of using opioids are even more intense in a drug-seeking patient, and frustration with the management of these cases can contribute to physician burnout. There is clearly some evidence of burnout on display in the current discussion, and this is not unusual. Over half of physicians report burnout in some studies, and the profession of medicine itself has a poor history of taking care its providers.[8] It is perfectly reasonable and expected to feel challenged or frustrated by a case like 's, but the discussion also provides some points of wisdom to help physicians avoid burnout.First, set expectations for the plan of care and responsibilities for all participants in the patient's care (comments # 10, 14, and 21). As mentioned, involvement of a care team can be critical in finding the best therapeutic approach as well as removing the full responsibility of caring for demanding patients from one individual clinician (comment # 49).Obtaining past medical records is critical, although some imaging studies may need to be repeated to reassess if invasive treatment might help and reduce her need for pain medications (comments # 11, 31). Online databases to identify prescription misuse can be very helpful as well (comment # 62).Finally, empathy for a patient not only produces better clinical care but is a key for physicians in avoiding burnout. Comments # 13, 18, and 30 address in very direct terms the perils of not having empathy. The lack of empathy for chronic pain patients in particular is evidence-based: a study of 72 patients with chronic pain found that they generally felt disrespected and distrusted in seeking care for chronic pain. They also believed that physicians dismissed their symptoms.[9] As stated eloquently in comment # 44 and by other readers, it is our responsibility to treat this patient professionally and, hopefully, with compassion. This style of practice enriches patient care overall, and larger problems in the profession of medicine or society truly appear smaller when viewed through the lens of a good therapeutic relationship between patient and physician.ReferencesGatchel RJ, McGeary DD, A, et al. Preliminary findings of a randomized controlled trial of an interdisciplinary military pain program. Mil Med. 2009;174:270-277. Abstract s L, Simon EP, Folen RA, Umphress V, Lagana L. The COPE program: treatment efficacy and medical utilization outcome of a chronic pain management program at a major military hospital. Mil Med. 2000;165:954-960. Abstract Skljarevski V, Desaiah D, Liu-Seifert H, et al. Efficacy and safety of duloxetine in patients with chronic low back pain. Spine. 2010;35:E578-585. Abstract Skljarevski V, Zhang S, Chappell AS, DJ, Murray I, Backonja M. Maintenance of effect of duloxetine in patients with chronic low back pain: a 41-week uncontrolled, dose-blinded study. Pain Med. 2010;11:648-657. Abstract Romanò CL, Romanò D, Bonora C, Mineo G. Pregabalin, celecoxib, and their combination for treatment of chronic low-back pain. J Orthop Traumatol. 2009;10:185-191. Abstract Reuben SS, Buvanendran A, Kroin JS, Raghunathan K. The analgesic efficacy of celecoxib, pregabalin, and their combination for spinal fusion surgery. Anesth Analg. 2006;103:1271-1277. Abstract Spitz A, AA, Papaleontiou M, Granieri E, BJ, Reid MC. Primary care providers' perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatr. 2011;11:35.Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1,000 oncologists. J Clin Oncol. 1991;9:1916-1920. Abstract Upshur CC, Bacigalupe G, Luckmann R. " They don't want anything to do with you " : patient views of primary care management of chronic pain. Pain Med. 2010;11:1791-1798 Abstract