Chronic Low Back Pain and Drug-Seeking Behavior

[Guest guest]

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 dc

Chronic

Low Back Pain and Drug-Seeking Behavior

P. Vega, MD

CME Released: 12/28/2011; Valid for credit through 12/28/2012

Case

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

Examination

The

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

Question

What 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 Controversy

Community

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 Nonnarcotics

In 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 Care

Can 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 Opioids

Physicians

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; and

Stigma 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 Physicians

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]

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.

References

Gatchel 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