Back Pain

From Clinicaltools.com

Contents 1 Course 5: Back Pain and Opioids 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Limit Opioid Use 1.3.2 Objective B. Recognize Misuse 1.3.3 Objective C. Consult or Refer 1.4 Case Studies/Simulated Patients

Course 5: Back Pain and Opioids

Need

Many clinicians overprescribe opioids for back pain. Back pain is the most common condition for which opioids are prescribed in primary care (Fleming et al., 2007; Reid et al., 2002). Furthermore, they often do not take the appropriate clinical steps to avoid triggering or contributing to an addiction problem when managing pain from back pain.

Physicians studied in a teaching hospital did not use a standard approach to common issues in addiction medicine and pain management (Merrill, et al, 2002). Aberrant behaviors related to taking medication are seen in up to 24% of patients on opioids for back pain and current substance use disorder among these patients is estimated as high as 43% (Martell et al., 2007). Opioids may be effective for short term pain relief in back pain, but the evidence for long term efficacy is not clear (Martell et al, 2007).

Goal

The learner will manage the back pain in primary care, in a way that avoids triggering or contributing to addiction problems.

Objectives

After completing this course, the learner will be able to:

Objective A. Limit Opioid Use

Limit use of opioids and prescribe appropriately when treating back pain

1. Use opioids for back pain only after first-line and second-line treatments have failed
2. Recognize the uncommon situation in which opioids are indicated for treatment of back pain
3. Use non-opioid medications on a schedule rather than as needed before trying opioids
4. When opioids are indicated, use in combination with other pharmacological and non-pharmacological therapies in order to minimize the dose and increase effectiveness
5. Use non-scheduled and/or extended-release opioids before scheduled, high-potency opioids

Objective B. Recognize Misuse

Recognize substance misuse in back pain patients

1. Monitor total use of opioids for back pain pain and compare to expected use for the diagnosis
2. Identify "yellow flags" that are indicative of substance misuse

Objective C. Consult or Refer

Recognize when patients with back pain require referral to a specialist or consultation

1. Determine which type of pain or addiction specialist is appropriate
2. Consider referring to patients who develop a chronic pain syndrome to a pain specialist
3. Refer back pain patients who require opioid therapy and have "yellow flags" for addiction to a pain specialist or orthopedist
4. Refer patients who have an addiction disorder for addiction treatment
5. Refer patients to other medical and mental health specialists when appropriate
6. Include all key patient information (history and current status) in referral report

Case Studies/Simulated Patients

Case 1: Becky Back Pain - 29YOWF

• Chief Complaint: Gradual onset of daily back pain, that intensifies at night.
• Narrative: Becky is a dentist who has been experiencing back pain despite attention to posture and doing back exercises. Her pain stopped responding to NSAIDs 2 months ago.
• Opioid Issue: Back pain not responding to NSAIDs.
• Relevant Past Medical, Psychosocial, Family History: Becky has been practicing dentistry for nearly one year now. Her back pain gradually came on over the last 6 months.
• Objectives Covered: A

Case 2: David Back Pain - 44YOBM

• Chief Complaint: Ran out of his back pain medication.
• Narrative: David went to physical therapy for 6 months after injuring his back in a bicycle accident and also took oxycodone for 1 month. He says that he "just felt better" while taking the oxycodone and he started buying it illegally on the Internet after his prescription ran out. He "isn't sure" how much oxycodone he takes now.
• Opioid Issue: Undiagnosed substance use disorder.
• Relevant Past Medical, Psychosocial, Family History: David sustained a back injury and broken arm 6 months ago when a car crashed into his bicycle.
• Objectives Covered: B, C