Transcript Managing Back Pain in General Practice “It’s a pain in the….”

Managing Back Pain in
General Practice
“It’s a pain in the….”
Presented by
- North East Valley Division of General Practice
- Northern Division of General Practice
- Melbourne Division of General Practice
- The National Prescribing Service
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Program
 Two case studies
– Initial presentation
• Acute case study
• Discussion in small groups
• Presentation & discussion
– Subsequent presentation
• Chronic case study
• Group discussion
 Panel Discussion
 Resources for GPs & patients
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Back Pain
 Most frequent musculoskeletal condition
seen in GP
– 7th most common reason for seeking care
– around 85% have a non-specific cause of pain
– serious conditions are rare
 Recovery time
– 80 and 90% of patients with acute back pain
recover within 6 weeks
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Back Pain
 Most common presentation
– is non-specific low back pain associated with
decreased spinal movement
 Less common causes of back pain
– include trauma, disorders producing neurological
lesions
– Infection
– neoplasm
– metabolic bone disease
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Acute Back Pain
Aim of management
– Identify potentially serious causes of
acute low back pain
– Promote effective self-management of
symptoms through the provision of
timely and appropriate advice
– Maximise functional status
– Minimise disability.
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Acute Low Back pain
 DEFINITION
– Refers to an episode of pain of less than 3
months duration
 ASSESSMENT should differentiate between:
– Acute low back pain (non-specific or ‘simple’)
– Spinal pathology
– Nerve root pain
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Initial Presentation
Brett
 32 year old air conditioning technician
 New to your practice
 Consults you at midday
 He has hurt his back
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Initial Presentation
……continued
 Brett hurt his back while working in the
roof space of a building
–
–
–
–
Twisted around to lift equipment
Felt sharp pain in lower back
Took a few minutes before he could move
Had considerable difficulty getting back down the
ladder
 He lay down for about 1/2 an hour until the
pain lessened
 Came straight to the clinic
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Initial Presentation
……continued
Brett has asthma
– Uses a salbutamol inhaler when he
needs it
[Airmir, Asmol, Epaq, Ventolin]
No other significant history
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Initial Presentation
……discuss in small groups
Case update in 10 -15 minutes
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Initial Presentation
……case update
Brett rates his current pain at 6/10
After assessment
– you conclude Bret has work related acute nonspecific low back
Brett has been prescribed paracetamol 500mg and
codeine 30mg (Codalgin Forte, Dymadon Forte,
Panadeine Forte) in the past for pain and says the only
thing the codeine does to him is to make him
constipated.
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Initial Presentation
……continued
Question 1
How would you assess the severity
of Brett’s pain?
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Initial Presentation
……continued
Question 1
How would you assess the severity
of Brett’s pain?
Also ….
How often should you measure pain?
Apart from pain severity, what else do
you look for in the pain history?
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Initial Presentation
……continued
Question 1
Key message
Assess & document characteristics
of pain to individualise & monitor
effectiveness of treatment.
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Initial Presentation
……continued
Question 2
What is the analgesic of first choice
for acute low back pain?
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Initial Presentation
……continued
Question 2
What is the analgesic of first choice
for acute low back pain?
Also ….
If you were to use paracetamol what
dosage is appropriate for acute low
back pain?
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Initial Presentation
……continued
Question 2
Key message
Use paracetamol first, as it is
effective when taken regularly in
appropriate doses and has a good
safety profile.
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Initial Presentation
……continued
Question 3
What about an NSAID?
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Initial Presentation
……continued
Question 3
 What about an NSAID?
Also ….
 Is a conventional NSAID appropriate for
Brett?
 Is a COX-2 selective NSAID appropriate
for Brett?
 What about a paracetamol/codeine
combination?
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Initial Presentation
……continued
Question 3
Key messages
 Before prescribing COX-2 selective or
conventional NSAIDS, review risk of peptic ulcer,
cardiac disease or renal impairment.
 COX-2 selective NSAIDS are not more effective
than conventional NSAIDS and have a similar
range of adverse effects.
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Initial Presentation
……continued
Question 4
What about tramadol?
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Initial Presentation
……continued
Question 4
 What about tramadol?
Also ….
 Is tramadol an opioid?
 What is tramadol's adverse event profile
 What about drug interactions with tramadol?
 If you did decide to prescribe tramadol for Brett
what dose would you use?
 Would a sustained release preparation be
helpful for Brett?
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Initial Presentation
……continued
Question 4
Key message
 Consider the range of adverse effects
and serious drug interactions with
tramadol when selecting therapy where
pain requires an opioid or opioid-like
analgesic.
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Initial Presentation
……conclusion
 As Brett is not on any interacting
medications
– you decide to prescribe Brett tramadol 50mg
four times/day for pain relief.
 You have provided him with information
on the potential adverse effects of
tramadol
– & Brett is happy to give it a try.
 You ask Brett to come back in 3 days
– so that you can monitor his progress and if
improving reduce/cease his tramadol.
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Subsequent Presentation
….4 months later
Group discussion
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Subsequent Presentation
….4 months later
Brett returns:
 He has persistent lower back pain and has
been unable to return to work.
 Brett was prescribed Oxycontin 20mg
capsules 6 hourly PRN by another doctor 2
wks ago. However, Oxycontin has not really
helped and it makes him nauseas.
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Subsequent Presentation
….4 months later





persistent lower back pain
unable to return to work.
prescribed Oxycontin
Oxycontin has not helped
makes him nauseas
 Brett is finding himself irritable & tired.
 His workplace has been unable to to offer
him “light duties”.
 He also informs you at this visit that his wife
is heavily pregnant with their third child. 27
Subsequent Presentation
….4 months later
Questions
 How would you assess Brett’s pain now?
– What else might you assess?
 What pharmacological solutions are
there?
– Is it appropriate to continue Oxycontin?
 What non-pharmacological solutions are
there?
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Summary
Contrast b/w Acute & Chronic Back
Pain
– Acute pain generally improves and
psycho-social factors are rarely an issue
– Chronic pain rarely has a recognisable
“pathological” cause and psychosocial
factors predominate
– Patients with chronic pain need to learn to
cope with the pain and move forward in
their lives
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Summary
Key messages – Assessment
 Assess & document characteristics of pain to
individualise & monitor effectiveness of
treatment (same for acute & chronic pain).
 Consider other morbidity
– Psychological issues eg self esteem, depression
– Social impact eg family relationships
– ADL disability eg unable to look after garden etc
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Summary
Key messages – Pharmacotherapy
 Use paracetamol first, as it is effective when
taken regularly in appropriate doses and has a
good safety profile.
 Before prescribing COX-2 selective or
conventional NSAIDS, review risk of peptic ulcer,
cardiac disease or renal impairment.
 COX-2 selective NSAIDS are not more effective
than conventional NSAIDS and have a similar
range of adverse effects.
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Summary
Key Messages – Non-pharmacological
 Physical & psychological therapies
 Yellow & red flags
 When to refer
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