Transcript Management of Lower Back Pain in Narcotic Abusers

Management
of
Lower Back Pain in
Narcotic Abusers
By: Braye Rueff
Lower Back Pain
• How common is it? 85 % of all people will
experience LBP during their lifetime
• How do you treat LBP: Difficult task!
• Complex system of Vertebrae/disc/nerves
• Surrounding soft tissue
• ALL capable of generating pain
Treatment of LBP
• Pharmacologic Analgesics are generally
administered as the initial treatment for
LBP.
• Most commonly prescribed: NSAIDS + Opioids
(ex. type of narcotic).
combination therapy:
• maximize pain relief
• provide greater speed and duration
• a synergistic affect.
Difficulties in Treating LBP in
Narcotic Abusers
4 Major Issues:
1) Lower Back Pain: Difficult to Manage:
Narcotic Abusers
2) “Drug Seeking” Patients
3) Physiological Differences
4) Mutual mistrust
Why??? Managing LBP in Narcotic
Abusers so Difficult
“Solution” is the “Problem”
1a) The class of drug patients abuse or have
abused is one of the primary pharmacological
tools for treating LBP
1b) The non-physical factors the abusers may be
presenting:
Depression
Substance Abuse
Non-physical Factors: Depression
It has been indicated that approximately
90% of persons with opioid dependence
have an additional psychiatric disorder,
such as major depressive disorder.
(Saddack 2004)
Pain + Depression = Cymbalta
• Cymbalta is an SNRI used to treat pain and has
also been indicated for depression.
• Studies have shown that treatment with
Cymbalta, 60 mg q.d. significantly reduced pain
compared with placebo. Improvements in pain
and changes in depression severity were due to
the direct effect of Cymbalta.
•
(Brannan 2005 and Fava 2004)
$ $ $ $ $ $
Non-Physical Factors:
Substance Abuse
• Substance Abuse: Encourage to get help
• Medical providers should:
– Be familiar with certain treatment options,
such as rehabilitation centers & detoxification
procedures in the area.
– You may be the person they turn to for help!
Difficulties in Treating LBP in
Narcotic Abusers
1) Lower Back Pain: Difficult to Manage:
Narcotic Abusers
2) “Drug Seeking” Patients
3) Physiological Differences
4) Mutual mistrust
2a) “Drug Seeking” Patients
Growing Problem:
It has been estimated that an
emergency department with 75,000
patients per year can expect up to 3,144
visits from fabricating drug-seeking
patients
2b) Red Flags: Drug Seeking
Patients
o The only solution to their pain is pain medication(s)-specifically
opioids or other controlled substances.
o The patient insists on receiving a controlled drug as first line
therapy.
o The patient refuses any type of alternative therapy to help relieve
their pain, such as physical therapy.
o
The patient makes remarks about having a high tolerance to
drugs so they may need a higher dosage in order for the
medication to work on them.
o Insistence on rapid-onset formulations and routes of
administration
(Longo et al. 2000 and Hansen 2005)
2c) Clinical Maneuvers:
“Weeding Out” the “Fakers”
•
•
•
•
Waddell Signs
simulated rotation of the hips en masse with the
lumbar spine without allowing spinal rotation
pressure upon the head
striking dissociation between sitting and supine
straight leg raising
demonstration of non-physiological weakness
and sensory deficits by the patient
2d) eKASPER: Helps Identify
• makes available that particular patient’s
medications as well as the doctor who
prescribed them
• It allows qualified users to get eKASPER
reports 24 hours a day, 7 days a week
within 15 minutes or less
Limitations of eKASPER
• It does not monitor the narcotics the patients are
obtaining from those other than a physician
• It does not detect those who are crossing the
state border in order to get their narcotics.
• Medical providers are only screening those who
have the typical characteristics of a “drug
abuser”
Difficulties in Treating LBP in
Narcotic Abusers
1) Lower Back Pain: Difficult to Manage:
Narcotic Abusers
2) “Drug Seeking” Patients
3) Physiological Differences
4) Mutual mistrust
3a) Physiological Differences In
Narcotic Abusers
• It has been shown that those who abuse opioids
can alter:
1) both the number of these opioid receptors
2) sensitivity which can result in an increase
in tolerance to this class of drugs
Clinical Sig: May need to increase analgesic
dosages.
3b) Why Users Have MORE Pain
Opioid Induced Hyperalgesia (OIH)
lowering of tolerance for pain
• Study: compared abusers and non-abusers
tolerance to pain by placing their arm in an ice
bath.
• Outcome: the non-abusers tolerated the ice
bath more than twice as long as the opioid
abusers
• Clinical Sig: May need to increase analgesic
dosage.
Difficulties in Treating LBP in
Narcotic Abusers
1) Lower Back Pain: Difficult to Manage:
Narcotic Abusers
2) “Drug Seeking” Patients
3) Physiological Differences
4) Mutual mistrust
4a) Mutual Mistrust
• Physicians feared being deceived by drug-using patients
• Lacked a standard approach to commonly encountered clinical
issues, especially the assessment and treatment of pain
• Physicians avoided engaging patients regarding key complaints,
and expressed discomfort and uncertainty in their approach to these
patients
• Drug-using patients were sensitive to the possibility of poor medical
care, often interpreting physician inconsistency or hospital
inefficiency as sign of intentional mistreatment
(Merrill et al 2002)
What to do about the LBP of the
Abuser
Negative side effects associated with narcotic pain
treatment.
VS.
It is unfair to the patient who is in pain and really has the
therapeutic need to withhold such effective medication
Unrelieved Pain

documented health consequences
associated with unrelieved pain.

withholding effective analgesics may
only serve to:
 increase drug craving
worsen addictive disease in the patient with pain
(Compton 2000).
Guidelines to Follow
• Prescribe short term courses of opioids that require frequent followup, and then monitor compliance
• choose a delivery route and formulation that are less likely to be
abused (ex. Transdermal delivery systems);
• Utilize adjuvant medications to enhance the efficacy of lower-dose
opioid analgesia;
• Set down, in written form if possible, a detailed pain management
agreement between the patient and the physician, with the
consequences of failure to comply clearly spelled out; and
• Order toxicological testing if a change from prior levels of alertness
suggests surreptitious drug use
(Breithart 1995.)
Percutaneous Electrical Stimulation
for Spinal Pain (PENS)
Combination: TENS + Acupuncture
How does it work? It delivers electrical stimulation
directly to the deep paraspinal tissues, where
the nerve pathways leading to the spinal column
reside
Outcome:
1) relieve the patient’s pain
2) increase physical activity,
3) reduces the dosage of pain
medications prescribed.
PENS Limitations
•
•
•
•
Compliance
Scared/ Pain???
Cost: Insurance may not cover procedure
Access
Summary
• Pain Management
–LBP
–LBP w/ Users
–LBP w/ Users +++
References
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Breithart W., McDonald M. Pain Management in Patients with HIV Infection.
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Chu, L., Clark, D. and Angst, M. Opioid Tolerance and Hyperalgesia in Chronic
Pain Patients After One Month of Oral Morphine Therapy. The Journal of
Pain. 2006; 7 (1): 43-48.
Compton P., et. al. Pain Response in Methadone-Maintained Opioid Abusers. Journal of
Pain and Symptom Management. 2000; 20(4): 237-245
Craig, C. and Stitzel, R. Modern Pharmacology with Clinical Applications. 2004;
6th Ed. Pg 319.
Fava, M et al. The Effect of Duloxetine on Painful Physical Symptoms in Depressed
Patients. J Clin Psychology. 2004; 65(4): 521-30.
Ghoname, E., Craig, W, White, P., et al. Percutaneous Electrical Nerve Stimulation for
Low Back Pain. JAMA. 1999; 281:818-23.
Hanson G., The Drug-Seeking Patient in the Emergency
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Jamison, R., Slawsby, E. et al. Opioid Thearapy for Chronic Non-Cancer Back Pain.
Spine. 1998; 23(23):2591-2600
Katz and Rothenberg. Section Four:Treating the Patient in Pain. J clin of in Reurmatol. 2005; 11: s16-28.
Longo, L., Parran,T., Johnson, B. and Kinsey, W. Identificatin and Management of Drug
Seeking Patient. American Family Physician. 2000; 61: 2401-8.