Management of

Lower Back Pain inNarcotic 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:

DepressionSubstance 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.

oThe 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 follow-

up, 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

Brannan S., et al. Duloxetine 60 mg once-daily in the treatment of painful physical symptoms in patients with major depressive disorder. Journal of PsychiatricResearch. 2005; 39(1): 43-53.

Breithart W., McDonald M. Pain Management in Patients with HIV Infection. HIV Newsline. 1995; 1 (6). www.hivnewsline.com/issues/Vol1Issue6/care.html

Chu, L., Clark, D. and Angst, M. Opioid Tolerance and Hyperalgesia in ChronicPain Patients After One Month of Oral Morphine Therapy. The Journal ofPain. 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 Room. Emergency Medicine Clinics of North America. 2005; 23: 349-365.

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.

Merrill, J., Rhodes, L., Deyo, R. et al. Mutual Mistrust in the Medical Care of Drug Users. J Gen Intern Med. 2002; 17 (5): 327-33.

Phillips, K., Ch’ien, A., Norwood, B. and Smith, C. The Nurse Practitioner. 2003; 28(8).Revord, J. Pain Management for Chronic Back Pain. www.spine- health.com/topics/conserv/pain/painm/painm01.html.

Sadock, B. and Sadock, V. Concise Textbook of Clinical Psychiatry. 2004; 9th Ed. Pg 118.Wheeler A., Therapeutic Injections for Pain Management. E medicine.http://www.emedicine.com/neuro/topic514.htm#section~sympathetic_nervous_system_blockade

White P., J. Phillips, T. Proctor and W. Craig. PENS: A Promising Alternative Medicine Approach to Pain Management. Journal of Pain. 1999; 9(2).

Yokoyama, Masataka MD, Sun, Xiaohui MD, Oku, Satoru et al. Comparison of Percutaneous Electrical Nerve Stimulation with Transcutaneous ElctricalNerve Stimulation for Long-Term Pain Relief in Patients with Chronic Low Back Pain. Anesthesia and Analgesia. 2004; 98(6): 1552-1556.

http://www.bambooweb.com/articles/p/a/Pain_management.htmltechlines.ky.gov/2005/april/drug_abuse.htm

http://www.ninds.nih.gov/disorders/backpain/backpain.htm

http://www.trinitypain.com/electrical_nerve_stimulation.htm