Pharmacologic Management of Acute and Chronic Back Pain

1. Pharmacologic Management of Acute and Chronic Back Pain Clare Beau Romero, MSN, FNP-BC

2. No Disclosures

3. Pharmacologic Management of Acute and Chronic Back Pain • Acute Non-Specific Mechanical Back Pain • Chronic Back Pain • Acute on Chronic Back Pain

4. A list of things my colleagues and I wish we were taught in school • How to say “no” • When to start Opioids • 50 shades of guidelines • CDC Guidelines • ACP/AAFP Guidelines • What do you do with your current patients on opioids? • Opioid Rotation • Opioid Induced Hyperalgesia • When & How to wean Opioids • Special Considerations • List of things to keep you out of trouble

5. Acute Back Pain • 85% of primary care visits for back pain is non- specific mechanical back pain • Rule out non-mechanical spine disease • Rule out visceral disease • Treatment also applicable in acute mechanical neck pain, acute pain with painful radiculopathy in the absence of weakness and other “red flag” symptoms

6. Acute Mechanical Back Pain • Up to 85% of all people worldwide experience low back pain • Good prognosis- 70-90% improve within 2-7 weeks (most improve in 2 weeks) • 5-20% go on to develop chronic back pain (risk factors include mal-adaptive coping behaviors, poor general health, psychological co-morbidities) • Recurrences are common, 30-70% in 12 months

7. First line therapy • Self-care advice- • Maintain activity as tolerated • Self-care education has similar outcomes to physical therapy, massage, spinal manipulation and acupuncture • Bedrest only for severe symptoms but should return to activity ASAP • BR does not improve function or pain • Fear avoidance beliefs are assoc with poorer outcomes

8. NSAIDS- Initial Monotherapy • NSAIDS (offers modest benefit compared with placebo or acetaminophen) • 2-4 weeks • Ibuprofen 400-600mg QID • Naproxen 220-500mg BID- 250-500mg BID (naproxen base) 220-500mg BID (naproxen sodium which has faster onset and absorption) • Contraindications- renal, GI, CV disease • Acetaminophen (several studies show no benefit over placebo)

9. Muscle Relaxers – rules of thumb • Muscle relaxers- reasonable to add with NSAIDS if can tolerate SE, use in caution with older adults • Must warn of sedating SE including CNS depression, increase risk of falls, dizziness, lightheadedness. No Alcohol, caution with driving • No Benzodiazepines (actually, BZD’s aren’t indicated for the primary treatment of any pain condition) • No Carisprodol (Soma) – too addicting, not superior to other muscle relaxers and when added to BZD & opioids “holy trinity of high”

10. Muscle Relaxers- Second line therapy

11. Not recommended for acute non-specific back pain • Use your clinical judgement • Know your patient • Complete a risk assessment • Check the PMP • No difference in pain after 7 days compared to treatment with oxycodone + naproxen vs naproxen alone

13. Tramadol • MOA: binds to mu opiate receptor in CNS inhibiting ascending pain pathway, inhibits the uptake of NE and serotonin in the descending inhibitory pain pathway responsible for pain relief • IR: Onset with 1 hr, peak 2-3 hrs, half-life 5-8hrs • No data showing efficacy for acute back pain, some use when NSAIDS are contraindicated • Lower risk of constipation and dependence compared to opioids • 50mg IR TID to QID PRN 3-7 days • Max dose 400mg daily (300mg daily with the elderly) • Risk of Serotonin syndrome when added to other serotonergic agents • Risk of CNS depression, hypotension, seizures (may lower threshold)

14. Opioids – Oxycodone IR 5mg tabs only • MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of pain; produces CNS depression • IR: onset 10-15 mins, peak 30-60 min, duration 3-6 hrs, half-life 3-4 hours • 5-10mg HS, TID PRN x 3 days, may go up to 7 days • Risk of CNS depression (no driving, operating machinery), constipation, respiratory depression, hypotension, addiction

15. Opioids – Hydrocodone 5-7.5mg tabs • MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of pain; produces CNS depression • Dose: Hydrocodone 5-10mg HS or TID PRN x 3 days, may go up to 7 • Risk of CNS depression (no driving, operating machinery), constipation, respiratory depression, hypotension, addiction

16. Opioids- Morphine IR 7.5mg-15mg • MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of pain; produces CNS depression • Onset 30 min, duration 3-5 hrs, peak 1 hr, half-life 2-4 hrs • Dose: IR 15mg tabs take half to 1 tabs HS or TID PRN for 3 days, may go up to 7 days • Risk of CNS depression (no driving, operating machinery), constipation, respiratory depression, hypotension, addiction • DO NOT USE in pts with renal impairment

17. The Art of Saying No • Have a “spiel” • Mirror their words, “I hear that….” • Recite the evidence • Focus on realistic expectations: • Low back pain IS painful and odds are, it will get better • Opiates only decrease pain on average by 30% and therefore, is not worth the risk of the dangerous SE • non-opiate medications do help decrease the severity • Empower the patient and focus what the patient can do to strengthen the core, be healthy, posture, exercise, self-care, etc • Use the words “dangerous”, “harmful”, “not good care” or “bad medicine”, “I don’t prescribe opioids for back pain”

18. Other medications • Antidepressants, systemic glucocorticoids, antiepileptics- no evidence to support use in acute back pain • Topical agents- weak evidence BUT capsaicin may benefit. Other herbal therapies have little evidence

19. Adjunctive Therapy • Exercise and Physical therapy • Acupuncture • Massage • Heat • Cold • Spinal Manipulation • Yoga • Paraspinal injections

20. Chronic Back Pain Defined as pain >12 weeks

21. Treatment of Chronic Back Pain Pharmacologic Therapies • Physical Medicine • Behavioral Medicine • Neuromodulation • Interventional • Surgical

23. History • HPI: Capture quality, duration, timing, alleviating/aggravating factors, severity at best and worst • ROS: Mental Health/Psychiatric history • CURRENT REGIMEN: side effects too • HISTORICAL MEDICATIONS AND TREATMENTS: mucho importante! (PMP) and chart why it wasn’t effective • FUNCTIONAL STATUS: How well you do function in life? • FUNCTIONAL GOALS: What would you like to be able to do that you feel you can’t (realistic). Always add activity goals • FUNCTIONAL PLAN: What is the patient going to do to get there? • OPIOID HISTORY: COMM or SOAPP score. How often have you ran out early? Asked for early fills? Lost/stolen? etc • SUBSTANCE USE HISTORY: ask specifically • FAMILY HISTORY: specifically substance, opioid or alcohol dependence or abuse

24. Multiple side effects- GI, CV, renal, loss of platelet function • First line therapy for acute and chronic back pain • Used only for the shortest period necessary/exacerbations/PRN • Compared with placebo, NSAIDS are more effective for pain relief and function.

25. NSAIDS • Naproxen • 250-500mg BID (naproxen base) 220-500mg BID (naproxen sodium which has faster onset and absorption) • A good choice for acute or chronic pain, high doses may have less CV toxicity than other NSAIDS • Ibuprofen 400-600mg QID or 600-800mg TID • Etodolac ER 400-600mg daily. Has second lowest GI SE profile (COX-2 selective) • Diclofenac 75mg BID or 50mg TID, also available as patch, solution, gel • Meloxicam 7.5-15mg daily, slow onset, COX-2 selective • Celebrex 100-200mg daily, has lowest GI SE profile (CV and renal risks are dose related and similar to those of non-selective NSAIDS)

26. Muscle Relaxers

27. Antidepressants

28. Antiepileptics

29. Who is an Opioid Candidate? Opioids are not first line therapy and use is controversial. Use ONLY if expected benefits for both pain and function outweigh the risks. If used, they should be combined with nonpharmcologic therapy and nonopioid pharmacologic therapy (CDC Recommendation #1). All chronic pain patients deserve treatment of their pain. Providers who are not comfortable treating certain patients should refer

30. Risk Screening Tools Screener and Opioid Assessment for Patients with Pain (SOAPP): Intended to predict patients who are being considered for long term therapy may exhibit aberrant behaviors in the future. Current Opiate Misuse Measure (COMM): ID’s whether a patient who is currently on chronic opioid therapy may be misusing their medication. Ideal for documenting decisions about the level of monitoring planned for a particular patient or justifying referrals to specialty pain clinic.

31. Opioid Calculator & CDC Guidelines • https://opioidcalculator.practicalpainmanagement.com – will modify for cross tolerance Calculate and document MME for every patient

32. Opioids- Initiating Treatment Before you begin chronic opioids:

33. Opioids • MOA: Acts on the central and peripheral mu-, kappa-, delta- opioid receptors inhibit the nociceptive input and the perception of pain. • Variation of distribution& density account for the global and varied effects • Mu receptors have a profound analgesic effect, concentrated in midbrain and spinal cord, also causes bradycardia, sedation, euphoria, dependence and respiratory depression. FORMULATIONS

34. Opioids-IR IR should be used PRN when combined with ER. Talk to the patient and discuss when it is best to use. Purpose is to improve function and meet goals.

35. When to start long acting opioids • Goal is have benefits outweigh risks and preserve/improve function. • Consider when patient is getting IR 10mg MME Q6hrs PRN and pt is reporting severe pain and adding a long acting opioid would reduce the drastic “up and down” effect of pain relief AND it will improve function. • Try to not increase the overall MME by more than 10-20% • Example: • Pt taking oxycodone 10mg QID. • Could consider adding long acting morphine 15mg BID + oxycodone 5mg QID PRN or 10mg BID.

36. Tramadol- IR and ER • MOA: binds to mu opiate receptor in CNS inhibiting ascending pain pathway, inhibits the uptake of NE and serotonin in the descending inhibitory pain pathway responsible for pain relief • IR: Onset with 1 hr, peak 2-3 hrs, half-life 4 hrs • ER: Peak 4-12 hours, half-life 8 hrs • Some use when NSAIDS are contraindicated & benefits outweigh risks • Lower risk of constipation and dependence compared to opioids • 50mg IR TID to QID & 100mg SR daily to BID • Max dose IR 400mg daily IR (300mg daily with the elderly) and max dose SR 300mg daily • Risk of Serotonin syndrome when added to other serotonergic agents • Risk of CNS depression, hypotension, seizures (may lower threshold) • Can also help with neuropathic pain • Long term therapy needs to be tapered when discontinuing

37. Opioids- SR

38. Opioids-SR

39. Acute on Chronic back pain exacerbation • Assess the patient as you would with any new patient with acute pain – H&P, examination, diagnostics, etc. Rule out visceral and non-mechanical spine disease, worsening mechanical spine disease • Expect your patients to have exacerbations. Discuss during the first visit, come up with a plan. • Discuss known triggers: worsening depression, stress, anxiety, etc and certain activities • Discuss fear, activity avoidance, bed rest • Give them a plan of action with PRN NSAIDS or muscle relaxers • Discuss expectations with opioids, “If you take more than Rx for any reason, I will not refill early. You must ____________” • If you would otherwise Rx opioids for an acute pain, do so while maintaining current regimen (unless they are on suboxone)

40. 50 Shades of Guidelines (CDC & AAFP) OPIOIDS ARE NOT FIRST-LINE THERAPY ESTABLISH GOALS FOR PAIN AND FUNCTION DISCUSS RISKS AND BENEFITS USE IMMEDIATE-RELEASE OPIOIDS WHEN STARTING USE THE LOWEST EFFECTIVE DOSE PRESCRIBE SHORT DURATIONS FOR ACUTE PAIN 7. EVALUATE BENEFITS AND HARMS FREQUENTLY 8. USE STRATEGIES TO MITIGATE RISK 9. REVIEW PDMP DATA 10. USE URINE DRUG TESTING 11. AVOID CONCURRENT OPIOID AND BENZODIAZEPINE PRESCRIBING 12. OFFER TREATMENT FOR OPIOID USE DISORDER

41. 50 Shades of Guidelines (ACP)

42. What do I do with my established pt? • Check PMP • Do UDS • Tell him/her there have been new guidelines published and the BON & NM are making you do certain things in order to reduce the number of New Mexicans dying from opiates every year • Document pain history/experience once yearly • Document function • Document measurable goals & follow up with tele apt or nurse visit • Discuss your medication goals • Ensure you are addressing physical rehabilitation, behavioral health

43. Opioid Rotation • Can help avoid escalation and give the patient a sense of control over regimen • Modify for a 20-30% cross tolerance • Rotate <2 times yearly should regimen become ineffective • Do not increase overall MME

44. Opioid Induced Hyperalgesia & Tolerance • Chronic stimulation of opioid receptors causes increased sensitivity to pain by 40-70%: • Central activation of NMDA receptors and protein • kinase-C • Upregulation of spinal dynorphin • Apoptosis of spinal dorsal horn neurons • Patients with OIH paradoxically experience less pain relief with increasing opioid doses and, as OIH increases, their pain may become more diffuse or otherwise change in quality.

45. When & How to Wean Opioids • Wean & refer when: • Multiple providers • Recurring aberrant behaviors • Substance abuse/dependence • Alcohol abuse/dependence • It becomes dangerous to the patient to continue to Rx • Patients will not die from opioid withdrawal alone • Consider hydroxyzine, promethazine, clonidine, loperamide, etc • Humane taper is 10% per week

46. Special Considerations • For post-op pain: allow pt to take rx opiates from surgeon on top of current regimen. • Marijuana: • Screen for dependence • If dependent, discuss treatment options just was you would any other substance. • Check your place of employment for policies. • Otherwise, it’s a personal decision. • For all pts on >50MME, discuss naloxone and Rx

47. List of things to keep you out of trouble • Check PMP • do UDS • see your patient frequently • multidisciplinary approach • be able to justify high doses • assess and document risk • prescribe/discuss naloxone

48. Chronic Pain Management (in the world according to Beau) • Every Visit • Q3-6 months • Check UDS, PMP • Complete FULL pain & BH assessment • Discuss Goals & Function • Assess risk (labs, behavior, comorbidities) • Plan • Pharmacologic Treatment • Physical Medicine & Rehab • Behavioral Medicine • Neuromodulation • Interventional Medicine • Surgical Options • Goals