“What do you mean my MRI is negative? My back still hurts! “My whole body aches.” and other statements to address in primary care pain management.
Annemarie M. Kallenbach RN CNP No Disclosures
Overview • Fibromyalgia and chronic back pain are two time consuming and frustrating diagnoses seen frequently in clinical practice • Choosing to treat or transferring care to a consultant or specialist has benefits and drawbacks. • Understanding the use of pain contracts /partner agreements and frequent intervals of visits will improve outcomes.
Overview • Chronic low back pain and fibromyalgia share two clinical features. • The visits are not quick • The visits are not easy.
Overview Implementing a consistent algorithm that incorporates current recommendations in today’s busy clinic will yield improved results in patient care.
Overview • Chronic pain must to be addressed in a multi directive model. • A clear, practical chart checklist will keep treatment plan on course.
Personal experience • Labor • Stubbing toe on chair leg • Burning shoulder pain from too much time on computer
Provider Response Jot down 5 honest reactions to seeing back pain-recurrent, fibromyalgia follow up on your schedule.
Provider reactions • Time consuming • Frustrated • Angry • Nervous • Agitated • Scared • Skeptical
Provider reactions • Excited for the challenge. • Ready to try a multiple facet approach to treatment. • Armed with excellent resources.
Provider reactions • Frustrated • Angry • Nervous • Agitated • Scared • Skeptical • Excited for the challenge • Ready to try a multiple approach to treatment • Armed with excellent resources
Patient questions to ponder • Does you patient have chronic pain? • Has a complete workup been done in the past? Labs, diagnostics
Patient questions to ponder • Has your patient been screened for mental health problems? • Does your patient have a diagnosis of mental health problems? • Is it the correct diagnosis? • Is the patient adequately treated for mental health (pharmacologic agents, talk therapy, support groups, behavior modification)
Patient questions to ponder • Do you believe you can have an honest patient provider relationship?
Patient questions to ponder • Does your patient have the ability to go to a chiropractor, PT, massage therapist, acupuncturist, etc?
Patient questions to ponder • Is your patient already on routine opiods? • Is your patient willing to partner to reduce/eliminate ineffective opiods?
Provider questions/beliefs • Do you have time and interest in treating? • Do you have knowledge to treat?
Provider questions/beliefs • Can you prescribe narcotics? What classes of narcotics? Long acting narcotics, including Methodone? • Do you have knowledge regarding medical marijuana? • Do you understand parameters for prescribing opioids?
Provider questions/beliefs • Do you have relationships with local pharmacists?
Provider questions/beliefs • Do you have the ability to drug screen your patient?
State level questions • Does your state have medical marijuana? • Does your state have a narcotic prescription reporting mechanism?
Elements of a Pain History Taking a Pain History • Location • Radiation • Onset: sudden or insidious • Duration • Frequency: continuous or intermittent • Description • Intensity • Alleviating factors • Exacerbating factors
Chronic pain site • Lumbar • Knee • Neck • Shoulder • Total body
Current (Previous) Medication Regimen • Anti inflamatory • Elavil/Pamelor • Neurontin • Lyrica • Antidepressent • SSRI • SNRI • Mood stabilizer • Anxiolytic • Opiod • Tramadol • Sleep agent • SUBOXONE, METHADONE
Diagnostic work up • Was it complete? • Exam findings • X-ray • MRI • Consult notes
Referrals • Orthopedic • Pain management • Neurosurgeon • Injection therapy • Psychologist
Physical therapy,Chiropractic care, massage therapy, Accupuncture • Dates • Goals • Patient’s adherence to sessions and to home exercises • Trial of TENS
Additive disorder • Tobacco smoker • Drug dependence • Alcoholic
Collaboration • Partner agreement • Pain contract signed