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Alternatives to Prescribing Controlled Substances for Chronic Pain

by Patti J. Brown, M.D.
Physical Medicine and Rehabilitation
Medical Director, HealthSouth Reading
Rehabilitation Hospital

The treatment of chronic pain has been a hot topic lately due to the opioid crisis our country is presently facing. As a physical medicine and rehabilitation specialist my interest in treatment of chronic pain has been long-standing. PM and R specialists have been trained in alternatives to opioids in the treatment of pain. When I started in practice in the 90s our rehab hospital had a multidisciplinary pain clinic based on non-narcotic approaches to pain. However, around that time the media and pharmaceutical companies started touting pain relief at all costs. It is my opinion that this approach is responsible for the crisis we are now facing. For that reason I was anxious to write this review article on a comprehensive treatment approach to chronic pain.

Chronic pain is among the most common reasons persons seek medical attention. It is reported by 20 to 50 percent of patients seen in primary care. Ten to 15 percent of the working population is affected by back pain each year.

Acute pain can be linked to a precipitating event. It may be accompanied by anxiety, anger and requires a temporary lifestyle adjustment. Acute pain has a high rate of successful cure. It is generally self limiting.

Treat acute pain aggressively, the longer pain persists, the less likely complete resolution becomes. Patients must be educated on preventative measures.

Address pain relief through modalities – RICE. Rest, ice, compression and elevation. Regain normal muscle length through range of motion. Address gradual muscle strengthening and exercise.

Chronic pain is persistent pain that lasts greater than six months. Complications of chronic pain are physical, psychological, and environmental.
Secondary physical pain develops due to inactivity. Patients develop decreased range of motion, myofacial pain and weakness due to deconditioning. Patients develop weight gain. They may develop drug dependency.
Psychological complications of chronic pain include depression, sexual dysfunction and marital stress.

Environmental complications of chronic pain include lost working days, decreased productivity, and escalating costs of workers compensation.
The characteristics of chronic pain patients is a person with low level of activity, high demand for medication, high verbalization of pain and inability to work. These patients are best approached in a multidisciplinary model.

The multidisciplinary approach includes a rehabilitation specialist for a clinical evaluation, psychologist for depression and motivation, interventionist for procedures and physical therapy for modalities and exercise. Occupational therapy should be available to address function and daily activities.

Treatment goals should be to teach patients to control or cope with the pain, improve their quality of life, improve functional capabilities, decrease dependence on drugs, decrease visits to physicians, increase physical activity and return to employment.
This pain treatment approach begins with patient education. Empower patients. Make them active participants in their own treatment program. Help patients understand what is causing the pain. Give them the appropriate tools – heat, ice, range of motion, non- narcotoic medication to deal with exacerbations. Instruct patients in a home exercise program. Instruct patients in proper body mechanics.

Physical modalities should be used in the acute phase and for exacerbations. They should be used in combination with active exercise.

Examples of physical modalities includes cold therapy which decreases pain, decreases muscle spasm and decreases inflammation. Heat therapy increases blood flow and decreases inflammation. Deep heat therapy such as ultrasound is used to decrease inflammation and increase range of motion.

Sensory modulation such as TENS, acupuncture and contrast baths utilizes the Gate theory, which is activation of large afferent fibers to inhibit the transmission of painful impulses.
Assistive devices can be used to support and decrease stress to the affected area. Orthoses such as casts, splints and braces can be used. Gait aids such as canes, crutches, and walkers can be used but only temporarily. The eventual goal should be restoring range of motion and function.

In the multidisciplinary approach, the patient should be instructed in behavioral and self regulation techniques. These include relaxation methods, such as breathing, meditation, yoga, and self hypnosis. Coping skills such as distraction and imagery can be used. Biofeedback can be a useful adjunct. Biofeedback involves using a relaxation technique to modify a physiologic parameter such as heart rate or breathing.

Therapeutic exercise is an important adjunct in pain therapy and should be used judiciously in acute pain. With acute pain and exacerbations rest should be limited to a very few days. Isometric exercises can be performed with range of motion to the point of pain. Range of motion and flexibility is addressed as inflammation subsides. Strengthening and aerobic exercise is added as pain improves.

Chronic pain developes in part due to immobilization and deconditioning. Work through pain slowly to achieve increasing goals.

Non narcotic pharmacologic interventions should be addressed. Adjuvant analgesics are drugs primarily approved for treatment of conditions other than pain but act as analgesics in selected circustances. Antidepressants work on serotonin and norepinephrine pathways, increase pain thresholds, improve sleep, improve mood and alter perception of pain. Anticonvulsants work by stabilizing neuronal membranes. Anti-inflammatories, muscle relaxants and scheduled analgesics can be used.

Invasive techniques include joint or soft tissue injections with corticosteroids and local anesthetics. Nerve blocks can be used and are most successful when followed by therapy. Trigger point injections address myofascial pain. Injections should be followed by routine, regular stretching. Epidural blocks are steroid injections into the epidural space close to the nerve root, often a series of three, several weeks apart. Neuroablation such as rhyzotomy and cordotomy are reserved for severe cases.

Modulating techniques are available such as implantation of drug infusion systems such as intrathecal morphine pump and chronic stimulators such as dorsal column stimulator.
Chronic pain is a difficult area of medicine. However, it is also an important one, due to the enormous consequences for the quality of patients lives. Patients appreciate when physicians listen attentively to their symptoms and make sincere efforts to intervene in ways that improve their quality of life. The physical medicine approach is a multi-disciplinary approach with a goal of decreasing dependence on narcotic medications. Goals should be — give patients control, improve function and improve quality of life.

Robinson James P. Chronic Pain.
Phys Med Rehabil Clin N Am 18 (2007)761-783

The Biggest Patient Safety Problem at Home: medications

Constance-Morrisonby Constance Morrison
President and CEO of Home Health Care Management, Inc.

Patients in the acute care facilities across the country receive high quality care every day and then go home. Often times alone because the family at the bedside disappears. They go home to a home that is not quite as easy to maneuver as the floors and bathroom at the hospital. They go home using a device that they never had before like a cane or a walker, and then forget everything that they were taught before they got back to the house. They try to cook for themselves but forget what to do with the walker when they do. Often times after that admission they have lost mobility and tire easily. They are unable to go shopping for the food they need.

Chronic Pain Management

Lucy J. Cairns, MD

In the following piece, BCMS member Dr. Jason T. Bundy provides a de-identified case history of a patient with chronic pain. It illustrates many of the complexities, competing priorities, and limitations physicians who treat chronic, non-cancer pain patients often grapple with, and delineates his approach to trying to help such patients while minimizing the risks. For Pain Management specialists such as Dr. Bundy, “threading the needle” is an apt description of the daily challenge of trying to provide the most effective treatment with the least possible risk, under the limitations imposed by patient histories that are not always reliable, lack of access to a prescription drug monitoring system, limited or no insurance coverage for certain treatments, and social and psychological challenges that affect many patients.

— Lucy J. Cairns, MD


Jason-T.-Bundy,-MD1. Mid back pain.
2. 6/10 back right anterior lateral thigh leg pain.

CHIEF COMPLAINT:
Mid back pain.

Dear Dr.:

I had the pleasure of meeting your patient here at Center for Pain Control today. As you recall, she is a pleasant 55-year-old female with a multiyear history of ongoing back and lower extremity pain. She was actually seen by my practice partner in 2012 who documented your patient underwent an L4-L5 laminectomy and lumbar fusion performed by a local spine surgeon back in 2008. Anyway due to a failed therapeutic relationship with my practice partner, the patient then followed up with another pain specialist who trialed lumbar epidural injections and other options including opioids with some initial relief, but then suboptimal treatment gain longer term. She apparently grew frustrated seeing that physician and now follows back up here to get my take on things.

Of note, my practice partner documented the patient has a prior history of illicit drug use and that she is not an optimal candidate to remain on controlled substances. I gather she disagreed. He did offer to consider a lumbar epidural, but she elected to hold off on that.

Over the interval years, the patient states she has noticed ongoing back pain and lately the pain has been radiating to her right thigh and leg. In addition she now complains of mid back pain. She fell this summer and underwent CAT scan imaging and these updated images and the old MRI were noted today.
Lumbar CAT scan 08/14/2015, “postoperative degenerative change mild-to-moderate stenosis L3-L4. No fracture traumatic subluxation.”

Four view lumbar spine 08/14/2015, “L4-L5 postoperative change. Minimal L4-L5 anterolisthesis. Degenerative change similar to prior study.”

Lumbar MRI 11/28/2011, “stable lumbar levoscoliosis, stable grade 1 spondylolisthesis L4/L5. Postsurgical change from previous decompressive laminectomy L4-L5 level with placement of bilateral pedicle screws at L4-L5 with a disk spacer. There is mild enhancing epidural fibrosis along lateral margin thecal sac bilaterally right more than left, moderate-to-severe right neural foraminal narrowing is noted at the L3-L4 level. This worsened in severity compared to prior exam.”

Indeed today the patient thinks that her prior treating pain management physician trialed a “L3-L4 level” epidural injection with initial relief, but then subsequent injections failed to replicate the good results of the first. She remained on opioids for a period of time, but seems to have good insight that she is not an optimal candidate to be on this or other habit-forming pain medications given her prior history of drug dependency in the past. She follows up with a psychiatrist and states she completely abstains from all illicit or un-prescribed prescription drugs at this point. I gather she was recently given a prescription for Tylenol 3 and Soma and did inquire about a Soma prescription today, but I recommended that we consider alternatives first given the incumbent risks in her particular case.
Today in the clinic the patient notes activities like sitting, standing, and walking tend to make her back and right leg pain worse. When her right leg pain is severe, sometimes her right leg feels weak. She denies a recent history of falling relating to it however. Changing position and taking Soma have been relieving factors. She trialed physical therapy within the past year with limited treatment gain and is reasonably compliant with a self-directed exercise program. She continues to take Celebrex and was taking ibuprofen, but reports overall marginal treatment gain with these options.

When questioned how pain affects her life and what agreed upon goals are today, we arrived at reviewing all diagnostic and therapeutic treatment options to both characterize and treat her ongoing back pain so she can avoid relying on habit-forming pain medications.

PMH:

  1. 1. Anxiety and other psychiatric problems. She follows up
    with un-recalled psychiatrist locally.
  2. Notes document a history of ADHD.
  3. History of illicit drug abuse in the 1980s (crystal meth,
    marijuana) in this patient who states she is abstaining.

PSH:

  1. Gastric bypass 2002.
  2. “Back fusion” 2007 – see HPI.

Current Medications:

  1. Celebrex, dose not recalled, daily.
  2. Cymbalta, dose not recalled, daily.

Allergies: Morphine and Fentanyl. She reports hallucinations on OxyContin.

SH: The patient has two children. She has been disabled for years due to her back pain. She smokes one pack of cigarettes per day and smoking cessation was encouraged. She denies a recent history of illicit or prescription drug abuse. She states she abstains completely from alcohol. She admits to a prior history of abuse which she states led to her drug abuse issues in the 1980s.

Review of Systems: Positive for associated weight loss after gastric bypass. She feels depressed. Denies suicidal thoughts. She continues to follow up with her psychiatrist, but she can’t recall his or her name.

PE: General: Alert and oriented x 3, in no acute distress, pleasant. Psychiatric: Mood is okay. Affect appropriate. Vital Signs: Blood pressure is 135/70. Respiratory rate is 18. Heart rates in the low 70s. Cardiovascular: Regular rate and rhythm. Pulmonary: Coarse bilaterally. Head and Neck Evaluation: Pupils are reactive. There is no thyromegaly or lymphadenopathy appreciated. She has normal neck range of motion. Musculoskeletal: Waddell’s signs are 3/5. There is mildly positive facet loading tenderness at the lumbosacral SI region. Negative straight leg extension test. Neurologic: Cranial nerves II through XII are intact. There is 5/5 upper and lower extremity strength noted. The gait is mildly antalgic, but she can get to the exam table unassisted. She leads with her left leg when doing so. There is some decreased sensation on the L3-L4 dermatome right leg versus left. There is easily appreciated 1-2/4 patellar and trace ankle jerk reflexes noted. Back Exam: Shows well-healed 3 to 4 inch low lumbar incision consistent with laminectomy and lumbar fusion. Extremities: Palpably warm. Tattoos noted. Homan’s sign is negative.

ASSESSMENT:

  1. Chronic pain, other.
  2. History of advanced lumbar spondylosis leading up to
    moderate-to-severe L3-L4 right-sided neural foraminal
    narrowing based on old lumbar MRI in this patient with a
    reassuring neurological exam.
  3. History of L4-L5 laminectomy and lumbar fusion – stable neurological exam.
  4. History of myofascial back pain.
  5. History of methamphetamine and marijuana use as documented by my practice partner.
  6. History of anxiety, ADHD, other psychiatric issues following up with un-recalled psychiatrist.

PLAN:

I reviewed the pain management options with your patient for about 50 minutes. Typically she would have followed up with my practice partner who got to know her back in 2012, but I gather due to some type of failed therapeutic relationship she wanted to be seen by me today. I let her know that I agree with my practice partner that she is a high risk candidate to be on habit-forming / controlled substance pain medications. She does not seem particularly interested in taking pain medications, but then goes on to point out that she has trialed numerous other options — all with limited treatment gain. In summary she does not see any other viable alternative. In any event, I advocated a stepwise approach.

INTERVENTIONAL PROCEDURES:

The patient does report significant relief after (what she thinks to be) a lumbar epidural offered by another local pain management physician years ago. With this thinking in mind I had the patient sign a release of medical records to understand what injections were offered and what her treatment response was. Tentatively she is interested in trialing L3-L4 lumbar epidural and we will tentatively schedule this, but I also recommended that we get updated imaging to give her the best chance of success with further injections.

ADDITIONAL STUDIES:

I provided the patient a referral for lumbar MRI with and without contrast to characterize the etiologic factors in her current pain presentation. Her old lumbar MRI does show epidural fibrosis and moderate-to-severe narrowing at the L3-L4 neural foramen so we will tentatively schedule lumbar epidural at this level, but modify the plan as indicated by the upcoming MRI.

PAIN MEDICATIONS:

The patient did inquire about a Soma prescription, but I recommend against it. Of all the muscle relaxers that is the one that can be habit forming. Given that she has prior illicit drug use and is considered a high risk candidate to remain on controlled substance pain medications, I recommended against that. I did give her trial prescription for Flexeril. She points out ibuprofen helps more than Celebrex. I explained to her why NSAIDs should probably be avoided given her history of bariatric surgery, but in the short run I gather she is tolerating them. It would probably be a good idea to add GI prophylaxis if she remains on them longer term though.

ACTIVITY MODIFICATION/PHYSICAL THERAPY:

I generally counseled the patient that one of the primary goals of the injections and her further workup would be that of characterizing her pain so hopefully she can make more progress with physical therapy. She would likely benefit from the Reading Hospital Behavioral Science Clinic, where she could focus on psychological support strategies and further develop physical therapy program.

ADDITIONAL CONCERNS:

Today the patient also complains of mid back pain. She has a history of lumbar thoracic scoliosis that is fairly subtle on physical exam. I gave her a referral for plain x-ray imaging of the thoracic spine to assess further. We will follow up on that study and plan appropriately.
Certainly, it was a pleasure meeting your patient here at Center for Pain Control today. Thank you for allowing me to participate in the care of this pleasant patient.

Sincerely,
Jason T. Bundy, M.D.


CHIEF COMPLAINT:
6/10 back, right anterior lateral thigh pain.

Dear Dr.:

Your patient follows up six weeks after her initial consultation evaluation on January 4, 2016. On that day, she was complaining of severe back, right leg pain. It was recognized she has a history of an L4-L5 lumbar fusion. She had followed up with another pain management physician over the years who had offered lumbar epidurals with variable treatment gain. Recognizing all of it, we decided to update her lumbar MRI.

Lumbar MRI 01/20/2016, “posterior spinal fusion decompression L4-L5. Multilevel degenerative change, spinal stenosis most predominant at L2-L3 and L3-L4. Neural foraminal narrowing most predominant right L2-L3 and right L3-L4 and bilaterally L5-S1.”

Basically, I offered to proceed to a right-sided lumbar epidural injection, but due to the patient’s deductible cost she is just simply unable to afford that option at this point. I offered for her to fill out charity care forms and she is going to look into that.

In the meantime:

Along the way, the patient has trialed various pain medications with some limited relief. When I last saw her she requested a prescription for Soma. I clearly recognized her as a high risk candidate to remain on controlled substance pain medications given her prior history of illicit drug use as documented by my practice partner. In fact, my practice partner refused to prescribe opioids to her years ago and she subsequently followed up elsewhere to remain on them. Given her history of bariatric surgery, she really is not a candidate to remain on NSAIDs. She has trialed antineuropathics with a lot of side effects. She further alludes the fact that she was given a temporary prescription for Percocet by another provider in a urgent care center about a month and a half ago. She further states that she has been using those with treatment effect and would like an updated prescription for Percocet. This is discussed below.

Interval PMH/SH/FH/SH: Not otherwise changed. The patient is disabled and states her back pain is very rate limiting.

Current Medications: None reported on her intake form. (When the patient was confronted with a urine drug screen, she admits to using Percocet, as prescribed by an unrecalled urgent care physician and also smoking marijuana for her birthday.)

Allergies: Morphine, Fentanyl. Hallucinations on OxyContin.

Review of Systems: She reports severe burning dysesthesias in the right thigh. She denies progressive weakness, recent history of trauma or fall. Initially she denies a history of illicit drug use but then later on in the encounter admits to marijuana use when confronted with a urine drug screen.

PE: General: Alert and oriented x 3, in no acute distress, very pleasant, fairly forthright historian. Psychiatric: Mood is okay. Affect appropriate. Musculoskeletal: There is positive lumbar facet loading, tenderness lateral to an otherwise well healed lumbar incision. There is some mildly positive right straight leg extension test negative on the left. Neurologic: Cranial nerves II to XII are intact. There is 5/5 upper and lower extremity strength noted. Gait is moderately antalgic. Her station is forward leaning. Back Exam: Shows well healed incision. There is no obvious deformity. Extremities: Palpably warm. There is no obvious size or length discrepancy.

ASSESSMENT:

  1. Chronic pain, other.
  2.  Advancing multilevel lumbar degenerative disk disease, facet arthropathy resulting now in right greater than left severe L2-L3, L3-L4 neural foraminal narrowing in this patient clinically complaining of right-sided predominant radicular pain.
  3. History of illicit drug use in the past and recently.
  4.  History of bariatric surgery – not an ideal candidate for NSAIDs.
  5. Status post L4-L5 laminectomy lumbar fusion – stable neurological exam.
  6. Myofascial back pain.
  7. History of anxiety, ADHD, prior history of abuse and other psychiatric issues. The patient follows up inconsistently with an un-recollected psychiatrist periodically, but due to cost issues, following-up for routine medical care is a challenge for this patient.

PLAN:

I reviewed the pain management options with your patient for about 35 minutes. Once again I emphasized a multimodal approach and also clearly recognized there is no easy answer here. The patient is considered a high risk candidate to remain on controlled substance pain medications, but given the cost issues of pursuing alternatives, she would basically like to remain on them. I encouraged her to go ahead and check into filling out charity care forms. In the meantime:

PAIN MEDICATIONS:

The patient once again inquired about a prescription for Soma and once again I recommended against it because this is one of the few muscle relaxers that can be habit forming. She inquired about a prescription for Robaxin and I did give her that.

We carefully weighed the risks and benefits of titrating opioids. She self discloses a prior history of methamphetamine / marijuana abuse in the 1980s. She indicated she was not using any illicit drugs or taking prescription pain medications, but then when confronted with a routine urine drug screen her story changed. I counseled it is absolutely unacceptable for her not to disclose her current pain medication use and/or illicit drug use to her care providers. She voiced understanding and was fairly contrite.

Recognizing all of it and giving her the benefit of the doubt this time, I was still willing to give her 60 tablets of Nucynta 50 mg tablet one tablet to be taken q. 8h. as needed for pain. We did collect a urine sample and had her sign our practice opioid agreement. We will monitor this patient quite closely.
If she further violates the opioid agreement we will not continue any controlled substance pain medications. She voiced clear understanding of that.

INTERVENTIONAL PROCEDURES:

I did counsel the patient she would likely benefit from a right-sided L2-L3 and L3-L4 transforaminal epidural injection. For now, she is electing to hold off on that, but again I encouraged her to consider filling out charity care forms. Down the road, I mentioned a spinal cord stimulator strategy could help her if the lumbar epidural truly fails to provide durable relief. I mentioned that she could always check back in with her spine surgeon, but I gather she was deemed a non-reoperation candidate in the past and she is not particularly interested in that option anyway.

ACTIVITY MODIFICATION/PHYSICAL THERAPY:

Once again I discussed a referral to the Reading Health System Behavioral Science Clinic where she could focus on psychological support strategies and develop a physical therapy program. Due to cost issues, she elects to hold off on this program for now.
Certainly, it was a pleasure meeting your patient here at Center for Pain Control today. Thank you for allowing me to participate in the care of this pleasant patient.

Sincerely,
Jason T. Bundy, M.D.