Navigating a Patient’s Concerns About Managing Low Back Pain

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Jane, a patient with no comorbidities, visits her primary care physician, Dr Smith, because of lower back pain. She injured her back 3 months ago. She saw initial improvement, but the pain has worsened over the past 6 weeks.

During Jane’s physical examination, Dr Smith observes signs of muscle tension, limited range of motion, and tenderness in her lower back. 

After listening to Jane’s concerns, Dr Smith emphasizes the importance of discussing all pain management options and assures Jane that they will work together in a shared decision-making process to find the most suitable approach to alleviate her pain. 

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Nonopioid therapies are the recommended initial approach. This aligns with the 2022 CDC Clinical Practice Guideline, which emphasizes that nonopioid therapies are preferred for subacute and chronic pain. Opioids should not be considered first-line or routine therapy for subacute or chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks.

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Noninvasive nonpharmacologic interventions can have a lasting impact on subacute and chronic pain conditions. Studies show that exercise therapy for back pain, fibromyalgia, and hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2-6 months.[1-6]Additionally, therapies such as psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, and multidisciplinary rehabilitation have shown effectiveness for managing chronic pain conditions.[1]

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According to the 2022 CDC Clinical Practice Guideline, when initiating opioids for opioid-naive patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. The lowest effective dose can be determined using product labeling as a starting point with calibration as needed based on the severity of pain and other clinical factors, such as renal or hepatic insufficiency. The 2022 CDC Clinical Practice Guideline recommendations related to opioid dosages are not intended to be used as an inflexible, rigid standard of care; rather, they are intended to be guideposts to help inform clinician-patient decision-making. 

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Dr Smith should consider that opioids are associated with potential risks and may not improve pain or function with long-term use, and complete elimination of pain is unlikely. According to the 2022 CDC Clinical Practice Guideline, there is insufficient evidence to determine long-term benefits of opioid therapy for chronic pain and an increased risk for serious harms related to long-term opioid therapy that appears to be dose-dependent.[7] These serious adverse effects may encompass potentially fatal respiratory depression and development of a potentially serious opioid use disorder that can cause distress and inability to fulfill major obligations. 

Patients should not be obligated to sequentially fail nonpharmacologic and nonopioid pharmacologic therapy before clinicians consider opioid therapy. Instead, opioid therapy should be based on evaluating expected benefits within the specific clinical context compared with the associated risks.

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The 2022 CDC Clinical Practice Guideline emphasizes the importance of adopting a multimodal multidisciplinary approach to pain management that considers physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person. This approach can include multimodal therapies and multidisciplinary biopsychosocial rehabilitation, which combine different therapies, such as psychological therapies, with exercise. This approach has been shown to reduce long-term pain and disability more effectively than usual care or single-modality treatments alone. 

Nonpharmacologic therapies can also provide synergistic benefits when nonopioid or opioid pain medications are used.[8] Medications should be combined with nonpharmacologic therapy to provide greater benefits to patients in improving pain and function. For patients who do not respond adequately to a single-modality therapy, it is recommended to consider multimodal therapies, and combinations should be tailored depending on patient needs, cost, convenience, and other individual factors. 

Initiating long-term opioid therapy for chronic pain may pose risks outweighing benefits. However, focusing solely on nonopioid pharmacologic therapies may not be appropriate for a specific patient or condition. In addition, these therapies may pose risks, especially in older adults, pregnant patients, and those with certain comorbidities such as cardiovascular, renal, gastrointestinal, and liver disease.

Recommending epidural steroid injections as the primary intervention for pain does not align with the 2022 CDC Clinical Practice Guideline, given reports of rare, serious adverse events associated with such injections.[9] 

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