Treating Chronic Pain

Treating Chronic Pain

by Douglas L. Gourlay, MD, MSc, FRCPC, FASAM

& Howard A. Heit, MD, FACP, FASAM

Expert authors received compensation from Janssen Pharmaceuticals, Inc. for their contributions to PrescribeResponsibly.com

Case Study Profile

  • Treating chronic back pain
  • Male
  • Age 30
Situation Overview

Mr. Jones is a 30-year-old computer programmer who suffered a work-related fall 3 years ago, which resulted in a herniated lumbar disc. Multiple lumbar surgeries were performed, culminating in an L4-S1 fusion with pedicle screws and bone grafts from the iliac crest. Unfortunately, the patient continued to suffer from moderately severe central lumbar region pain (7 to 8 out of 10) with right-sided radicular symptoms. Recent nerve conduction studies and MRI suggest a failed back syndrome and the patient is not considered to be a candidate for surgery. He is referred to your office for management of his chronic back and leg pain.

Scenario

During the course of your risk assessment, you determine he has a CAGE Questionnaire Adapted to Include Drugs (CAGE–AID) score of 3 out of 4 and an Opioid Risk Tool (ORT) score of 10 which you interpret to suggest a significant risk for aberrant behavior. He has been in recovery from heroin abuse for the past 8 years and has been abstinent of all substances, including alcohol, for the past 2 years. Unfortunately, treatment with nonopioid analgesic pharmacotherapy and aggressive physical therapy has failed to meaningfully reduce his pain. His goal remains to improve sufficiently to return to work, at least on a part-time basis.

Key Learning

The key question here is not if there is risk, but rather, what is the risk, and more importantly, what is the best way to manage it? Mr. Jones, despite his elevated risk, has a potentially manageable pain syndrome which might respond to a cautious trial of opioid analgesic therapy. With carefully set limits and boundaries, including clearly identified treatment goals, his pain may be managed effectively.

It is important to clarify, from the outset, what Mr. Jones can expect from his treatment team and what his treatment team will need to expect of him. Specifically, patients suffering from chronic pain need to take an active role in their own pain management plan, including the management of possible risks for aberrant behavior.

By making Mr. Jones an integral part of the treatment team, we can explain the nature of a therapeutic trial of opioid analgesics and specifically define success of treatment. In addition, we can determine what strategies for exit management are available if opioid analgesics are shown to no longer be effective or a safe option for continued use.

Given the elevated risk in this case, a review with an addiction medicine specialist may result in a risk management plan that includes referral to, and co-management by, a pain specialist program. Once therapeutic goals are achieved, the patient can be transferred back to the primary care physician with the option of referral to a specialty service, if necessary.

Urine drug testing (UDT) plays an important role in managing risk in any treatment plan. Beyond its obvious role in risk management, UDT also allows for objective and credible advocacy for the patient with relevant third-parties such as insurers or concerned family members. The treating physician should avoid treatment with morphine and codeine, because it would result in the presence of morphine in the urine and make it difficult to identify the use of illegal opioid analgesics. Similarly, any use of dietary supplements and over-the-counter medications must be disclosed prior to the interpretation of UDT results.

Consistent with your clinic policy, this patient agrees to consent to communicate with all members of the treatment team.

As the patient progresses through treatment, he is able to gradually return to full-time employment with routine pain scores in the 2 to 3 out of 10 range, through the appropriate use of a combination of opioid and nonopioid analgesic pharmacotherapy. He continues to remain active in recovery programs. All objective and subjective measures continue to support the impression of clinical stability.

Application

When assessing a high-risk patient, it is important to establish your own level of comfort early on. By carefully assessing your experience and resources, it becomes easier to decide who to manage, co-manage, or refer on to specialty levels of care. As part of your assessment, keep in mind that predisposed does not mean predestined; an elevated risk profile complicates therapy, but it does not preclude it.

Risk management is a shared responsibility between the patient and the pain treatment team. Failure to establish an open relationship based on mutual trust and honesty can undermine even the most basic treatment goals.