Based on an Interactive Case Study from PAINWeek 2010
This educational case study is made possible by an independent educational grant from Cephalon, Inc.
| Larry is a 42-year-old, middle school teacher who is referred to a pain specialist due to a 9-month history of low back pain. “Unbearable” pain in his back has forced him to miss 7 days of work during the last 2 months. He rates his pain at rest as 8 on a scale from 0 (no pain) to 10 (worst pain imaginable) and states that his symptoms worsen when he sits, bends, dresses, or does any moderately heavy lifting. He describes the pain as “aching and throbbing” in his lumbar region and reports obtaining temporary relief with a heating pad, which reduces his pain to 6/10. Neither over-the-counter ibuprofen 400 mg taken 4 times daily nor a physical therapy program recommended by his primary care physician has provided any notable amelioration of his pain. A 3-week course of cyclobenzaprine 10 mg taken 3 times daily left him feeling considerably sedated and fatigued and did not provide any significant pain relief. Larry’s physical examination reveals forward and slight left antalgia with pronounced left lumbar paraspinal muscle spasm. Heel and toe walk are normal but difficult to perform. Standing range of motion testing is limited in all directions with extreme guarding. Straight leg raise test on the right elicits pain in the left lower lumbar region at 60 degrees with some referral to the left calf. Larry is sent for a magnetic resonance imaging (MRI) exam, which identifies a L5/S1 disc herniation and a bulging disc at L4/L5. At his next appointment, Larry mentions that the severe pain has forced him to reduce his work load to part time. As the single father of 2 young children, he is extremely anxious about his inability to put in a full day’s work. He shares that he is feeling depressed about his wife’s death from breast cancer last year, although he has not received a clinical diagnosis of depression. Additionally, he is having trouble sleeping because of his low back pain. The pain specialist considers referring Larry for cognitive behavioral therapy (CBT) based on the rationale that a patient’s maladaptive thoughts and coping behaviors may interact with a variety of biologic and social factors to exacerbate chronic pain and produce or exacerbate negative outcomes. The goal of CBT is to identify dysfunctional or irrational thoughts that prevent a patient from appropriately adjusting to chronic pain and associated disability. By modifying these maladaptive thought patterns and increasing adaptive behavior through positive and negative reinforcement, CBT can reduce both affective and behavioral symptoms related to feelings of suffering. The pain physician mentions that many of her patients have benefited from CBT and that some well-controlled studies have demonstrated that CBT can be effective for patients with chronic low back pain. The pain specialist recommends that Larry enroll in a coping skills program. She also tells him about the potential benefits of epidural steroid injections in some patients with low back pain. She cautions, however, that the benefits may be limited in duration. Larry agrees to this treatment and receives a fluoroscopically guided, transforaminal epidural injection with 4 mL of 0.25% bupivacaine and 40 mg of methylprednisolone. He makes an appointment with his pain specialist for a follow-up visit in 1 month. One month later, Larry returns to his pain specialist stating that the epidural steroid injection reduced his pain from 8/10 to 3/10 for approximately 2 weeks. Thereafter, the pain returned and is now as intense as it was on his first visit. Larry again expresses concern about being unable to work and provide for his family. He also mentions that he has developed a short temper that he attributes to pain-related stress and is taking a toll on his relationship with his children. The pain specialist explores other pharmacologic options. Larry states that, following a recent root canal procedure, he was given a 1-week prescription of oxycodone/acetaminophen that resulted in some improvement in his back pain symptoms. The pain specialist suggests an opioid trial but, before prescribing, stratifies Larry’s risk for aberrant opioid-related behavior. | Dr. Brennan discusses an initial work-up of a patient presenting with chronic low back pain. | |
 Dr. Harris discusses tailoring CBT for patients with chronic noncancer pain. Dr. Brennan and Dr. Hayner comment on the essential role of risk stratification when prescribing long-term opioid therapy. | ||
Larry is asked to sign a treatment agreement and submit a sample for urine drug testing, which comes back negative. He is prescribed oxycodone/APAP 5 mg/325 mg to be taken 4 times daily. The pain specialist tells Larry to fill his prescription at a single pharmacy and recommends a pharmacist with whom she has previously established a collaborative relationship. She explains that the pharmacist is a medication expert who can help Larry use his pain medications appropriately and assist with monitoring Larry’s response to therapy. After 2 weeks, Larry’s current treatment regimen reduces the pain severity from 8/10 to 6/10, although Larry is still unable to spend a full day teaching class. He reports some constipation and feeling a little “out of it,” particularly earlier in the week when he started taking the opioids. The physician prescribes a bowel regimen and advises Larry that the sedation is likely to diminish with continued opioid use. The pain specialist suggests increasing the opioid dose in an attempt to obtain additional analgesia and help Larry get back to work full time. She says that she would like to transition him to a long-acting opioid to simplify his dosing schedule and limit his daily intake of APAP. Larry is prescribed oxycodone extended-release (ER) 20 mg to be taken twice daily. At a re-evaluation 1 month later, Larry’s pain score is reduced from 6/10 to 4/10. He still experiences sharp bursts of severe pain in his lower back, however, that reach a maximum within minutes and last up to 1 hour. He rates these episodes as 9–10/10. The spikes usually occur when he is physically active (eg, while gardening). Larry also experiences pain episodes in his low back in the morning when he is getting ready for work and in the evening just before dinner. He notes that these periods are characterized by a more gradual increase in pain levels and usually occur just prior to his next scheduled dose of oxycodone ER. The pain in the late afternoon often arises on his way home from work and sometimes makes driving difficult. The pain specialist explains to Larry that he is likely experiencing breakthrough pain (BTP), moderate-to-severe flares of functionally impairing pain that occur on a background of otherwise well-controlled, persistent pain. She further notes that BTP episodes can be precipitated by specific activities (incident BTP), not associated with any identifiable event (idiopathic BTP), or experienced as the plasma levels of the around-the-clock analgesic medication begin to decrease (end-of-dose failure). Based on Larry’s description of the episodes, the pain specialist believes that he is experiencing both incident BTP and end-of-dose failure.The pain specialist increases Larry’s around-the-clock opioid dose schedule from oxycodone ER 20 mg taken twice daily to oxycodone ER 30 mg taken twice daily. She explains to Larry that, by increasing the dose, she is hoping to address the pain episodes that he is experiencing in the morning and evening. The pain specialist also discusses prescribing a short-acting opioid for Larry’s incident BTP. She explains that treating these BTP flares by again raising the around-the-clock opioid dose would increase plasma drug levels at times when additional analgesia is not required and may precipitate additional side effects such as constipation and sedation. Moreover, because the episodes are usually predictable, Larry can take the short-acting medication as prophylaxis 30–40 minutes before any precipitating activity. If the incident BTP does not respond to the short-acting opioid, or if it proves too difficult to predict the onset of the episodes, the pain specialist states that she may consider prescribing a rapid-onset opioid after first determining that Larry is opioid-tolerant based on the US Food and Drug Administration thresholds for daily opioid doses and that the potential benefits outweigh the risks. Larry is prescribed oxycodone/APAP 5 mg/325 mg to be taken before potentially strenuous activities and instructed to return in 2 weeks for a follow-up visit. At follow-up, Larry notes that he no longer experiences the gradual increases in pain before his next scheduled dose, and he has not experienced a significant increase in constipation. The short-lived incident BTP episodes are fairly well managed by predosing with the short-acting opioid. | Dr. Brennan and Dr. Hayner comment on structuring opioid therapy in higher risk patients. | |
| Dr. Brennan comments on initiating an opioid trial. Dr. Hayner comments on the roles of pharmacists in the management of patients on long-term opioid therapy.Dr. Brennan discusses the assessment, differential diagnosis and management of BTP. |
The pain specialist asks Larry about his personal and family history of substance abuse and has Larry complete the Opioid Risk Tool (ORT). She explains to Larry that all patients who are prescribed opioids in her practice are asked similar questions to ensure that therapy can be structured to reduce potential harm to the patient. Larry mentions that both his father and sister have been treated for alcohol addiction; he does not smoke. His score on the ORT is 4 (medium risk).Select References:
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The Joint Meeting of the Drug Safety and Risk Management Advisory Committee with the Anesthetic and Life Support Drugs Advisory Committee and the Nonprescription Drugs Advisory Committee, which met June 29-30, 2009 to discuss steps to reduce acetaminophen-related overdoses and associated liver toxicity...
Bridget Martell et al presented an ambitious, systematic review of the effectiveness of opioid therapy in the treatment of chronic back pain.
Patient J.L. presented to pain management/neurology with complaints of low back pain and radiating right greater than left buttocks pain. Patient also complained of radiating right antero-lateral thigh pain, which occasionally radiated to antero-lateral lower leg.