1. Management of Lower Back Pain in Narcotic Abusers
By: Braye Rueff

2. Lower Back Pain
How common is it? 85 % of all people will experience LBP during their lifetime
How do you treat LBP: Difficult task!
Complex system of Vertebrae/disc/nerves
Surrounding soft tissue
ALL capable of generating pain

3. Treatment of LBP
Pharmacologic Analgesics are generally administered as the initial treatment for LBP.
Most commonly prescribed: NSAIDS + Opioids (ex. type of narcotic).
combination therapy:
maximize pain relief
provide greater speed and duration
a synergistic affect.

4. Difficulties in Treating LBP in Narcotic Abusers
4 Major Issues:
1) Lower Back Pain: Difficult to Manage: Narcotic Abusers
“Drug Seeking” Patients
Physiological Differences
Mutual mistrust

5. Why??? Managing LBP in Narcotic Abusers so Difficult
“Solution” is the “Problem”
1a) The class of drug patients abuse or have abused is one of the primary pharmacological tools for treating LBP
1b) The non-physical factors the abusers may be presenting:
Depression
Substance Abuse

6. Non-physical Factors: Depression
It has been indicated that approximately 90% of persons with opioid dependence have an additional psychiatric disorder, such as major depressive disorder.
(Saddack 2004)

7. Pain + Depression = Cymbalta
Cymbalta is an SNRI used to treat pain and has also been indicated for depression.
Studies have shown that treatment with Cymbalta, 60 mg q.d. significantly reduced pain compared with placebo. Improvements in pain and changes in depression severity were due to the direct effect of Cymbalta.
(Brannan 2005 and Fava 2004)
$ $ $ $ $ $

8. Non-Physical Factors: Substance Abuse
Substance Abuse: Encourage to get help
Medical providers should:
Be familiar with certain treatment options, such as rehabilitation centers & detoxification procedures in the area.
You may be the person they turn to for help!

9. Difficulties in Treating LBP in Narcotic Abusers
1) Lower Back Pain: Difficult to Manage: Narcotic Abusers
“Drug Seeking” Patients
Physiological Differences
Mutual mistrust

10. 2a) “Drug Seeking” Patients
Growing Problem:
It has been estimated that an emergency department with 75,000 patients per year can expect up to 3,144 visits from fabricating drug-seeking patients

11. 2b) Red Flags: Drug Seeking Patients
The only solution to their pain is pain medication(s)-specifically opioids or other controlled substances.
The patient insists on receiving a controlled drug as first line therapy.
The patient refuses any type of alternative therapy to help relieve their pain, such as physical therapy.
The patient makes remarks about having a high tolerance to drugs so they may need a higher dosage in order for the medication to work on them.
Insistence on rapid-onset formulations and routes of administration
(Longo et al and Hansen 2005)

12. 2c) Clinical Maneuvers: “Weeding Out” the “Fakers”
Waddell Signs
simulated rotation of the hips en masse with the lumbar spine without allowing spinal rotation
pressure upon the head
striking dissociation between sitting and supine straight leg raising
demonstration of non-physiological weakness and sensory deficits by the patient

13. 2d) eKASPER: Helps Identify
makes available that particular patient’s medications as well as the doctor who prescribed them
It allows qualified users to get eKASPER reports 24 hours a day, 7 days a week within 15 minutes or less

14. Limitations of eKASPER
It does not monitor the narcotics the patients are obtaining from those other than a physician
It does not detect those who are crossing the state border in order to get their narcotics.
Medical providers are only screening those who have the typical characteristics of a “drug abuser”

15. Difficulties in Treating LBP in Narcotic Abusers
1) Lower Back Pain: Difficult to Manage: Narcotic Abusers
“Drug Seeking” Patients
Physiological Differences
Mutual mistrust

16. 3a) Physiological Differences In Narcotic Abusers
It has been shown that those who abuse opioids can alter:
1) both the number of these opioid receptors
2) sensitivity which can result in an increase in tolerance to this class of drugs
Clinical Sig: May need to increase analgesic dosages.

17. 3b) Why Users Have MORE Pain
Opioid Induced Hyperalgesia (OIH)
lowering of tolerance for pain
Study: compared abusers and non-abusers tolerance to pain by placing their arm in an ice bath.
Outcome: the non-abusers tolerated the ice bath more than twice as long as the opioid abusers
Clinical Sig: May need to increase analgesic dosage.

18. Difficulties in Treating LBP in Narcotic Abusers
1) Lower Back Pain: Difficult to Manage: Narcotic Abusers
“Drug Seeking” Patients
Physiological Differences
Mutual mistrust

19. 4a) Mutual Mistrust
Physicians feared being deceived by drug-using patients
Lacked a standard approach to commonly encountered clinical issues, especially the assessment and treatment of pain
Physicians avoided engaging patients regarding key complaints, and expressed discomfort and uncertainty in their approach to these patients
Drug-using patients were sensitive to the possibility of poor medical care, often interpreting physician inconsistency or hospital inefficiency as sign of intentional mistreatment
(Merrill et al 2002)

20. What to do about the LBP of the Abuser
Negative side effects associated with narcotic pain
treatment.
VS.
It is unfair to the patient who is in pain and really has the therapeutic need to withhold such effective medication

21. Unrelieved Pain
documented health consequences associated with unrelieved pain.
withholding effective analgesics may only serve to:
increase drug craving
worsen addictive disease in the patient with pain
(Compton 2000).

22. Guidelines to Follow
Prescribe short term courses of opioids that require frequent follow-up, and then monitor compliance
choose a delivery route and formulation that are less likely to be abused (ex. Transdermal delivery systems);
Utilize adjuvant medications to enhance the efficacy of lower-dose opioid analgesia;
Set down, in written form if possible, a detailed pain management agreement between the patient and the physician, with the consequences of failure to comply clearly spelled out; and
Order toxicological testing if a change from prior levels of alertness suggests surreptitious drug use
(Breithart 1995.)

23. Percutaneous Electrical Stimulation for Spinal Pain (PENS)
Combination: TENS + Acupuncture
How does it work? It delivers electrical stimulation directly to the deep paraspinal tissues, where the nerve pathways leading to the spinal column reside
Outcome: 1) relieve the patient’s pain ) increase physical activity,
3) reduces the dosage of pain medications prescribed.

24. PENS Limitations Compliance Scared/ Pain???
Cost: Insurance may not cover procedure
Access

25. Summary
Pain Management
LBP
LBP w/ Users
LBP w/ Users +++

26. References
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