Case Study

1
Case Study

• Low Back Pain

2
Chronic Low Back Pain

• Epidemiology
• 6085 lifetime prevalence
• Second most common complaint to prompt medical
  evaluation
• Leading cause of long-term work disability

(Loesser et al, 2001 Wall et al, 1994)
3
Chronic Low Back Pain

• Most common reason for early Social Security
  disability in U.S.
• U.S. indirect costs 33 billion annually
• Disability and costs related to pain, not to the
  disease process

4
Chronic Low Back Pain

• Pathophysiology
• Activation and sensitization of the nerve root
  nervi nervorum from root compression/traction
• Sensitization of the nociceptors of the annulus
  fibrosus, periosteal spinal structures, and
  ligaments, due to acute inflammation, e.g.,
  status post-trauma

(Loesser et al, 2001)
5
Chronic Low Back Pain

• Hyperalgesia (deep spinal and dermatomal) due to
  central sensitization

6
Chronic Low Back Pain

• Clinical Characteristics
• Preoccupation with pain
• Consistently disabled from pain
• Depression and anxiety are common
• High incidence of psychiatric diagnoses
• Drug misuse is common, but addiction relatively
  rare

(Wall et al, 1994)
7
Chronic Low Back Pain

• Diagnosis
• History
• medical, psychosocial
• pain location, duration, severity,
  alleviating/aggravating influences
• Physical Examination
• posture and range-of-motion evaluation
• routine neurologic and vascular exams

(Wall et al, 1994)
8
Chronic Low Back Pain

• Diagnosis
• Imaging Studies
• X-rays with flexion/extension
• MRI
• CT in some

9
Chronic Low Back Pain

• Treatment Considerations
• Analgesic Medications
• Adjuvant Analgesics
• Physical Therapy Approaches
• Complementary Therapy Approaches
• Neural Stimulation
• Psychologic Management
• Multidisciplinary Pain Centers

(Portenoy et al, 1994)
10
Low Back Pain Case Study

• This CasesToGo presentation is based on the
  interactive case study, Low Back Pain, which
  can be viewed on the National Pain Education
  Council Web site at www.npecweb.org. 

11
Client Presentation

• Bob H. is a 28-year-old plumber with severe low
  back pain of 2 years duration
• Pain was the result of lifting a large pipe at
  home
• Currently taking 2 tablets hydrocodone 5 mg and
  acetaminophen 500 mg (Vicodin) qid (240
  tablets/month)
• 600 mg Ibuprofen 3x/day
• Previous physician wants to taper patient off
  medication

12
Case History

• Bob H. states he had a fulfilling life, enjoying
  sports and fishing trips before back pain started
  
• Medical records confirm that physical therapy,
  carbamazepine (Tegretol), and gabapentin
  (Neurontin), among other therapies, failed to
  provide adequate pain relief

13
Case History

• Social history confirms that patient is a social
  drinker and tried marijuana once over a year ago
• Smokes 1 pkg cigarettes/day for 10 years
• Urine drug screen negative
• Patient reports that 8 tablets a day of
  hydrocodone/acetaminophen and 600 mg ibuprofen
  have been somewhat helpful but effect is waning
  he wants better pain relief

14
Referral to CM

• Records indicate Bob H. has visited the local ED
  3 times recently with unrelieved pain
• Meperidine administered
• Case manager receives referral

15
Table Activity 1

• Determine what information indicates this
  individual meets criteria for your health plan CM
  program
• Rationale
• Additional information needed?
• How will you get to mutual goal setting with this
  client?

16
Equianalgesia Activity

• Calculate how much medication Bob H. had been
  taking every 24 hours based on patient report
• Use the equianalgesic table and convert to
  morphine equivalence
• Options/decisions/factors to consider for next
  steps in plan

17
Treatment Plan

• Prescribe a long-acting opioid to achieve better
  pain control
• Start a bowel regimen to avoid constipation
• Discuss roles and responsibilities of patient and
  physician/provider
• Role of Case Manager

18
Potential Advantages of Long-acting Opioids

• Long-acting opioids can produce more consistent
  blood levels
• Long-acting opioid use can result in improved
  sleep, less daytime sedation, and improved
  function

19
Potential Advantages of Long-acting Opioids

• Long-acting opioids are not available in
  combination products with dose-limiting
  nonopioids
• The dose may be advanced as high as necessary no
  absolute ceiling dose

20
Treatment

• Using the equianalgesic chart 40 mg of
  hydrocodone per day converts to 40 mg of oral
  morphine
• Initially prescribe sustained-release morphine 15
  mg by mouth twice a day
• Continue hydrocodone 5 mg/acetaminophen 500 mg, 1
  by mouth 46 times a day for breakthrough pain
• Docusate 100 mg/d bisacodyl 12 tablets prn

(1. McCaffery, 1999)
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1 Month Later

• Patient returns for a follow-up visit and reports
  excellent relief with his current regimen
• Average pain score is 4
• Patient reports taking 8 doses of hydrocodone per
  day for breakthrough pain

22
Equianalgesic Activity

• Calculate the total amount of medication Bob H.
  is taking every 24 hours
• Is the current regimen effective?
• Decisions

23
Revision of Plan

• Increase sustained release morphine to 30 mg by
  mouth twice a day
• Rationale is to increase dose by 25-50
• Continue same dosage of medication for
  breakthrough pain but follow up plan needs to be
  increased

24
6 Months Later

• Patient is fishing again and enjoying gardening
• He reports generally increased activity levels
• He reports his long-acting opioid seems to lose
  effectiveness before the next dose
• Pain score can reach a 6 out of 10 at end of
  long-acting dosage period

25
Activity

• Assessment data needed
• What effect is patient experiencing from the
  analgesic regimen?
• Does monitoring plan need to be adapted?

26
Activity

• Case Management Implications
• What could you have anticipated in this clients
  course?
• What changes in your monitoring are needed?

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Opioid Rotation

• At next visit, patient reports constipation,
  increased somnolence, and twitching of legs
• Well known adverse effects of higher doses of
  opioids
• Opioid rotation may be indicated

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Opioid Rotation Considerations

• Attempt to reduce adverse effects of current
  regimen
• Activity level has increased
• Has been on current regimen for an extended
  period of time

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Activity

• Calculate total medication over 24 hours
• Use an equianalgesic chart and calculate an
  equivalent dose of chosen opioid to rotate

30
Options

• Fentanyl transdermal system (Duragesic) is an
  appropriate choice because it provides long
  acting pain relief for 72 hours

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Recommended Initial Transdermal Fentanyl Dose
Based Upon Daily Oral Morphine Dose

• Refer to Equianalgesic Dose Conversion chart on
  Web site
• Patient using 160 mg morphine equivalents per day
  equivalent to 80 mcg/hour transdermal fentanyl
• 2533 reduction in dose to factor in for
  cross-tolerance 6053.6 mcg/hour
• Round down to next available patch dosage
• Begin on 50 mcg/hour patch every 72 hours

(1. Duragesic PI)
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Recommended Initial Transdermal Fentanyl Dose
Based Upon Daily Oral Morphine Dose1
Transdermal Fentanyl Dose (mcg/hour)
Oral 24-hour Morphine (mg/day)
25
60134
50
135224
75
225314
100
315404
125
405494
150
495584
175
585674
200
675764
225
765854
250
855944
275
9451034
300
10351124
(1. Duragesic PI)
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Ongoing Consistent Evaluation

• Monitoring the 4 As
• Analgesia (pain relief)
• Adverse effects
• Activities of Daily Living (psychosocial
  functioning)
• Aberrant drug-taking behavior

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Case Management Considerations

• What is required for ongoing monitoring?
• When do you discharge this client from CM
  service?
• Are there other services within the health plan
  to which this client should be referred?
• How are you going to measure the impact of case
  management?

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