Managing Back Pain in General Practice “It’s a pain in the….”

1. Managing Back Pain in General Practice“It’s a pain in the….” Presented by - North East Valley Division of General Practice - Northern Division of General Practice - Melbourne Division of General Practice - The National Prescribing Service

2. Program • Two case studies • Initial presentation • Acute case study • Discussion in small groups • Presentation & discussion • Subsequent presentation • Chronic case study • Group discussion • Panel Discussion • Resources for GPs & patients

3. Back Pain • Most frequent musculoskeletal condition seen in GP • 7th most common reason for seeking care • around 85% have a non-specific cause of pain • serious conditions are rare • Recovery time • 80 and 90% of patients with acute back pain recover within 6 weeks

4. Back Pain • Most common presentation • is non-specific low back pain associated with decreased spinal movement • Less common causes of back pain • include trauma, disorders producing neurological lesions • Infection • neoplasm • metabolic bone disease

5. Acute Back Pain • Aim of management • Identify potentially serious causes of acute low back pain • Promote effective self-management of symptoms through the provision of timely and appropriate advice • Maximise functional status • Minimise disability.

6. Acute Low Back pain • DEFINITION • Refers to an episode of pain of less than 3 months duration • ASSESSMENT should differentiate between: • Acute low back pain (non-specific or ‘simple’) • Spinal pathology • Nerve root pain

7. Initial Presentation • Brett • 32 year old air conditioning technician • New to your practice • Consults you at midday • He has hurt his back

8. Initial Presentation ……continued • Brett hurt his back while working in the roof space of a building • Twisted around to lift equipment • Felt sharp pain in lower back • Took a few minutes before he could move • Had considerable difficulty getting back down the ladder • He lay down for about 1/2 an hour until the pain lessened • Came straight to the clinic

9. Initial Presentation ……continued • Brett has asthma • Uses a salbutamol inhaler when he needs it [Airmir, Asmol, Epaq, Ventolin] • No other significant history

10. Initial Presentation……discuss in small groups Case update in 10 -15 minutes

11. Initial Presentation ……case update • Brett rates his current pain at 6/10 • After assessment • you conclude Bret has work related acute non-specific low back Brett has been prescribed paracetamol 500mg and codeine 30mg (Codalgin Forte, Dymadon Forte, Panadeine Forte) in the past for pain and says the only thing the codeine does to him is to make him constipated.

12. Initial Presentation ……continued Question 1 • How would you assess the severity of Brett’s pain?

13. Initial Presentation ……continued Question 1 • How would you assess the severity of Brett’s pain? Also …. • How often should you measure pain? • Apart from pain severity, what else do you look for in the pain history?

14. Initial Presentation ……continued Question 1 Key message • Assess & document characteristics of pain to individualise & monitor effectiveness of treatment.

15. Initial Presentation ……continued Question 2 • What is the analgesic of first choice for acute low back pain?

16. Initial Presentation ……continued Question 2 • What is the analgesic of first choice for acute low back pain? Also …. • If you were to use paracetamol what dosage is appropriate for acute low back pain?

17. Initial Presentation ……continued Question 2 Key message • Use paracetamol first, as it is effective when taken regularly in appropriate doses and has a good safety profile.

18. Initial Presentation ……continued Question 3 • What about an NSAID?

19. Initial Presentation ……continued Question 3 • What about an NSAID? Also …. • Is a conventional NSAID appropriate for Brett? • Is a COX-2 selective NSAID appropriate for Brett? • What about a paracetamol/codeine combination?

20. Initial Presentation ……continued Question 3 Key messages • Before prescribing COX-2 selective or conventional NSAIDS, review risk of peptic ulcer, cardiac disease or renal impairment. • COX-2 selective NSAIDS are not more effective than conventional NSAIDS and have a similar range of adverse effects.

21. Initial Presentation ……continued Question 4 • What about tramadol?

22. Initial Presentation ……continued Question 4 • What about tramadol? Also …. • Is tramadol an opioid? • What is tramadol's adverse event profile • What about drug interactions with tramadol? • If you did decide to prescribe tramadol for Brett what dose would you use? • Would a sustained release preparation be helpful for Brett?

23. Initial Presentation ……continued Question 4 Key message • Consider the range of adverse effects and serious drug interactions with tramadol when selecting therapy where pain requires an opioid or opioid-like analgesic.

24. Initial Presentation……conclusion • As Brett is not on any interacting medications • you decide to prescribe Brett tramadol 50mg four times/day for pain relief. • You have provided him with information on the potential adverse effects of tramadol • & Brett is happy to give it a try. • You ask Brett to come back in 3 days • so that you can monitor his progress and if improving reduce/cease his tramadol.

25. Subsequent Presentation….4 months later Group discussion

26. Subsequent Presentation….4 months later Brett returns: • He has persistent lower back pain and has been unable to return to work. • Brett was prescribed Oxycontin 20mg capsules 6 hourly PRN by another doctor 2 wks ago. However, Oxycontin has not really helped and it makes him nauseas.

27. Subsequent Presentation….4 months later • persistent lower back pain • unable to return to work. • prescribed Oxycontin • Oxycontin has not helped • makes him nauseas • Brett is finding himself irritable & tired. • His workplace has been unable to to offer him “light duties”. • He also informs you at this visit that his wife is heavily pregnant with their third child.

28. Subsequent Presentation….4 months later Questions • How would you assess Brett’s pain now? • What else might you assess? • What pharmacological solutions are there? • Is it appropriate to continue Oxycontin? • What non-pharmacological solutions are there?

29. Summary • Contrast b/w Acute & Chronic Back Pain • Acute pain generally improves and psycho-social factors are rarely an issue • Chronic pain rarely has a recognisable “pathological” cause and psychosocial factors predominate • Patients with chronic pain need to learn to cope with the pain and move forward in their lives

30. Summary Key messages – Assessment • Assess & document characteristics of pain to individualise & monitor effectiveness of treatment (same for acute & chronic pain). • Consider other morbidity • Psychologicalissues eg self esteem, depression • Social impact eg family relationships • ADL disability eg unable to look after garden etc

31. Summary Key messages – Pharmacotherapy • Use paracetamol first, as it is effective when taken regularly in appropriate doses and has a good safety profile. • Before prescribing COX-2 selective or conventional NSAIDS, review risk of peptic ulcer, cardiac disease or renal impairment. • COX-2 selective NSAIDS are not more effective than conventional NSAIDS and have a similar range of adverse effects.

32. Summary Key Messages – Non-pharmacological • Physical & psychological therapies • Yellow & red flags • When to refer