Introduction

Low back pain is a common and burdensome condition, affecting approximately 25% of U.S. adults in a three-month period and costing an estimated $26.3 billion in direct healthcare costs annually. While many acute episodes resolve quickly, up to one-third of patients report persistent moderate to severe pain one year later. Wide variations in diagnostic testing and treatment practices exist among providers, leading to differences in costs without significant impact on patient outcomes. The following guidance provides evidence-based recommendations to help providers deliver high-quality, cost-effective care for low back pain patients, aiming to reduce practice variation and improve patient outcomes.

Diagnostic Considerations

1. Patient History: Begin by obtaining a detailed history from the patient, including the onset, duration, location, and characteristics of the pain. Inquire about any associated symptoms, such as numbness, tingling, or weakness in the legs. Additionally, gather information about the patient’s medical history, previous treatments, and any potential risk factors for LBP.
2. Physical Examination: Conduct a comprehensive physical examination, focusing on the spine and neurological system. Assess the patient’s posture, range of motion, and tenderness along the spine. Perform neurological tests, such as deep tendon reflexes, sensory testing, and muscle strength assessment, to identify any potential nerve involvement.
3. Red Flags: Be vigilant for red flags that may indicate a more serious underlying condition. These include severe or progressive neurological deficits, bowel or bladder dysfunction, unexplained weight loss, a history of cancer, immunosuppression, or intravenous drug use. If any red flags are present, consider further investigation or referral to a specialist.
4. Imaging Studies: In most cases of acute LBP, imaging studies are not necessary. However, if the patient presents with red flags or if the pain persists for more than 4-6 weeks despite conservative treatment, imaging studies such as X-rays, MRI, or CT scans may be considered to rule out specific pathologies.

Treatment Considerations

1. Patient Education: Provide patients with clear and concise information about their condition, the expected course of recovery, and the importance of staying active. Encourage them to maintain their normal activities as much as possible and reassure them that most cases of LBP resolve within a few weeks.
2. Non-Pharmacological Interventions: Recommend non-pharmacological interventions as first-line treatment for acute LBP. These include heat or cold therapy, physical therapy, exercise programs, and manual therapies such as spinal manipulation or massage. Emphasize the importance of maintaining proper posture and ergonomics in daily activities.
3. Pharmacological Management: If necessary, consider pharmacological options for pain relief. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first choice for mild to moderate LBP. In cases of severe pain or when other options are ineffective, short-term use of muscle relaxants or weak opioids may be considered, but caution should be exercised due to the potential for side effects and addiction.
4. Multidisciplinary Approach: For patients with chronic or complex LBP, a multidisciplinary approach involving collaboration with other healthcare professionals may be beneficial. This can include referrals to physical therapists, pain specialists, psychologists, or occupational therapists who can provide additional expertise and support in managing the patient’s condition.
5. Surgical Intervention: Surgery should be considered a last resort and only in cases where there is a clear indication, such as severe or progressive neurological deficits, spinal instability, or when conservative treatments have failed to provide relief. Patients should be informed about the potential risks and benefits of surgical interventions.

Follow-Up and Monitoring

1. Regular Follow-Up: Schedule regular follow-up appointments to monitor the patient’s progress and adjust the treatment plan as needed. Assess the effectiveness of the prescribed interventions and address any concerns or questions the patient may have.
2. Reassessment and Referral: If the patient’s condition does not improve despite initial conservative treatment, reassess the diagnosis and consider further investigations or referral to a specialist. This may include referral to a spine surgeon, pain specialist, or other relevant healthcare professionals.
3. Preventive Measures: Discuss preventive measures with the patient to reduce the risk of future episodes of LBP. This may include maintaining a healthy weight, engaging in regular physical activity, practicing good posture, and avoiding activities that put excessive strain on the back.

Summary

Diagnosing and treating low back pain requires a comprehensive approach that considers various factors. As a physician, it is crucial to obtain a thorough history, conduct a physical examination, and be vigilant for red flags. Treatment should focus on patient education, non-pharmacological interventions, and judicious use of pharmacological options. In complex cases, a multidisciplinary approach and timely referrals may be necessary. By keeping these key considerations in mind, physicians can provide effective care and improve outcomes for patients with low back pain.

References

1. Krebs, E. E., Gravely, A., Nugent, S., Jensen, A. C., DeRonne, B., Goldsmith, E. S., … & Noorbaloochi, S. (2018). Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA, 319(9), 872-882. Link: https://jamanetwork.com/journals/jama/fullarticle/2673971
2. Oregon Health Authority Health Evidence Review Commission (HERC). (2018). Low back pain: Non-pharmacological/Non-invasive interventions. Link: https://www.oregon.gov/oha/HPA/DSI-HERC/EvidenceBasedReports/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdf
3. Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514-530. Link: https://www.acpjournals.org/doi/10.7326/M16-2367
4. Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., … & Brodt, E. D. (2017). Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine, 166(7), 493-505. Link: https://www.acpjournals.org/doi/10.7326/M16-2459
5. Chou, R., Deyo, R., Friedly, J., Skelly, A., Weimer, M., Fu, R., … & Grusing, S. (2017). Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine, 166(7), 480-492. Link: https://www.acpjournals.org/doi/10.7326/M16-2458
6. Goertz, C. M., George, S. Z., & Vining, R. D. (2018). Patient-centered outcomes used in manual therapy trials for low back pain. Journal of Manipulative and Physiological Therapeutics, 41(7), 589-596. Link: https://www.jmptonline.org/article/S0161-4754(18)30112-6/fulltext
7. Kazis, L. E., Ameli, O., Rothendler, J., Garrity, B., Cabral, H., McDonough, C., … & Saper, R. (2019). Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open, 9(9), e028633. Link: https://bmjopen.bmj.com/content/9/9/e028633

OHA Acute-Prescribing-Guidelines

OHA Chronic-Opioid-Prescribing-Guidelines

Nociceptive and Neuropathic Pain

Historically, almost all chronic non-cancer pain (CNCP) was thought to be either nociceptive or neuropathic. In this model of CNCP, the underlying cause of pain was believed to result from stimulation of peripheral pain or sensory nerve fibers located within the painful anatomic region. In this pain schema, peripherally directed therapies such as topical treatments, injections, opioids, and surgery are believed to be helpful. Examples of peripheral nociceptive pain include osteoarthritis, rheumatoid arthritis, and cancer pain. While examples of peripheral neuropathic pain include diabetic neuropathic pain and post-herpetic neuralgia.

However, over the past decade, a body of evidence has accumulated to suggest that a third type of pain, centralized pain, is likely to be much more prevalent than either nociceptive or neuropathic pain amongst working-age adults with CNCP. This distinction is very important to make as centralized pain, unlike nociceptive and neuropathic pain, is not responsive to peripherally directed therapies or opioids.16

Central Pain or Central Sensitization (CS)

The prototypical central pain state is fibromyalgia syndrome. But current research suggests that centralized pain is a spectrum disorder, which includes a large family of common chronic non-cancer pain diagnoses. Chronic low back pain, chronic headaches, and fibromyalgia are highly associated with CS.16,17,18

Screening for centralized pain syndromes is essential both for successful treatment and to avoid the unnecessary harms of over-medicalization with repeated scans, injections, surgeries, and opioids. Because the examination, imaging, and labs are often unremarkable in centralized pain syndromes, diagnosis rests upon a careful history, review of symptoms, and the use of validated CS screening instruments. Moreover, given the high co-occurrence of depression, anxiety, PTSD, and addictive disorders within individuals with CS, it is recommended that screening for these co-morbidities is also included in the initial evaluation.

If we treat centralized pain syndromes with drugs alone, we will fail. This is akin to treating diabetes with insulin or drugs alone, without any corresponding attempt to modify diet or weight.

Additional Concerns

• Secondary Gain: Disability payments, legal actions, and illicit financial incentives can complicate the treatment of pain. Practicing safe and appropriate medicine, with thorough documentation, will serve as a starting point, with specialty referral being necessary at times.
• Suicidality: Individuals whose lives have revolved around opioids for decades may have significant and legitimate concerns about dose reduction. These individuals need patience and behavioral support. Be sure to ask about suicidal thoughts and provide referrals to counseling when needed.
• Addiction (opioid-use disorder): It is sometimes hard to distinguish between patients who take opioids to relieve pain and those who are taking medication obsessively to relieve cravings or to achieve a pleasurable effect. Individuals who have an unnatural focus on their medications and respond poorly to opioid treatment may be identified as either having ineffectively treated pain or having an opioid-use disorder.

You may have patients to whom you were prescribing opioids for the treatment of pain, but who over time showed evidence of addiction. Ideally, if you prescribe opioids for chronic pain, you also have the capability to prescribe buprenorphine (or refer to others with that capability) for your patients who you feel have a substance-use disorder. Regardless of the terminology you use, some patients would be safer being prescribed buprenorphine rather than pure mu agonists.

An in-depth knowledge of your community addiction services is an important component of chronic pain treatment.

Treatment Comparisons

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Source: David Tauben, MD, Chief of Pain Medicine at the University of Washington.

Non-Opioid Treatment Options

The following list shows various non-opioid treatment options, including behavioral, movement, and pharmacological treatments. This is not meant to be an exhaustive list but, rather, is intended to show the many empowering ways our patients can use readily accessible resources to help manage their pain.

Patient Lifestyle

• Healthy sleep management
• Weight reduction
• Diet/Nutrition
• Stress reduction
• Exercise

Physiotherapy Interventions

• Functional therapies
  • Physical therapy (PT)
  • Occupational therapy (OT)
  • Passive modalities

Behavioral Interventions

• Educational groups
  • Preventive
  • Support
  • Peer-to-peer/Living Well workshops
  • Shared medical appointments
• Psychotherapy
  • Individual counseling
  • Group therapy
  • Cognitive behavioral therapy
• Supportive care
  • Case management
• Substance-abuse treatment
  • Residential
  • Outpatient
  • Medication-assisted treatment referral
• Trauma-informed care
  • PTSD screening
  • Domestic violence screening
  • Child abuse screening

Medical Interventions

• Non-opioid medications that may aid in chronic pain management
  • NSAIDS, acetaminophen
  • Tricyclic antidepressants (neuropathic pain)
  • Anti-epileptics (neuropathic pain)
  • Topical medications
• Minimally invasive surgical procedures
  • Nerve blocks, steroid injections
  • Interventional treatments: ablations, restorative injections, stimulators, implantable devices
  • Surgical treatment
• Complementary and alternative treatments
  • Manipulative therapy
  • Acupuncture

Behavioral Treatment Options

Cognitive behavioral therapy (CBT)

›     What is CBT?  CBT is a form of psychotherapy that emphasizes the importance of the causal relationship between our thinking and our feelings and behaviors. The cognitive, or thinking part of our experience, very much affects the behavioral, or action part of our experience. With training, we can change the way we think to affect the way we feel and behave, even if the situation has not changed. CBT has an educational focus and teaches rational self-counseling skills.

›     What does the research say about CBT for the treatment of chronic pain?  Studies show that a patient’s report of chronic pain intensity is far more about that individual’s capacity to manage his or her pain than it is about stimulation of nociceptors.26 Additional studies show that patients experience between 30% to 60% reduction in pain intensity by learning and applying CBT techniques. This compares favorably to the estimated efficacy of 30% for chronic opioids.

›     What are some of the key components of CBT for patients with CNCP?  In general, CBT for chronic pain works to reduce patients’ pain, distress, and pain behavior while improving their daily functioning. Components of CBT may include helping patients to decrease negative emotional responses to pain and perceptions of disability while increasing their acceptance of pain as well as orientation toward self-management. CBT helps patients change the way they relate to pain so they can experience life more fully.

›     What is the goal of CBT for patients with CNCP?  Two fundamental concepts are at play in this strategy. One is that a person must accept the aspects of the pain that cannot be changed, including all the difficult thoughts, feelings, and bodily sensations that come with it. The second is that this acceptance allows for the possibility of the patient opening to the pain and committing to acting in ways that make the patient feel vital and energized. Learning to accept pain to live life is often referred to as “victory by surrender.”

Living Well with Chronic Pain

This program is one of a group of validated syllabus-based programs developed at Stanford University for the purpose of empowering individuals living with chronic pain. It is available in many communities around the country and teaches self-management skills concerning the management of chronic diseases, including pain.

Shared medical appointments

One approach for a busy practice to incorporate peer support, education, and behavioral treatment into the office visit is to use a shared medical appointment. The prescriber and a facilitator, often a nurse, can meet with patients as a group to discuss common issues, while simultaneously taking individual patients aside for brief patient-specific evaluations. Many insurance companies will pay for this treatment approach.

Peer-to-peer meetings

Trained peer educators can facilitate groups of pain patients to share successes, set goals, and help overcome common obstacles. Peer educators can work under the auspices of a licensed practitioner or enroll patients independently. Such programs can work in parallel with the other modalities mentioned in this section.

Patient Selection for Pain Specialty Care

• Patients on high doses (>90 mg MED) or unsafe drug combinations (e.g., benzodiazepines + opioids) who either refuse dosage reduction, exhibit substance-use disorder behaviors, or have significant behavioral conditions beyond the scope of the provider, may require referral to a pain specialty program or substance abuse program for evaluation or ongoing care.
• Any chronic pain patient beyond the expertise of the primary care provider.
• The Oregon Medical Board (or similar state boards), UW “Tele-Pain” (or similar regional peer education), can be excellent resources for helping manage difficult patients in lieu of specialty referral.

Screening and Evaluation

All patients being prescribed chronic opioids need screening for behavioral, respiratory, and other psychosocial risks because, by definition, the specialty-referral clients are at higher risk. A more thorough evaluation of such patients is to be expected:

• Ongoing functional evaluation: PEG, Oswestry or similar, monitored over time.
• Respiratory: S T O P   B A N G or similar, with appropriate referral or further evaluation as necessary.
• Central sensitization screening including but not limited to Central Sensitivity Index, Pain Catastrophizing Scale (PCS), PHQ-15, etc.
• Validated addiction-screening tests such ORT/SBIRT/DAST-28, appropriate for age and history.
• Query of the PDMP initially and episodically.
• Evaluation for possible unforeseen sources of nociception, such as identification of ongoing
  tissue destruction.

Oversight

Pain specialists, accredited, self-identified, or working under the license of others, can succumb to lack of time and inadequate resources resulting in a loosening of appropriate safeguards in the management of chronic pain. A process of peer review can provide feedback at the expert level (and can be an educational resource for primary care) to assure quality and consistent care for complex, high-risk patients. This may include:

• Regularly scheduled multi-disciplinary meetings of healthcare professionals, including behavioral specialists, addiction counselors/specialists, pharmacy, case management, and more to facilitate case discussions. Review of treatment data (MED, functional improvement, adherence to risk stratification) in a transparent fashion by the participants is an expected component.
• A committee that could serve as a “brain trust” for others providing pain management in the community.

Pain Specialty

It is clear from the latest research that chronic pain is often, if not largely, a disorder of nociceptive perception and dysregulation.27 Chronic pain patients often represent a subset of the population with specific bio-psycho-social characteristics. This means that a pain specialty clinic needs to have a foundation of understanding and resource accessibility to care for individuals with historical trauma, substance-use disorder, catastrophizing, as well as an understanding of the pharmaco-dynamics of opioids. Chronic pain is often best viewed through the lens of chronic disease management rather than cure. Therefore, to be considered a pain specialty clinic for the purposes of referral and reimbursement, items 1 through 6 will need to be provided by the clinic staff.

Services

A pain specialty clinic should include the following:

1. Clinicians willing to be transparent and share de-identified treatment data.
2. An organization with deeply embedded behavioral health experts to provide evidence-based counseling, education, and substance-use disorder treatment.
3. Prescribers specifically educated concerning the use and abuse of opioids, or who can demonstrate their expertise through an objective testing process.
4. The ability to provide buprenorphine to appropriate patients for the treatment of opioid-use disorder.
5. The ability to provide referral and expert care for complex chronic pain patients. It should be the goal of pain specialty to develop and establish a treatment plan and return the patient to primary care. In extremely complex patient situations, pain specialty should provide direct care until exceptional care needs are addressed, managed, and a care plan is established; at which point the patient should be returned to primary care. It is expected that all providers participating in a patient’s care will employ common treatment goals and communicate regularly amongst themselves.
6. The previously listed components are essential for quality chronic pain care. If they are not offered on site, then close collaboration, integration, and management of such services is expected.

Long-Term Management Goals

The evidence supporting long-term benefits of opioids is lacking, while the risks and harms are evident. Tapering opioids after long-term use can be challenging and may elicit preexisting conditions. Patients with underlying trauma, mental health disorders, co-existing benzodiazepine use, and substance-use disorders can be exceptionally challenging when tapering, and specialty care can provide additional structure, expertise and support.

• The OPG guidelines, including < 50 MED for most patients, with an absolute MED maximum of < 90 MED, are appropriate for patients managed by pain specialty, as well.
• It is understood that these complex patients may require additional services, support, and time to achieve those goals. Specialty care, by definition, will provide that level of expertise and care.

Chronic Pain in the Elderly Population

• Persistent pain (three to six months) is present in 25–50% of older adults, and increases with age. Nursing home patients may have prevalence as high as 45–80%.33
• Chronologic markers for old age are arbitrary; however, various factors such as socioeconomic impacts, health-style choices and medical comorbidities may all factor into a patient’s physiologic age.

Evaluation of the Elderly Patient

• Identify the source of the pain and the impact that pain is having on the patient. Assess previous consultations, workups, and imaging studies. Be suspicious of increases in pain above baseline as pathologic pain promoters are much more likely with advanced age.
• Cognitive impairment resulting from delirium, dementia, or other mental health conditions may make both the assessment and management of symptoms more difficult.
• In a patient with complicated emotional issues, they may describe the pain in imprecise, inconsistent terms.
• Poly-pharmacy is common. Be aware of potential adverse effects from multiple medications.
• Imaging should be symptom and examination driven. Avoid duplication of previous testing.
• The management of symptoms in the older patient follows the same principles as that in younger persons. However, the elderly are more sensitive to medication side effects.34

Goals of Treatment

• The goals of treatment are modulated pain; ability to perform valued activities; improved function; to feel well enough to socialize; to have additional freedom from chronic, painful conditions; and enhanced quality of life.35
• Persistent pain is multifactorial. It is a treatable but not curable condition. Let the patient know that although pain may not be eliminated, substantial improvement in function is a realistic goal.

Non-Pharmaceutical Approach

• Often beneficial, with low cost and minimal side effects.
• Includes physical therapy, occupational therapy, acupuncture, chiropractic, and massage therapy. When ordering therapies, be sure to specify what conditions you want targeted and your goals of treatment. Monitor the modalities to ensure that they are being applied appropriately (positioning, hot/cold).
• Behavioral – Cognitive behavioral therapy and meditation along with patient education.
• Localized therapy – Joint injections and trigger-point injections.
• Continue these treatments when introducing medications to minimize medications and their side effects.

Pharmaceutical Approach

Non-opioids

Non-opioids are preferred over opioids. Used primarily for nociceptive pain (post-op pain, mechanical low back pain, injuries/trauma, arthritis). Involve a pharmacist for help in reviewing side effects and concomitant medications (including supplements) for drug-drug/supplement interactions.

• Acetaminophen is the first-line approach to mild, persistent pain:
  • Acetaminophen lacks inflammatory activity; therefore it’s effects may be limited in the long-term treatment of inflammatory conditions.
  • Beware of potential drug interactions and drug-dosing limits (determine the doses of all acetaminophen-containing products).
  • Reasonable prescribing: 3 grams/24 hours OR fewer than 2 grams in frail patients, those more than 80 years old or those who use alcohol on a regular basis.
• Non-steroidal, anti-inflammatory drugs (NSAIDs)
  • Start at low doses in the elderly.
  • Use briefly; no more than one to two weeks during periods of increased pain.
  • Tailor the medication to the patient’s cardiac and GI risk factors.
  • For those at risk for GI complications, add a gastro-protective agent.
  • There is a potentially lower GI risk with non-acetylate salicylate or COX-2 inhibitors.
• Antidepressants-for chronic neuropathic pain (postherpetic neuralgia, neuropathic back pain, polyneuropathy, trigeminal neuralgia). All have increased side effects in the elderly.36
  • TCAs – Tricyclic antidepressants have been shown to have effectiveness preventing migraine and tension headaches and in treating chronic pain. Common side effects are sedation, cognitive dysfunction, and orthostatic hypotension. Watch for drug interactions.
  • SNRIs – Selective noradrenalin reuptake inhibitors (e.g., duloxetine, venlafaxine) are frequently used in treating neuropathic pain.
  • SSRIs – Selective serotonin reuptake inhibitors (e.g., paroxetine, citalopram) have been used in the treatment of neuropathic pain. These agents may be particularly useful in elderly patients because of their favorable side-effect profiles.
• Anticonvulsants – gabapentin, pregabalin and carbamazepine may be effective for neuropathic pain. Use of these medications is frequently limited because of dizziness, somnolence, fatigue and weight gain. Tolerance improves over time. Side effects and potential for drug-drug interactions limit their utility in older adults.37
  • Start at low doses, titrate slowly upward, and taper off when stopping the medication.
• Transdermal lidocaine can be useful in the elderly to treat neuropathic and localized, nociceptive pain and has a low incidence of side effects.
• Muscle relaxants should be avoided in individuals older than 65 because of intolerance to side effects.

Opioids – General Considerations

• Opioid analgesics are the mainstay for the treatment of moderate to severe pain in patients with advanced illness. Long-acting or sustained-release analgesic preparations should be used for continuous pain. Breakthrough pain should be identified and treated by the use of fast-onset, short-acting preparations.
• Elderly are more sensitive to the effects of the opioids, due to age-related physiologic changes (e.g., decreased renal or hepatic function and altered body-fat distribution) as well as comorbid medical conditions.
• Always consider if there is an alternative therapy that is likely to have an equal or better therapeutic benefit for pain control, functional restoration, and improvement in the quality of life.
• Consider whether the patient (or caregiver) is likely to manage use of the opioid responsibly.
• Patients may require other forms of medication other than pills. These may be liquid, patch or injections. Try to stay with the least-complicated mode of treatment to help with compliance.
• Opioids can cause mental clouding, which may clear over time. However, there may be persistent sedation, cognitive and psychomotor impairment, hallucinations, dreams and nightmares while on the medication.
• Never initiate opioid therapy with patches or other long-acting opiates in opioid-naïve patients.
• Reasonable dosing recommendations should start at 30% to 50% of the recommended starting dose at the same dosing intervals, and then titrate doses upward in 25% increments for comfort and side-effect tolerance. There is substantial individual variation in the response to the different opioids, and the drug with the most favorable balance between analgesia and side effects cannot be predicted.
• Potential medication choices:
  • Morphine, oxycodone, hydrocodone +/- acetaminophen, hydromorphone, tramadol, fentanyl, buprenorphine. Avoid meperidine and methadone. When choosing a medication, identify the targeted goal of treatment, the preferred route of administration, the patient’s frailty and comorbid conditions along with your clinical experience.
  • Opioid side effects:
    • Constipation – There is little adjustment to this side effect over time. Constipation is predictable, so start prophylactic laxative therapy when initiating narcotics.
    • Balance/Falls
  • Particularly in patients taking poly-pharmacy, who are deconditioned, or who have vision difficulties.
  • If there is evidence of risk for falls, consider avoiding use of opioids.
  • Consider a possible referral for PT and mobility aids prior to initiating treatment.
  • Ensure a safe environment for the patient with impaired mobility. Consider a home safety evaluation through the appropriate agency.
  • Respiratory
  • Sleep apnea and sleep-disordered breathing are seen with narcotic use.
• The exaggerated respiratory depression seen with opioid use can be minimized by starting at low doses and with appropriate titration. Use significant caution when increasing doses, especially in elderly individuals with risk factors for sleep apnea.
  • Nausea is common. Nausea can be minimized with a slow titration upward in the opioid dosing.
  • Depression – Opioids may precipitate or worsen depression, which is a treatable condition that may respond to therapy.
  • Opioids affect the functioning of the hypothalamic-pituitary-adrenal axis, resulting in increased levels of prolactin, decreased levels of sex hormones and, rarely, secondary adrenal insufficiency.

Pain Treatment in Patients with Dementia

• Because chronic, non-cancer pain is more likely to be reduced than eliminated, ongoing pain reporting is common.
• In those with advanced dementia who may be unable to communicate verbally about their pain, you may need to evaluate their condition (and their response to treatment) by facial expressions, verbalizations, body movements, changes in interpersonal interactions, activity patterns and routines such as sleep disruption and appetite suppression. Multiple questionnaires have been developed with variable success rates in eliciting pain levels in persons with dementia, with no general consensus on which one is superior.38
• Patients may also exhibit striking out, refusing medications, agitation, delirium, increased restlessness, and social withdrawal. Rule out other potential infectious, metabolic, medication-related, and social-situation changes as possible causes for acute decline.
• Prescribe a trial of scheduled medications (be cautious with scheduled NSAIDs). Use a stepwise approach.
  • Start low, go slow, be aware of possible under treatment.
  • Monitor the patient carefully to balance the risks and benefits of the treatment.
• Be alert to herbal and dietary supplements taken by older patients who may not volunteer this information. They may be prone to drug-supplement interactions.
• Patients who don’t respond to one medication may respond to another.

What Is Palliative Care

• Palliative care employs an interdisciplinary team to focus on relieving suffering in all stages of disease and is not limited to end-of-life care. This care may occur at the same time as curative or life-prolonging treatments.
• Palliative care is not hospice and doesn’t need to have a six-month-terminal-condition prognosis.
• The basic goal of palliative care is symptom management. The care team can typically better manage symptoms of pain, anxiety, shortness of breath, nausea, emesis, constipation, and diarrhea than the busy, multitasking provider.
• Palliative care providers continually strive to clarify the goals of treatment interventions and determine whether they are consistent with the values and decisions of the patient and with the reality of the disease process.
• Palliative care improves quality of life for the patient and their family.
• After serious illnesses, the primary care providers, friends, family members, nursing facilities, specialists, and also hospitalists refer patients to palliative care.
• For patients who have a terminal cancer condition and transition from palliative care onto hospice, the goal of treatment for cancer pain is to improve comfort (compared to the goal for treatment of CNCP to improve function). Escalating doses and high MEDs are not unusual in these circumstances. The risk/benefit balance is not the same as it would be in a patient with the expectation of years of productive life. Care must still be taken to ensure that your medication is going to your patient, and not being diverted.

Why Is Palliative Care Important

• Primary care management of pain and symptom relief in the pre-terminal and terminal patients may vary considerably between provider offices.
• PCPs may not have the training or experience to feel comfortable with symptom management, and their offices may not have the dedicated resources for integrated services.
• Palliative care teams are responsive to the questions and needs of the patient and families, and can serve as the eyes and ears for the provider.
• Palliative care can serve as a seamless transition to hospice care during the last six months of life. This benefits everyone.

Palliative Care Approaches

• Non-pharmacologic treatments may include electrical nerve stimulation and TENS units, therapeutic exercise, splints, and nerve blocks.
• Alternative or complementary therapies for pain may include psychological therapies (e.g., guided imagery, cognitive interventions), acupuncture, music therapy, massage, rehabilitation, and physical therapy, along with other mind-body approaches.
• Pharmacologic approaches to pain include the same medications as mentioned above in Pain Control in the Elderly, page 32.
• Novel uses of medications to manage a wide spectrum of symptoms may also be effective.
• Major depression is a treatable condition, even in terminally ill patients.
• Opioids are the mainstay of treatment for pain at the end of life.