Regular communication with patients may be helpful. A systematic review of 14 controlled trials of patient education interventions for low back pain showed that structured messaging by providers can reassure patients more than usual care/ control education both in the short and long term. 13 Messaging was significantly more reassuring to patients when delivered by physicians as opposed to other primary care practitioners, and such communication reduced the frequency of primary care visits. Non-opioid options for acute pain The initial choice for treating acute pain conditions should not involve opioids because, as noted above, many of the problems and risks associated with managing chronic pain with opioids are also in play when managing acute pain with opioids. For example, a number of studies demonstrate increased risk of new persistent opioid use in opioid-naïve patients after having been prescribed opioids for acute pain. 3-6 Although the risk of opioid misuse in patients prescribed opioids for acute post-surgical or post-procedural pain is relatively small (roughly 0.6% per year) 14 , the volume of such procedures (approximately 48 million ambulatory surgeries or procedures in 2010) 15 means large numbers of patients (i.e., approximately 160,000) may develop misuse, abuse, or overdose every year. Non-drug treatments for acute pain The degree to which it is possible to treat acute pain without opioids depends on the severity, type, and origin of the pain, but many
non-pharmacological approaches can be very effective and their use avoids the potential side effects and risks associated with pharmacological interventions. 16 Physical methods of pain management can be helpful in all phases of care, including immediately after tissue trauma (e.g., rest, application of cold, compression, elevation) and later in the healing period (e.g., exercises to regain strength and range of motion). Non-pharmacologic methods can include: 16 • Application of cold (generally within first 24 hours) or heat • Compression • Elevation • Immobilization • Relaxation exercises • Distraction/guided imagery • Acupuncture • Massage • Electroanalgesia (e.g., transcutaneous electrical nerve stimulation) • Physical therapy • Yoga Physical therapy may be useful for a range of musculoskeletal issues and can be helpful in recovering from acute pain-producing traumas initially treated with other methods. A 2018 study reported that patients with low back pain who first consulted a physical therapist were less likely to receive an opioid prescription compared to those who first saw their primary care physician. 17
Exercise therapy can take many forms, including walking, swimming or in-water exercise, weight training, or use of aerobic or strength-training equipment. According to a review by the Centers for Disease Control and Prevention (CDC), conditions that may improve with exercise therapy include low back pain, neck pain, hip and knee osteoarthritis pain, fibromyalgia, and migraine. 18 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1.
Non-opioid pharmacologic treatments for acute pain
Acetaminophen and NSAIDs Mild-to-moderate acute pain generally responds well to oral non-opioids (e.g., acetaminophen, non- steroidal anti-inflammatories [NSAIDs], and topical agents). Although they are weaker analgesics than opioids, acetaminophen and NSAIDs do not produce tolerance, physical dependence, or addiction and they do not induce respiratory depression or constipation. The choice of medication may be driven by patient risk factors for drug-related adverse effects. If acetaminophen or NSAIDs are contraindicated or have not sufficiently eased the patient’s pain or if functioning has not improved despite maximal or combination therapy, other drug classes (e.g., opioids) may be considered. Non-opioid analgesics are not without risk, particularly in older patients. The FDA recommends that the total adult daily dose not exceed 4,000 mg in patients without liver disease (with a lower ceiling for older adults – generally 3,000 mg). 19
Case Study 1
Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow.
Ruth is a 66 year old female with history of right knee pain from osteoarthritis that was becoming progressively worse and limiting her activity. Ruth lives in a two-story home and has enjoyed sports and being physically active. She underwent a right total knee replacement three days ago and is scheduled to start physical and occupational therapy soon. Ruth was discharged with a prescription for oxycodone 10 mg q4-6 hrs. which she has been taking, although she complains of constipation. She is afraid to take more oxycodone because she says she’s afraid of becoming addicted, but is also anxious about getting off the opioids. She has come for a check of the incisions, which are healing well, but she is very worried that the physical therapy will be too painful to bear.
1. What might you be able to communicate to Ruth to help allay her anxieties?
2. What alternatives to the oxycodone might you suggest that Ruth try?
3. How can you and Ruth create a plan, or record, that will provide some objective measures of progress, both in terms of pain relief as well as function?
25
Powered by FlippingBook