Back pain

Question 1

Non-pharmacological Mx of back pain?

Answer 1

Self-care advice

• Maintain activity as tolerated
• Advice against prolonged bed rest
• Heat pads
• Stretching
• Self-help education books e.g “The Back Book”

Exercise therapy - improve symptoms, function and safe.

• Core strengthening
• Stabilization exercises
• Mind-body programs like Yoga + Taichi
• CBT
• Physio - spinal manipulation.

Question 2

Goals of managing back pain?

Answer 2

Manage pain

Increase function

Maximising coping skills

Question 3

Pharmacological options for back pain?

Answer 3

Paracetamol.

NSAIDs - avoid in FRACP.

Duloxetine

Tramadol

Question 4

What is your approach to an elderly patient who has a high-centrally acting drug requirement for low-back pain?

Answer 4

Goals

• Lower the MME (morphine milligram equivalent) dose, by maximizing non-pharmacological therapies
• Utilise 1st + 2nd line pharmacotherapy (paracetamol + Duloxetine [SNRI] > tramadol, as tramadol is still mixed opiate agonist - misuse and dependency)
  
  • Duloxetine***: start 30mg OD, and increase to 60mg OD in 1 week if tolerated (also benefit of treating depression, which is common)
• 3rd line (UTD): skeletal muscle relaxant (preferred over tramadol) - cyclobenzaprine or tizanidine - not readily available in Australia
• 4th line = Tramadol

I would attempt to taper opioid to lower dose (especially if >90mg/d) - aim <50mg/d

• Slow wean, decrease by 10mg per week (if <1 year)
• Or decrease by 10mg per month (if has been on for >1year)
• If only on PRN - drop by 50% per week
• Monitor symptoms of withdrawal - sweating, diarrhoea, abdo pain, nausea, anxiety) - follow up regularly (e.g. monthly)

Concomitantly, maximise NP Mx

• Body-mind program: Taichi or Yoga
• Exercise program