question...

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

neutro

Full Member
10+ Year Member
Joined
Apr 8, 2009
Messages
854
Reaction score
876
Greetings.

What do you say to your patients, who arent really looking for opioids, but have side effects to gabapentin, lyrica, nortyptiline and cymbalta...

They do say that ibuprofen works, etc...

lets take chronic lumbar radicular pain not responsive to ESIs in a 64 year old patient as an example. lets say that the patient does not want surgery or SCS trial or "anything invasive" - which I personally understand also. a lot of my elderly patients are reluctant to this, and also do not want to repeat many ESIs. Majority of the times they are concerned about acute rise in BG because of their DM.
Its always this mixed picture. There are characteristics of these patients which do not make me suspect any addiction or drug seeking behavior, nor their history would suggest - but then I am lost as to what to do next in regards to "non narcotic options". Often times, esp. the elderly with normal psychosocial profile, I have given them tramadol or vicodin, because they have tried everything else...injections which work and they want to repeat them, PT, and are now refractory to meds. Often they do not want to undergo surgery.

How do you approach this. And how does your management change between a young-ish patient (<45) vs. elderly. Or do you say flat out no?

Members don't see this ad.
 
I start talking about their daily routine. I try to find out what they are doing, what they miss doing because of the pain. Try to learn about life goals, family, future travel plans, etc.

For the younger folks, I might delve in to the psychology of pain catastrophizing. For the elderly, there is usually more of a tendency to discuss cognitive skills.

Typically I'll discuss the home exercises they are doing, and see if they have interest in more mind-body exercises. More tai chi for older, and how they may access these therapies.

I may talk about obvious limitations - occasionally I'll see a senior who expects to do what they did at age 30, and how they should consider reasonable expectations.

If they do decide to forgo meds or injections, I ensure them that it is okay to do so. They are adjuncts...

These patients I have already assessed for possible opioid use, and if appropriate, I will mention that we could try low dose opioids like tramadol or butrans or Nucynta.
Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 users
In the past, I believed the patient should be offered the options, the risks with each option, and then a joint decision was made regarding the ultimate therapy that may have included opioids. Now my answer is hell no. Tramadol maybe, but nothing else in the opioid realm. There are patients that try to box their physicians into only one option, using any number of excuses or irrational reasons. I tell patients that opioids have significant risks of addiction and death, significant risks to me prescribing them even if they are prescribed completely appropriately, and that they are a short term solution to a long term problem.
 
  • Like
Reactions: 5 users
Members don't see this ad :)
Tramadol possibly. Lay out options and talk about function/expectations. If they are in enough pain they will be more likely to give something a try. Have had some mild success with night time TCA's or membrane stabilizers in people that otherwise worry about cognitive effects. Join a heated pool, encourage exercise as tolerated. Their choice.
 
If they have primarily axial pain I go through the whole spiel as above re multimodal, lifestyle changes etc. very rarely appropriate for cot.

If radiculopathy or claudication from neural compressive pathology failed all reasonable conservative options..... that is not a good indication for cot either.... It's fixable. Surgical referral. They want chronic narcs over decompression? Not my rec. not my problem. Occasional exception for me is elderly...


Sent from my iPhone using SDN mobile app
 
That's where the Turmeric comes in!
In all seriousness, there is a very large number of patients who are troubled by painful conditions that aren't responsive or suitable for injections or surgery and who don't get much benefit from various pain type medications. I pretty much do what Ducttape suggested above.
 
Nucynta. If this doesn't work. Butrans or possibly oral buprenorphine.

If that doesn't work - opioid failure.
 
Nucynta. If this doesn't work. Butrans or possibly oral buprenorphine.

If that doesn't work - opioid failure.

agree with this. Disagree with those who suggest nothing stronger than tramadol.

Butrans and nucynta are a totally different risk category for treating pain that has failed the usual non mu acting meds.
 
  • Like
Reactions: 2 users
I agree Nucynta is far safer than other opioids but we have significant coverage issues with this drug, so is a non-starter for most patients. Nucynta is also unfortunately (and mis-catagorized as) Schedule II. In some locations, Schedule II prescribing is treated far differently than schedule III from a legal risk, documentation and compliance with local statutes standpoint. Butrans is also a good option. Butrans delivers 20mcg/hr = 0.5mg/24 hours. This is about the same as 1mg sublingual buprenorphine per 24 hours. But then again.......what is the end point? How do you measure effectiveness of these drugs? What happens when there are repeated requests/demands for dosage escalation or changing to a more effective drug? Nucynta, tramadol, and butrans/buprenorphine can be abused by simply self escalation of dosage. Do you test them with UDS just as frequently as those taking oxycontin for compliance? Some practices become complacent and test those taking these medications less frequently because of perceived less abuse/overdose tendencies but miss the fact they are "borrowing" percocet from others because what you are giving them is not strong enough to satisfy them. And since tramadol and butrans/sublingual buprenorphine are refillable, are these patients seen with the same frequency as all other patients receiving opioids or do we fall into the same trap family doctors writing for hydrocodone did for years- refills up to 6 months without seeing the patient in follow-up or reassessment or drug testing? Lots of questions remain about these drugs, but if these patients are treated the same as all other Schedule II opioid patients in your practice, then it is probably logical to prescribe for a small subset of the chronic pain population.
 
  • Like
Reactions: 2 users
i treat them the exact same as the Schedule II drugs. Treatment agreement, UDS including LC/GS for the specific substance and metabolites, pill/patch counts, 1-2 month follow ups, minimal escalation of dosage, etc. i do refill tramadol but not butrans.
 
No efficacy out of long term opioids therapy. What I often find amusing is the fact that these grandmas are taking these drugs as a matter of psychological habit and to not really treat/address underlying pain/gain of functionality. If you don't want me to help you in other ways, I won't treat you based on your "demand" that only opioids work. Beyond a very short course of treatment toward achieving better functionality, I won't keep grandma on that stuff....


Sent from my iPhone using SDN mobile app
 
  • Like
Reactions: 1 user
Top