What is the best treatment approach for a patient with severe low back pain and a history of non-compliance with physical therapy instructions who is requesting narcotic pain medication?

From the Guidelines

The best treatment approach for a patient with severe low back pain and a history of non-compliance with physical therapy instructions who is requesting narcotic pain medication should prioritize nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation, and if pharmacologic treatment is desired, select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants. The patient's request for T4 (likely referring to a narcotic pain medication) should be cautiously considered due to the risks associated with opioid use, especially in patients with a history of non-compliance with treatment instructions 1. Given the patient's severe low back pain, a multimodal approach can be considered, starting with nonpharmacologic treatments.

Some key considerations for this patient include:

• Nonpharmacologic treatments such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, or spinal manipulation should be the initial approach for chronic low back pain management 1.
• If pharmacologic treatment is necessary, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants can be considered as first-line options due to their moderate-quality evidence supporting their use 1.
• Opioids should only be considered if the patient has failed the aforementioned treatments and after a thorough discussion of the known risks and realistic benefits with the patient, given the weak recommendation and moderate-quality evidence for their use in chronic low back pain 1.

In this case, increasing amitriptyline to 50 mg may be beneficial for chronic pain management, but prescribing T4s (narcotic pain medication) for 5 days may not be the best initial approach due to the patient's history of non-compliance and the potential risks associated with opioid use. Instead, a more comprehensive approach focusing on nonpharmacologic treatments and safer pharmacologic options should be prioritized to address the patient's severe low back pain while minimizing the risk of opioid dependence and promoting long-term recovery.

From the Research

Treatment Approach for Severe Low Back Pain

The patient in question is experiencing severe low back pain with a history of non-compliance with physical therapy instructions and is requesting narcotic pain medication. Considering the patient's condition and history, the following points should be taken into account:

• Non-compliance with physical therapy instructions: A study by 2 found that poor compliance with back pain treatment is a serious and complex problem, and that patient compliance can depend on various factors such as demographic factors, clinical factors, and perceptions of disability and quality of life.
• Request for narcotic pain medication: The patient's request for T4 (likely referring to a narcotic pain medication) should be carefully considered, as the evidence for the effectiveness of opioids in treating chronic low back pain is limited, and there are concerns about the risks of addiction and side effects 3, 4.
• Alternative treatment options: Non-pharmacologic treatments such as counseling, exercise therapy, spinal manipulation, and physical therapy may be effective in managing chronic low back pain, and should be considered as first-line treatment options 5, 6.
• Medication management: If medication is necessary, nonsteroidal anti-inflammatory drugs (NSAIDs) may be a better option than opioids, as they have been shown to be effective in reducing pain intensity and disability in patients with chronic low back pain 4.
• Patient education and compliance: Patient education and compliance with treatment recommendations are crucial in managing chronic low back pain, and healthcare providers should work with patients to develop a treatment plan that is tailored to their individual needs and circumstances 2, 6.

Key Considerations

• The patient's history of non-compliance with physical therapy instructions should be taken into account when developing a treatment plan.
• Alternative treatment options such as non-pharmacologic therapies should be considered before resorting to narcotic pain medication.
• Medication management should prioritize NSAIDs over opioids, due to the limited evidence for the effectiveness of opioids in treating chronic low back pain.
• Patient education and compliance are crucial in managing chronic low back pain, and healthcare providers should work with patients to develop a treatment plan that is tailored to their individual needs and circumstances.

Treatment Recommendations

• Increase amitriptyline to 50 mg as planned, but carefully monitor the patient's response to this medication.
• Prescribe T4s BID for 5 days as requested, but with caution and close monitoring due to the risks associated with opioid use.
• Consider alternative treatment options such as non-pharmacologic therapies, and work with the patient to develop a comprehensive treatment plan that addresses their individual needs and circumstances.
• Emphasize the importance of patient education and compliance with treatment recommendations, and work with the patient to develop strategies for improving adherence to the treatment plan.