What is a suitable pain management regimen for a patient with intractable low back pain, despite receiving epidural injections by anesthesiology (anesthesia department), to determine the feasibility of discharge or need for hospital admission?

From the Guidelines

For intractable low back pain after failed epidural injections, I recommend starting with a multimodal approach, prioritizing non-opioid medications first, due to the potential harms and lack of long-term effectiveness of opioids, as highlighted in the studies by 1 and 1.

Initial Management

Begin with IV ketorolac 15-30mg (if no contraindications like renal impairment or GI bleeding risk), combined with IV acetaminophen 1000mg. This approach is supported by the American College of Physicians guideline, which suggests the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as first-line treatments for acute and chronic low back pain 1.

Breakthrough Pain Management

For breakthrough pain, consider hydromorphone 0.5-1mg IV every 2-4 hours as needed, titrating based on pain response and monitoring for respiratory depression. However, it's crucial to use opioids judiciously, given the concerns about their long-term effectiveness and potential for harm, as noted in the study by 1.

Transition to Oral Medications

After initial pain control, transition to oral medications including acetaminophen 1000mg every 6 hours, an NSAID like naproxen 500mg twice daily (if tolerated), and oral oxycodone 5-10mg every 4-6 hours as needed. Muscle relaxants such as cyclobenzaprine 5-10mg three times daily may help if muscle spasm is present.

Reassessment and Admission Criteria

Reassess pain control after 2-3 hours of this regimen. If pain remains poorly controlled despite appropriate medication administration, admission for pain management may be warranted. This multimodal approach targets different pain pathways simultaneously - NSAIDs for inflammation, acetaminophen for central pain processing, opioids for severe pain, and muscle relaxants for spasm - providing more effective relief while minimizing opioid requirements. Key considerations in managing intractable low back pain include:

• Using a multimodal approach to target different pain pathways
• Prioritizing non-opioid medications due to the potential harms of opioids
• Monitoring for potential side effects and adjusting the treatment plan as needed
• Considering admission for pain management if pain remains poorly controlled despite appropriate medication administration.

From the FDA Drug Label

The usual starting dose in adults is 0.1 mg to 0.2 mg per kg every 4 hours as needed to manage pain. Administer the injection slowly. A good recommendation for starting the patient on pain medication in the ER is to use morphine (IV) with a starting dose of 0.1 mg to 0.2 mg per kg every 4 hours as needed to manage pain, administering the injection slowly 2.

• Key considerations for determining the dose include:
  • The patient’s prior analgesic treatment experience
  • The patient’s degree of opioid tolerance
  • The general condition and medical status of the patient
  • Concurrent medications
  • The type and severity of the patient’s pain
  • Risk factors for abuse, addiction, or diversion It is essential to individualize treatment and continually reevaluate the patient receiving morphine sulfate injection, with special attention to the management of pain and the relative incidence of side effects associated with therapy 2. Important: Have naloxone injection and resuscitative equipment immediately available for use in case of life-threatening or intolerable side effects and whenever morphine therapy is being initiated 2.

From the Research

Patient Assessment and Treatment

The patient has intractable low back pain despite receiving epidural injections by anesthesiology the previous day. To determine the best course of action, the following points should be considered:

• The patient's pain level and medical history should be thoroughly assessed to determine the most effective treatment plan.
• The use of epidural steroid injections has been shown to be effective in managing chronic low back pain, with studies indicating significant pain relief and improved functional status 3, 4, 5.
• However, the patient has already received an epidural injection, and the effectiveness of additional injections is unclear. One study suggests that multiple epidural steroid injections prior to a minimally invasive procedure may not provide additional benefits and may even delay patient care 6.

Pain Management Options

The following pain management options could be considered for the patient:

• Medication: The patient may require medication to manage their pain, with options including narcotics and non-narcotic pain relievers. Studies have shown that epidural injections can reduce the need for narcotics 3, 5.
• Alternative interventions: Other interventions, such as spinal cord stimulation, may be effective in managing the patient's pain. One study found that epidural spinal cord stimulation was effective in treating intractable low back pain 7.
• Admission or discharge: The decision to admit or discharge the patient will depend on their overall condition and response to treatment. Studies have shown that epidural injections can be effective in reducing pain and improving functional status, potentially allowing for discharge 3, 5.

Considerations for Discharge or Admission

The following factors should be considered when deciding whether to discharge or admit the patient:

• Pain level: The patient's pain level should be adequately managed before discharge.
• Medical history: The patient's medical history and overall condition should be taken into account when making the decision.
• Response to treatment: The patient's response to treatment, including epidural injections and medication, should be carefully monitored to determine the best course of action.
• Studies have shown that hospital admissions for back pain can be prolonged and costly, and that epidural injections can be a cost-effective alternative 3.