From the Guidelines
I strongly recommend a multimodal approach to manage this patient's chronic back pain, prioritizing non-pharmacologic therapies and minimizing opioid dependence. The patient's current use of oxycodone PRN at 5-10mg daily should be continued, but with a focus on implementing a structured physical therapy program focused on core strengthening, flexibility, and pain-reducing movements, as recommended by the American College of Physicians 1.
Non-Pharmacologic Therapies
The patient should be encouraged to participate in non-pharmacologic therapies such as:
- Exercise, including core strengthening and flexibility exercises
- Multidisciplinary rehabilitation
- Acupuncture
- Mindfulness-based stress reduction
- Cognitive behavioral therapy These therapies have been shown to be effective in reducing pain and improving function in patients with chronic low back pain 1, 1.
Pharmacologic Therapies
In addition to non-pharmacologic therapies, the patient may benefit from pharmacologic therapies such as:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy
- Tramadol or duloxetine as second-line therapy
- Opioids should only be considered if the patient has failed the aforementioned treatments and the potential benefits outweigh the risks 1.
Monitoring and Follow-up
Regular follow-ups every 4-6 weeks would help monitor progress and medication effectiveness. This multimodal approach addresses the complex nature of chronic pain by targeting different pain pathways simultaneously, potentially improving function while minimizing opioid dependence. The psychological component of pain management remains important, so continuing mental health support alongside physical interventions will likely yield the best outcomes for this patient's quality of life and functional capacity 1.
From the FDA Drug Label
Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5)] Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5. 1)] Patients with chronic pain should have their dosage given on an around-the-clock basis to prevent the reoccurrence of pain rather than treating the pain after it has occurred.
The patient is currently using 5-10mg of oxycodone per day. Considering the patient's chronic back pain and current dosage, the next step would be to:
- Continue monitoring the patient's response to the current dosage and adjust as necessary to achieve adequate analgesia while minimizing adverse reactions.
- Consider alternative pain management strategies, such as increasing the frequency of physiotherapy sessions or exploring other non-pharmacological interventions, to reduce the patient's reliance on oxycodone.
- Regularly review the patient's mental health and substance use history to assess the risk of addiction, abuse, or misuse of oxycodone 2.
- The patient should be educated on the proper use of oxycodone, including the importance of taking the medication as prescribed and not exceeding the recommended dose 2.
From the Research
Current Situation
The patient is a 37-year-old male with chronic back pain stemming from a workplace incident multiple years ago, and has undergone multiple spinal surgeries since. He currently controls his pain with oxycodone PRN, having been weaned off targin, and uses 5-10mg of oxycodone per day. The patient is trying to relink with physiotherapy, and his mental health is improving, but his back pain remains.
Recommended Next Steps
Based on the available evidence, the following steps could be considered:
- Continue with physiotherapy, as it has been shown to be effective in managing chronic low back pain 3
- Consider multidisciplinary pain management programs, which include a variety of treatment modalities such as individual physiotherapy, group-based physiotherapy, relaxation therapy, and psychological pain therapy 3
- Evaluate the patient's perceived treatment helpfulness, as it has been shown to influence treatment outcomes 3
- Consider cognitive behavioral therapy (CBT) or mindfulness-based therapy (MBT), as they have been shown to be effective in managing chronic low back pain and reducing opioid use 4
- Avoid surgery, as it has been shown to have no significant advantage over nonoperative treatment for chronic low back pain in the long term 5
Key Considerations
- The patient's chronic back pain is likely to be complex and multifaceted, requiring a comprehensive and multidisciplinary approach to management 6
- The use of opioids, such as oxycodone, should be carefully monitored and optimized, as they can have significant risks and side effects 4, 7
- The patient's mental health and overall well-being should be taken into account when developing a treatment plan, as they can have a significant impact on pain perception and management 4, 3