What is the best approach to manage a patient with chronic back pain, anxiety, history of anorexia, and abnormal thyroid function, who also smokes and has financial struggles?

Management Approach for Complex Patient with Multiple Comorbidities

This patient requires immediate thyroid hormone replacement with levothyroxine for her low TSH (0.351 mU/L), combined with a biopsychosocial pain management strategy using the STarT Back tool for risk stratification, smoking cessation support with varenicline, and coordinated multidisciplinary care addressing her eating disorder and anxiety. 1, 2

Immediate Priorities

Thyroid Management

• Start levothyroxine immediately for the low TSH of 0.351 mU/L, as hypothyroidism can directly worsen back pain, fatigue, anxiety, and depression 3, 4
• Proceed with the thyroid ultrasound as planned to evaluate the reported thyroid enlargement 1
• Recheck TSH in 6-8 weeks after initiating treatment, as thyroid dysfunction independently contributes to musculoskeletal symptoms and anxiety 3, 4
• Critical pitfall to avoid: Do not rely on over-the-counter supplements for hypothyroidism—they are ineffective and delay appropriate treatment 3

Chronic Back Pain Stratification

• Apply the STarT Back tool within 2 weeks to stratify her risk for persistent disability 1
• Given her multiple psychosocial factors (anxiety, financial stress, anorexia history, smoking), she likely qualifies as high-risk 1
• For high-risk patients: Refer immediately for biopsychosocial assessment performed by a multidisciplinary team with skills in comprehensive psychological evaluation 1
• Avoid the "physical therapy for all" approach—stratified care directs resources appropriately based on risk level 1, 5

Pain Management Without Opioids

• Start with NSAIDs (e.g., naproxen) as first-line therapy, using the lowest effective dose for the shortest duration 5
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs 5
• If NSAIDs are contraindicated, use acetaminophen as an alternative 5
• Strongly avoid opioids: The British Pain Society recommends tight restrictions on strong opioids due to lack of long-term benefit and potential for harm 1
• Advise staying active and avoiding bed rest, as activity is superior to rest for back pain management 1, 5

Smoking Cessation

Pharmacological Approach

• Prescribe varenicline (Chantix) as first-line treatment for smoking cessation 2
• Dosing schedule: Days 1-3: 0.5 mg once daily; Days 4-7: 0.5 mg twice daily; Day 8 onward: 1 mg twice daily 2
• Set a quit date 1 week after starting varenicline, or allow quitting between days 8-35 of treatment 2
• Treat for 12 weeks initially, with an additional 12 weeks if successfully abstinent to increase long-term abstinence 2
• Alternative if varenicline is not tolerated: Nicotine inhaler with individualized dosing of 6-16 cartridges daily 6

Rationale for Urgency

• Smoking directly worsens chronic low back pain severity, functional disability, anxiety, and depression 7
• In anorexia nervosa patients during refeeding, smoking independently increases resting energy expenditure and contributes to resistance to weight gain 8
• The patient has already expressed motivation to quit due to financial constraints—capitalize on this readiness 2

Eating Disorder Management

Immediate Interventions

• Develop a comprehensive, culturally appropriate treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise via a coordinated multidisciplinary team 1
• Document current weight, BMI, vital signs including orthostatic measurements, and complete metabolic panel 1
• Address food insecurity directly: Connect with social services for food assistance programs, food banks, and meal planning resources for fixed incomes 1
• For her history of anorexia with current restrictive eating (skipping meals from 7 AM to 7 PM), eating disorder-focused psychotherapy is recommended to normalize eating behaviors 1

Nutritional Considerations

• The patient's fatigue and inability to complete household tasks may be partially due to inadequate caloric intake combined with hypothyroidism 3, 8
• Anxiety and depressive mood are independently associated with increased energy expenditure in anorexia nervosa patients, compounding nutritional deficits 8

Anxiety Management

Non-Pharmacological First

• High-intensity cognitive behavioral therapy (CBT) should be provided as part of the multidisciplinary pain management approach for high-risk patients 1
• Anxiety is significantly elevated in subclinical thyroid dysfunction and should improve with thyroid hormone replacement 4
• Address the specific stressor (son's school behavior) through supportive counseling and connection to school-based resources 1

Medication Considerations

• Avoid benzodiazepines per clinic policy and due to lack of evidence for long-term benefit in chronic pain 1
• If anxiety persists after thyroid replacement and CBT, consider SSRI therapy (e.g., fluoxetine 20-60 mg daily), which also has evidence for bulimia nervosa if binge-eating behaviors emerge 1

Functional Support and Disability Assessment

Wheelchair and Home Health Aide Requests

• Conduct formal functional assessment before approving durable medical equipment 1
• The request for a manual wheelchair in a patient with scoliosis-related pain requires evaluation of whether this represents appropriate accommodation versus maladaptive pain behavior 1
• Biopsychosocial assessment by the MDT should determine if functional limitations are primarily due to deconditioning, pain catastrophizing, or true structural limitations 1
• Consider vocational rehabilitation services to support her cosmetology school attendance and future work capacity 1

Work and Activity Management

• Use "fit notes" (statements of fitness for work) to provide information on how her conditions affect ability to work and attend school 1
• The workplace and educational setting can play an important role in recovery when properly supported 1

Timeline for Specialist Referrals

Immediate (Within 2 Weeks)

• Biopsychosocial assessment for high-risk back pain 1
• Eating disorder treatment team coordination 1
• Thyroid ultrasound 1

If No Improvement by 12 Weeks

• Consider referral to specialist pain center or specialist spinal center 1
• Reassess eating disorder treatment intensity 1

Avoid These Common Pitfalls

• Do not prescribe bed rest—staying active is superior for back pain 1, 5
• Do not order MRI at primary care level without red flag symptoms (progressive neurological deficits, cauda equina symptoms, night pain) 1
• Do not assume all symptoms are psychological—the low TSH is a treatable organic cause contributing to multiple symptoms 3, 4
• Do not delay smoking cessation support—smoking independently worsens all her presenting problems 7, 8
• Do not provide simple signposting to resources without direct support—this patient needs frequent contact and reinforcement given her complex psychosocial situation 1

Coordinated Care Plan

Establish clear communication between primary care, pain management team, eating disorder specialists, and any mental health providers 1

Schedule close follow-up: Review within 2 weeks for thyroid medication tolerance and smoking cessation progress, then monthly until stable 2, 3

Monitor for treatment response: Expect improvement in fatigue, pain, and anxiety within 8 weeks of thyroid replacement 3