What would be the treatment plan for a 24-year-old male with a history of substance abuse (fentanyl, oxycodone) and chronic back pain, currently experiencing unrelieved pain (6-8/10) despite taking gabapentin (300mg three times a day), Cymbalta (20mg twice a day, duloxetine), Buspar (10mg twice a day, buspirone), and a lidocaine patch (4%)?

Treatment Plan for Young Adult with Substance Use Disorder and Chronic Back Pain

This patient requires immediate optimization of his current non-opioid regimen with dose escalation of gabapentin and duloxetine, addition of NSAIDs and a muscle relaxant (tizanidine), and urgent initiation of nonpharmacologic therapies including cognitive-behavioral therapy and physical modalities—opioids must be avoided given his active fentanyl and oxycodone use disorder. 1, 2

Critical Context: Substance Use Disorder Changes Everything

• Opioids are absolutely contraindicated in patients currently addicted to illicit substances including fentanyl and oxycodone, regardless of pain severity 3
• The safest pain treatment strategy for an individual at risk or recovering from addiction is a nonopioid and benzodiazepine-free approach 3
• Chronic pain treatment with opioids should not be undertaken in patients who are currently addicted to illicit substances or alcohol 3
• Persons with co-occurring pain and substance use disorder have the right to receive evidence-based, high-quality assessment and management for both conditions using an integrated approach 4

Immediate Pharmacologic Optimization (Next 1-2 Weeks)

Step 1: Optimize Current Medications

Gabapentin dose is subtherapeutic and must be increased:

• Current dose of 300mg three times daily (900mg/day) is below the therapeutic range 5
• Titrate to 600mg three times daily (1800mg/day) over 3-7 days, which is the minimum effective dose for neuropathic pain 5
• Can increase further to 3600mg/day if needed, as doses up to this level have been well-tolerated 5
• Maximum 12 hours between doses 5

Duloxetine (Cymbalta) dose is subtherapeutic:

• Current dose of 20mg twice daily (40mg/day) is below standard dosing 2
• The American College of Physicians recommends duloxetine as first-line treatment for depression in patients with chronic pain 2
• Standard therapeutic dose is 60mg daily for both depression and chronic pain 1, 2

Step 2: Add First-Line Agents

NSAIDs are the first-line pharmacologic treatment:

• The American College of Physicians recommends NSAIDs as first-line for chronic back pain 1, 6
• NSAIDs provide moderate pain improvement with small to moderate functional improvement 1
• Prescribe scheduled dosing (e.g., naproxen 500mg twice daily or ibuprofen 600-800mg three times daily) rather than as-needed 6
• Monitor for gastrointestinal and cardiovascular adverse effects 6

Add tizanidine (muscle relaxant):

• Tizanidine is the most effective muscle relaxant option for lumbar radiculopathy with demonstrated efficacy in 8 trials 7
• Start with 2-4mg at bedtime, titrate up to 2-4mg three times daily as tolerated 7
• Combining tizanidine with NSAIDs provides consistently greater short-term pain relief than monotherapy (RR 2.44 for CNS adverse events but RR 0.54 for GI adverse events) 7, 6
• Limit treatment duration to 7-14 days maximum for acute exacerbations 7
• Monitor for sedation and hepatotoxicity 7

Step 3: Continue Lidocaine Patches

• The 4% lidocaine patch can be continued as adjunctive therapy with minimal systemic absorption 1

Nonpharmacologic Therapies (Initiate Immediately)

The American College of Physicians strongly recommends initially selecting nonpharmacologic treatment for chronic back pain 1, 2

Priority Interventions (Start Within 1 Week):

Cognitive-behavioral therapy (CBT):

• CBT is as effective as other therapies for chronic low back pain and is specifically recommended for patients with depression and substance use disorders 1, 2
• Should be initiated early as depression is a stronger predictor of poor outcomes than pain severity itself 2
• Addresses both pain catastrophizing and relapse prevention 8

Physical therapy and exercise:

• Exercise therapy has moderate evidence for effectiveness in chronic low back pain 1
• Graded task assignments help maximize function 1
• Should be initiated within the first week 1

Additional Evidence-Based Options (Weeks 2-4):

Spinal manipulation:

• Supported with moderate evidence of effectiveness for chronic low back pain 1
• Can be combined with other therapies 1

Acupuncture:

• Moderate evidence for pain relief in chronic low back pain 1
• Effects typically small to moderate 1

Mindfulness-based stress reduction:

• As effective as cognitive behavioral therapy for chronic low back pain 1, 2
• Particularly useful for patients with comorbid anxiety (note: patient is on Buspar) 2

Massage therapy:

• Low to moderate evidence of effectiveness 1
• Can be used as adjunctive therapy 1

Integrated Substance Use Disorder Management

This patient requires concurrent addiction treatment:

• Pain management should be integrated within a multidisciplinary substance abuse treatment program 8
• Half of patients with concurrent chronic pain and substance use disorders show statistically reliable improvement with integrated treatment 8
• Establish a written treatment agreement specifying one prescribing physician, limited medication supply without refills, and same pharmacy for all prescriptions 3, 9
• Implement random urine drug screens to monitor for illicit substance use and medication compliance 3, 9
• Consider medication-assisted treatment (MAT) for opioid use disorder (buprenorphine or methadone) through addiction specialist 4

Monitoring and Follow-Up Protocol

Week 1-2:

• Assess response to gabapentin and duloxetine dose escalation 2
• Monitor for sedation from tizanidine 7
• Ensure CBT and physical therapy have been initiated 2
• Obtain baseline urine drug screen 3

Week 4:

• The American College of Physicians recommends reassessing patients with persistent symptoms after 1 month of initial treatment 2
• Evaluate pain scores (goal: reduction from 6-8/10 to ≤4/10) 1
• Assess functional improvement using validated measures (e.g., Oswestry Disability Index or Roland Morris Disability Questionnaire) 1
• Random urine drug screen 3

Ongoing (Every 4-8 Weeks):

• Continue monitoring pain and function 2
• Random urine drug screens 3, 9
• Monitor for aberrant drug-related behaviors 9
• Assess engagement with nonpharmacologic therapies 2

Critical Pitfalls to Avoid

Never prescribe opioids:

• Despite inadequate pain control, opioids are contraindicated in active substance use disorder 3
• Opioid prescribing would likely trigger relapse and escalate problematic substance use 4
• Even tramadol (which has opioid properties) should be avoided in this population 1, 3

Avoid benzodiazepines:

• Patient is currently on Buspar (buspirone), which is appropriate as it is not a benzodiazepine 3
• Do not add benzodiazepines for anxiety or muscle relaxation given substance use history 3

Do not delay addiction treatment:

• Pain management and addiction treatment must occur simultaneously 4, 8
• Waiting to address substance use will undermine pain management efforts 8

Recognize pseudo-addiction vs. true addiction:

• Behaviors like requesting early refills may reflect undertreated pain (pseudo-addiction) or active addiction 1
• In this case with known fentanyl/oxycodone use, assume active addiction and maintain non-opioid approach 3

Expected Outcomes

• 50% of patients with concurrent chronic pain and substance use disorders are opioid-free at 12 months with integrated treatment 8
• Significant improvements in pain, emotional distress, and functional status are achievable with non-opioid approaches 8
• Nonpharmacologic therapies show small to moderate effects (5-20 points on 0-100 scale) that are clinically meaningful when combined 1