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Medication Options for Low Back Pain Relief
- 1. What Medica+on for Low Back Pain? Dr Brendan Moore Pain Medicine Specialist Physician Adjunct Associate Professor, University of Queensland Honorary Associate Professor, University of Hong Kong
- 2. RaAonal use of analgesia in nocicepAve pain 1 First line 1. Non-opioid analgesics – Paracetamol or NSAID 2. Combination therapy – Use non-opioids first – paracetamol + NSAID – COX-2 inhibitors 3. If pain persists or involves neuropathic component – Adjuvant – TCA or anticonvulsant – Tramadol, Tapentadol 4. Strong opioids 2.
- 3. “SciaAca”: mixed pain state with several possible pathological mechanisms Baron R, Binder A. Orthopade 2004; 33: 568-‐75. Central sensiAsaAon Disc C fibre C fibre A fibre NocicepAve component: SprouAng from C-‐fibres into the disc Neuropathic component I: Damage to a branch of the C fibre due to compression and inflammatory mediators Neuropathic component II: Compression of nerve root Neuropathic component III: Damage to nerve root by inflammatory mediators
- 4. Analgesic targets 1 Pharmacotherapy • Non-‐opioid analgesics • Adjuvant analgesics • Opioid analgesics
- 8. First line treatment in nocicepAve pain: Non-‐opioid analgesics Paracetamol NSAIDs
- 9. • Drug of choice in mild to moderate pain • EffecAve analgesic and anApyreAc Benefits . Familiar . High efficacy profile for mild nocicepAve pain . Minimal side effects . Can be used as adjunct therapy with NSAIDs and op First line analgesia – paracetamol
- 10. • Give adequate doses • 4 gm per day in divided doses • Controlled release preparaAons may improve compliance • 665 mg X 2 three Ames a day • Paracetamol when combined with an NSAID allows a lower dose of the NSAID Paracetamol – dosing
- 11. Reactions involved in paracetamol metabolism3 Non-steroidal anti-inflammatory drugs (NSAIDs) – biochemical pathway
- 12. • Analgesic and anA-‐inflammatory • AnApyreAc acAon • Non-‐selecAve cyclo-‐oxygenase inhibiAon of COX-‐1 and COX-‐2 • Inhibit prostaglandin synthesis in peripheral Assues, nerves and the CNS NSAIDs
- 13. NSAIDs are valuable analgesics inappropriately selected paAents Consider whether the potenAal benefits of adding an NSAID outweigh the potenAal harms NSAIDs (continued)
- 14. Prefer NSAIDs with a low risk of gastrointesAnal adverse effects Assess cardiovascular and renal risk before prescribing an NSAID Monitor for renal impairment and symptoms of heart failure in paAents at risk Use NSAIDs at the lowest effecAve dose for the shortest possible duraAon NSAIDs (continued) NSAIDs (continued)
- 15. Pooled relative risk of serious upper GI complications with NSAIDs versus ibuprofen
- 16. Cardiovascular risk – Increased BP – High cholesterol – LVH Diabetes Renal impairment MedicaAons – ACE inhibitors especially with a diureAc Cardiovascular risk assessment References: 1. National Prescribing Service, 2008. 2. The Australian COX-2 Specific Inhibitor Prescribing Group, 2002.
- 17. • Volume depleAon • MedicaAons • – DiureAcs • – ACE inhibitors • GFR <60 mL/min Renal impairment
- 18. • Pre-‐exisAng renal impairment • Hypovolaemia, hypotension • Serious cardiovascular complicaAons have been reported with the use of COX-‐2 • InteracAons with nephrotoxic agents and ACE inhibitors COX-2 inhibitors – contraindications
- 19. Second line treatments in nocicepAve pain CombinaAon therapy: Tramadol, Tapentadol Tricyclic anAdepressants
- 20. Second line treatment: • CombinaAon therapy improves efficacy of paracetamol and NSAIDs vs paracetamol alone1,2 Many pa+ents will self-‐prescribe codeine as a second line treatment3 • Seen as a ‘stronger’ analgesic, paAents may not fully understand the risk of dependence and side effects • It is important to advise paAents against ongoing use for chronic pain • Consider TCAs, tapentadol or tramadol if mixed nocicepAve/ neuropathic pain is suspected or if sleep disturbance is prominent Second line treatments
- 21. Neuropathic pain analgesic pathways
- 22. 2nd line treatment2 3rd line treatment2 Neuropathic pain treatment pathways Multidimensional approach Coordinated assessment and treatment GP + psychologist + physiotherapist Early intervention, diagnosis and treatment result in improved patient outcomes1 References: 1. Nicholas, 2004. 2. Allen, 2005. 1st line treatment Tricyclic antidepressants or Antiepileptic (1 drug only) 2nd line treatment2 3rd line treatment2 Tricyclic antidepressants + Antiepileptic (combination) Strong opioids. Alone or in combination with tricyclic antidepressants +/- Antiepileptic +/- Invasive procedures Dorsal column stimulator
- 23. First line treatment (ini+al monotherapy trial) Tricyclic anAdepressant OR AnAepilepAc First line analgesia – neuropathic pain 1
- 24. Tricyclic an+depressants (TCAs) • EffecAve therapy for neuropathic pain1 • Amitriptyline – iniAal low dose 5– 10 mg nocte2 • Side effects: sedaAon and anAcholinergic effects2 First line analgesia – neuropathic pain 1
- 25. Selec+ve Noradrenalin Reuptake Inhibitors (SNRIs) Venlafaxine – Level II evidence, inhibits the reuptake of both serotonin and noradrenaline DuloxeAne Side effects include (but are not limited to) agitaAon, insomnia or somnolence, gastrointesAnal distress and inhibiAon of sexual funcAoning Second line treatments Adjuvant therapy in neuropathic pain
- 26. Gabapen+noids Have become the treatment of choice1 EffecAve treatment for: – Painful diabeAc neuropathy, postherpeAc neuralgia, spinal cord injury pain and HIV-‐ related neuropathy PharmacokeneAc advantages Anticonvulsants in chronic pain References: 1. Backonja, 2002. 2. Gilron & Flatters, 2006.
- 27. Modulates neurotransmimer release e.g. Pregabalin binding to alpha2-‐delta Voltage gated Ca2+channel NeurotransmiQer tTransporter Noradrenaline Glutamate Substance P Presynap+c α2δ subunit Postsynap+c NeurotransmiQer binding site
- 28. Pregabalin binds to the α2δ subunit of voltage-‐gated Ca2+ channels in the brain
- 29. Benzodiazepines1 Clonazepam (0.5–1 mg bd) has been successfully used to treat phantom limb pain Side effects include (but are not limited to) dizziness, sedaAon, depression Tolerance and dependence Alpha2 agonists2 Clonidine produces analgesia at the spinal level through sAmulaAon of cholinergic interneurons Side effects include sedaAon and hypotension Other adjuvant therapies for neuropathic pain
- 32. Opioid prescribing: dose limits and considerations
- 33. Suggested maximum opioid dose • Consult a Pain Medicine Specialist if higher doses considered necessary 1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010 Drug Maximum dose for GP prescription Morphine 120mg daily Oxycodone 80mg daily Hydromorphone 24 mg daily Methadone 40mg daily Fentanyl transdermal patch 25 mcg/hr applied every 3 days Buprenorphine transdermal patch 40 mcg/hr applied weekly Tramadol 400 mg daily
- 34. Dose conversion Morphine equivalence to Ratio morphine : named opioid Examples of equivalent doses Codeine 1:6 Morphine 10 mg Codeine 60 mg Oxycodone 1.5:1 Morphine 60 mg Oxycodone 40 mg Hydromorphone 5:1 Morphine 60 mg Hydromorphone 12 mg Tramadol 1:5 Morphine 10 mg Tramadol 50 mg Fentanyl Morphine 90 mg Fentanyl 25 mcg/h Buprenorphine 75:1 Morphine 9 mg Buprenorphine 5 mcg/h Methadone 3:1 Morphine 60 mg Methadone 20 mg 1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010
- 35. Opioid trial guidelines • Commence trial with low dose sustained-release opioid Use a lower dose and titrate slowly in patients who are: • Elderly • Taking other CNS depressants • Opioid naïve • Have severe hepatic or renal dysfunction 1. Graziotti & Goucke, 1997.
- 36. Review of opioid trial • Discuss progress and outcomes • Functional goals achieved? • Medication used responsibly? • Discuss risks / benefits of continued therapy • Assess 4 ‘A’s1 – Analgesia – Activity – Adverse effects – Aberrant drug behaviours 1. Gourlay & Heit, 2005.
- 37. Federal requirements PBS prescription Restricted benefit • Chronic severe disabling pain not responding to non- narcotic analgesics (treatment <12 months) • If treatment required beyond 12 months, patient must be reviewed by a second medical practitioner • Authority required when prescribing increased quantities of opioid and/or repeats – By phone – 1 month’s supply with no repeats – In writing – 1 month’s supply with 2 repeats • Short term supply can be prescribed without an authority Department of Health and Ageing, 2008.
- 38. State requirements - QLD • If intend to prescribe S8 drugs for longer than 8 weeks, forward a “Report to the Chief Executive” through the Drugs of Dependence Unit (DDU) • A treatment approval from the Chief Executive is required prior to treating, for any controlled drug for a patient considered to be drug dependent • For approvals and “Reports to the Chief Executive” contact the Drugs of Dependence Unit – Phone 3328 9890 – Fax 3328 9821
- 39. Preventing doctor-shopping Medicare Australia Prescription Shopping Information Service • If patient suspected of getting medicine in excess of medical need, contact the Prescription Shopping Information Service: – Complete and sign the registration form available at www.medicareaustralia.gov.au • Registration confirmed within 2 business days (fax) or by mail – Information Service available 24/7 for registered GPs to: • Find out if patient has been identified under the Prescription Shopping Program • Receive information on the amount and type of PBS medicine recently supplied to that patient ( 1800 631 181