So, now, we’re going to discuss the
important issue of pain management
and this has got a lot of attention in the United States,
in particular over the past few years with
the opioid crisis that we've been facing.
I’m going to discuss pain management
in the context of the whole patient
and from the beginning of pain where I see a lot of
patients who have more mild to moderate pain
before they get to severe pain.
But we will cover opiates too at the end,
some the limitations that they have.
So, just to understand the
epidemiology of pain,
this is an Internet-based
survey of over 27,000 US adults.
The prevalence of pain that was chronic,
over six months in duration, was about 30%,
more common among
females and males with chronic pain.
Most common cause of pain,
low back pain.
Secondarily was osteoarthritis coming at number two.
And I thought it was important in the study that
half of these patients with more than six
months of pain were experiencing pain daily
and a third of them qualified their pain as severe.
So, there's just a lot of pain out
there among the general US population.
And that's why the use of drugs in general is so high.
Between chronic illnesses
and conditions such as pain,
about half of Americans have received at least
one prescription in the past month,
and this is all Americans –
man, woman, child.
The overall rate of using at least five
prescription drugs among adults is 11%.
So, this starts to be a lot of
medications that patients are taking.
In particular in older adults,
over a third are using at least five
prescription drugs at any one time.
Then if you just take a step back,
I mentioned that about half of Americans are taking
some kind of medication prescribed.
Well, about half of adults
who are middle-aged and older
are also using over-the-counter medications.
And the risk for drug-drug interactions
in examining these patients is pretty high.
Overall, it’s about 4% among middle-aged and older adults,
the risk of drug-drug interactions.
And half of these cases involve
medications that are over-the-counter
that the doctor treating the patient may not even know about.
And the biggest problem with these
medications is drugs that promote bleeding.
So, that’s something to be
particularly cognizant about.
So, it’s the non-steroidal
anti-inflammatory drug you’re taking
over the counter along with the prescribed aspirin
or warfarin that you may be taking,
and those have a strong
interaction for bleeding, obviously.
So, let’s look at a case of low back pain.
I’ve got a 45-year-old man with a
one-week history of low back pain
without radiation or associated symptoms.
He has a history of hypertension
and he’s not tried any analgesics yet.
So, what's the most recommended
treatment initially for this case
where he hasn't tried anything yet for his low back pain?
Is it, A, acetaminophen;
or D, oral diclofenac?
The answer is A, acetaminophen.
So, guidelines from the American Pain
Society say that acetaminophen,
NSAIDs and muscle relaxants
are all associated with a mild to moderate
decrease in pain on a 100-point scale.
There's not much to really separate them.
They have, again, a mild to moderate
improvement in causing significant pain relief.
The trials –
the clinical trials of these
agents have generally been pretty short,
with very little evidence of
how they improved function.
I very much believe that function is actually a more
important outcome than pain for many patients.
And there’s very few studies of combination therapy.
Most patients may use acetaminophen with an
NSAID and/or a muscle relaxant together,
but there’s little to recommend that practice
because there’s little research on it.