A 59-year-old man presents to you for severe low back pain that he says he has had for 8 years. He initially injured his back while working on his home. He has just completed 8 weeks of physical therapy, and he has been receiving chiropractic care for 1 year. He had been evaluated by a neurosurgeon and has declined any surgical interventions. He elects medical management of his pain.
He has attempted multiple nonpharmacologic therapies, including tai chi, cognitive behavioral therapy, acupuncture, exercise, low-level laser therapy, and electromyography biofeedback. However, none of these modalities have reduced his pain.
Past medical history includes heroin use disorder, which is in remission. Current medications include baclofen 10 mg every 8 hours as needed for spasms and meloxicam 15 mg daily. He has tried duloxetine, tramadol, carbamazepine, gabapentin, nortriptyline, and amitriptyline for pain management, but he has had no success. He has also tried multiple skeletal muscle relaxants, but they have only minimally reduced his pain.

His vital signs are: 98.6 °F (37 °C), pulse 84 beats/minute, blood pressure 136/81 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. His body mass index is 25.3 kg/m². He rates his pain as a 9 on a 10-point scale.
His laboratory studies are normal.
X-ray of the lumbar spine shows diffuse, severe arthritis and degenerative disc disease at L4 to L5.
Which of the following is the most appropriate next treatment option?

 Use a risk-stratification tool such as the Opioid Risk Tool or the Screener and Opioid Assessment for Patients with Pain (v 1) to determine risk of abuse or misuse.
 Refer him to physical therapy for extended treatment, with emphasis on ultrasonography and transcutaneous electrical nerve stimulation (TENS).
 Consider referring him to pain-management and substance use disorder specialists for additional evaluation and management given his history of substance abuse.
 Evaluate risk factors for opioid-related harms, discuss pain treatment goals, and, if the benefit outweighs the risk, begin immediate-release opioid therapy (≤ 50 morphine milligram equivalents [MMEs)/day).

Correct Answer:

Consider referring him to pain-management and substance use disorder specialists for additional evaluation and management given his history of substance abuse.

Educational Objective:

Describe the appropriate initiation of treatment for long-term low back pain with opioid therapy in patients with a past history of substance use disorder.

Key Point:

Patients with a history of substance use disorder should be referred to pain and substance use disorder specialists prior to initiation of opioid therapy for long-term pain management.

Explanation:

Patients with a history of substance use disorder should be referred to pain and substance use disorder specialists prior to initiating opioid therapy for long-term pain management. The Drug Abuse Screening test is validated for the primary care setting to screen patients for substance use disorder. Given the high incidence of opioid use disorder, properly screening patients prior to initiating therapy is recommended.

The Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain (v 1) are not accurate for risk stratification for substance use disorder. Ultrasonography and TENS have not been shown to be effective in reduction of pain for long-term low back pain. Initiation of opioid therapy with immediate-release opioids in a patient with substance use disorder is not recommended.

References:

Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain. MMWR Recomm Rep. 2016; 65(1):1-49.

Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.

Department of Health and Human Services; Centers for Disease Control and Prevention. Calculating total daily dose of opioids for safer dosage. Accessed May 23, 2017.

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