Doc Savage Posted January 19, 2011 Share Posted January 19, 2011 SO... There is this thing called a CRP or clinical reasoning problem that we do periodically through the quarter. I flew through most the whole thing until I got to the end. Then it was time to write the prescription... I seriously sat here for almost an hour debating my prescription choice for fear of getting reamed on it. It was not contraindicated and there was no other drug interactions or allergies, so it should be short and sweet right? Am I just a indecisive freak... or do I just lack confidence in that choice and should have went with a safer less effective drug??? If you are wondering I chose ketorolac for a 30 year old smoker with a lumbar disc herniation... I kept wanting to put motrin or naproxen but the history said this guys pain was a 9-10. It said you could give them opoids on top of a NSAID but then it also said to keep them active in their ADL's and not let them lie around ... if i give opoids i thought that would make him less active... and he would be more prone to lie around all doped up. How do I determine whether I am over worrying or if the drug is not the right choice? Link to comment Share on other sites More sharing options...
andersenpa Posted January 19, 2011 Share Posted January 19, 2011 These problems are good to make you think but there is no "right" answer. Severe LBP....with radiculopathy? You could easily go with NSAIDs- even in a young pt with presumed good kidneys yours need to limit ketorolac exposure. Ok for acute but you need a bridge for prolonged tx. Other OTC NSAIDs are good but again, kidney/GI issues Opioids and/or muscle relaxants (cyclobenzaprine or methocarbamol) I don't know what answer they're looking for but I'd give nsaids plus narcotics for a short term then reassess. For radicular sx add steroids. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted January 19, 2011 Administrator Share Posted January 19, 2011 Why would you get reamed for choosing one appropriate drug regimen over another? In the real world, it's going to depend on his insurance, your gut, and your SP's take on pain management. I don't see the entire case, but assuming you didn't order an MRI and are just treating conservatively, when did you ask him to return, assuming you're in primary care and not an ED? How much, if any, bed rest did you prescribe? Did you consider oral corticosteroids? I would put a lot more stock in my clinical impression of the patient's pain than a pure number on a 0-10 scale... it's hard to translate that to a case scenario. Assuming that you're doing conservative treatment for 4-8 weeks prior to any surgical referral, you've got some time to e.g. give the patient one prescription in hand, and tell him to call back if it doesn't manage the pain so you can call in a different/additional one. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 19, 2011 Moderator Share Posted January 19, 2011 my standard rx in this situation: vicodin/robaxin/motrin. prednisone for radiculopathy. no mri unless foot drag, incontinence or muscle atrophy. pain scales are worthless. everyone says their pain is 10/10 while eating chips and texting on their cell phones...then you get a guy who understands the pain scale like my 81 yr old pt with subarachnoid hemorrhage in fast track with "neck pain" . rated his pain 6/10 while in obvious distress.. when asked he said 10/10 was when the germans shot him 3 times in the chest in ww2. that was worse so this must be a lower #. Link to comment Share on other sites More sharing options...
Just Steve Posted January 20, 2011 Share Posted January 20, 2011 It may be a little snarky for use in a clinic, but in the back of the ambulance I often describe "if 0 is pain free, and 10 is so bad that you would be relieved if I lit you on fire, how would you rate your pain?" I always have to resist the urge to pull out a lighter when they pause their cell phone conversation to say "10"... :-) As to the clinical practice question...Coming only from the background of working in Uncle Sam's Canoe Club, I would have gone with Motrin and Cyclobenzaprine. But that's what I am attending school. Learn a better reason to my answer instead of "that's the way we did it when..." Steve Link to comment Share on other sites More sharing options...
Doc Savage Posted January 20, 2011 Author Share Posted January 20, 2011 Why would you get reamed for choosing one appropriate drug regimen over another? In the real world, it's going to depend on his insurance, your gut, and your SP's take on pain management. I don't see the entire case, but assuming you didn't order an MRI and are just treating conservatively, when did you ask him to return, assuming you're in primary care and not an ED? How much, if any, bed rest did you prescribe? Did you consider oral corticosteroids? I would put a lot more stock in my clinical impression of the patient's pain than a pure number on a 0-10 scale... it's hard to translate that to a case scenario. Assuming that you're doing conservative treatment for 4-8 weeks prior to any surgical referral, you've got some time to e.g. give the patient one prescription in hand, and tell him to call back if it doesn't manage the pain so you can call in a different/additional one. It is a primary care setting, conservative treatment, no MRI, the injury is acute, there is no foot drop or incontinence, positive SLR test and i did not order bed rest because the CDMT said to keep him active in his ADL's and to explain how to protect his back with ergonomics and I gave him a "no lifting any weight profile". I would have given him opoids but I remember when I took percocet for the first time (for my ruptured TM) i thought i was going to be able function and even contemplated going to work... well then 17 hours later i woke up in a pile of my own drool. I thought it would impair his ADL's and the book said that stagnating can prolong recovery time. I only gave him 3 days of Ketorolac and scheduled a follow up in 3 days. I was trying to get him through the acute phase and I told him if the ketorolac did not do anything for the pain I would have him come back and put him on opoids and Motrin. I just thought the Ketorolac had the best of both worlds as far as pain managment for moderate to severe, and it has the NSAID properties as well. That was my original reason. I just have been so criticized on these assignments in the past... They told us not to use steroids in lecture and the book did not say not to ... it just said there was not significant evidence of their efficacy... they say you can adjunct with opoids but then they tell them to stay active ... i am just conflicted... Link to comment Share on other sites More sharing options...
sbellin Posted January 20, 2011 Share Posted January 20, 2011 I'd avoid the opiates if possible as they don't work overly well on neurogenic pain. Disc herniation itself is usually pain free and common, it's the neuro impingment that hurts. One time Depomedrol IM +/- NSAID of choice PO +/- gabapentin. Cyclobenzaprine have increased sedation and interactions so I avoid, If muscle spasm are issue then methocarbamol. MRI won't change the acute care unless there is significant neuro deficit. Link to comment Share on other sites More sharing options...
bradtPA Posted January 20, 2011 Share Posted January 20, 2011 It's true you can get some side effects with flexeril, but some of those can be avoided with good efficacy by using the extended release form Amrix in the 15 mg dose HS. It's drawback is it is brand name and not cheap.... Link to comment Share on other sites More sharing options...
Madison1979 Posted January 20, 2011 Share Posted January 20, 2011 I'm curious as to why you considered ketorolac for an out-patient? It's only available IM or IV, so is he giving himself the injections? I wonder if a lidocaine patch would be effective in this situation, in addition to a combo opiod-APAP product like Norco or Percocet. In order to be active the patient needs to have adequate pain control. Maybe the lidocaine patch would reduce his opiod requirements, or take enough of the edge off to just use an oral NSAID. My 2 cents. Link to comment Share on other sites More sharing options...
andersenpa Posted January 20, 2011 Share Posted January 20, 2011 Ketorolac is available PO. Link to comment Share on other sites More sharing options...
Madison1979 Posted January 20, 2011 Share Posted January 20, 2011 I stand corrected. I remember only seeing it IV in the hospital and thought I remember being told it was only available parenterally. Learning new things every day! Link to comment Share on other sites More sharing options...
Hemegroup Posted January 21, 2011 Share Posted January 21, 2011 A lot of the pain from disc herniation is related to muscle spasm, so agree about the Amrix although I have found the 30mg dose to be much more effective (QHS 5PM, as it peaks around 5-6 hours). Correct that it is over the top in price (about $600), it will max out a low coverage plan in a few months. SOMA 250 or 350mg can be given for acute spasm/pain that needs to be dealt with more immediately. Ibuprofen 800mg for short term pain/inflammation management (maybe a few Percs or Vics, and a short course of prednisone), and this is the clincher (as was mentioned above) ... ... Lidoderm patches. They soothe and numb for about 6-8 hours, huge. Referral to Pain Mgmt for epidural steroid injection for the radiculopathy, and for possible longer-term opiate management. Referral to PT to help strengthen spinal support. Link to comment Share on other sites More sharing options...
bradtPA Posted January 21, 2011 Share Posted January 21, 2011 Soma 250 has less chance of abuse, but once again is brand name. Copay card makes it a reasonable option for non government insurance providers. I tend to stay away from soma 350; too much risk for abuse when mixed with hydrocodone products. Lidoderm patches work great for chronic back pain, but are often denied by the insurance companies because it's only indication is post-herpetic neuralgia. I have seen decent success with topical diclofenac as well (either patches or gel). Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 21, 2011 Moderator Share Posted January 21, 2011 please folks, don't ever write for soma. highly addictive and many better options out there(robaxin/flexeril/baclofen/skelaxin/tizanidine). if someone has serious muscle spasm I will write a short course of valium. never soma. Link to comment Share on other sites More sharing options...
Hemegroup Posted January 21, 2011 Share Posted January 21, 2011 I had the 250mg Soma for my back when it went out, and they were like aspirin that I took around once a week if needed (if that much, even). But maybe I have a high dependency threshold, who knows. But more addictive than Percs or benzos? Not sure about that. Oddly, the skelaxin/flexeril never worked as well as the Amrix. But I do know from patients that the Baclofen and Zanaflex work great on spasticity, great reminder. That's a bummer to hear about the Lidoderm patches, tho I have written them for a few patients and they were able to obtain. The diclofenac patch made me nauseous, but then again I'm not a huge sample population. Oh yea, and refer to Chiropractor! *puts flame suit on* Link to comment Share on other sites More sharing options...
VictoriaO Posted January 22, 2011 Share Posted January 22, 2011 From what I've heard about Soma, there's a large street value/name recognition. Apparently if you take them with Vicodin, it's similar "high" to heroin. My preceptors would never prescribe it. Honestly, depending on the patient's insurance or access to a pain clinic, I'd go with the IBU 800mg/Methocarbanol/couple of percocets or vicodin, maybe a prednisone course if nerve-impingment symptoms. Great thread for us students Link to comment Share on other sites More sharing options...
bradtPA Posted January 22, 2011 Share Posted January 22, 2011 Soma metabolizes into meprobromate, and that can be addictive. IMHO, flexeril is the best. It's cyclic ring is similar to the tricyclics such as elavil, which have proven benefit in chronic pain Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 22, 2011 Moderator Share Posted January 22, 2011 Soma metabolizes into meprobromate, and that can be addictive. IMHO, flexeril is the best. It's cyclic ring is similar to the tricyclics such as elavil, which have proven benefit in chronic pain yup, when pts ask why I won't refill their soma I say " it is changed into something dangerous in the liver". the downside to flexeril is the anticholinergic side effects(dry mouth, constipation, significant sedation.) I use it but not as first line or in the elderly. skelaxin has the best side effect profile to efficacy IMHO but it's expensive so I usually write robaxin first. Link to comment Share on other sites More sharing options...
Hemegroup Posted January 22, 2011 Share Posted January 22, 2011 Well, Valium and Percocets can also be highly addictive. I think the key point here is to avoid any long-term use of any of the medications that carry risk of dependency, and refer to PT as soon as possible (and/or Pain Mgmt for epidurals). The main directive should be rehabilitation until that option no longer exists, at which point it's probably time for chronic Pain Management (unless Skelaxin or Flexeril do the trick, which doesn't seem to happen too often). Never used Robaxin but will definitely check it out. Quadratus lumborum, Psoas ... these can work wonders when they're strengthened up a bit. Link to comment Share on other sites More sharing options...
Doc Savage Posted January 22, 2011 Author Share Posted January 22, 2011 I guess you would need to read the whole case in order to make your own decisions. I forgot to mention that the patient is on Carbamazepine for a history of epilepsy (last seizure was in 2002) which is why I was skeptical to put him on Narcotics. I was just wondering if this kind of doubt and reasoning goes into all prescriptions that might be considered. Maybe I am over-thinking everything! Great responses though. There is a lot more out there than I thought for treatment options! (which actually makes it even harder to decide now lol) Thanks everyone... I will see what comments or feedback I get for my treatment on my grade for this assignment. Hopefully it will not be too bad! Link to comment Share on other sites More sharing options...
MikeyBoy Posted January 23, 2011 Share Posted January 23, 2011 From what I've seen/experienced over the past year, ketorolac PO is crap. Just lousy outcomes with it. Check out the WHO pain ladder. Just something to think about..... Link to comment Share on other sites More sharing options...
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