NSAID alternatives for ms pain with associated heart disease/ bb treatment

[Guest JMPA]

Question for all, what is a preferred prescription alternative to NSAIDS for musculoskeletal pain / inflammation for a patient with heart disease and on betablockers?

[jen0508]

a rheumatologist i rotated with when i was in school would do "high dose tylenol" 1000mg 3 times daily for his patients that couldnt take NSAIDS... not sure about Rx alternatives though.

[Joelseff]

You can try topical diclofenac or I usually go with APAP.

 

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[mkrumm]

I second the Voltaren gel.

[wilso2ar]

Not an anti-innflamatory, but Cymbalta works and is approved for chronic musculoskeletal pain.

[Guest JMPA]

thanks all, really looking an anti-inflammatory (aside from steroids) that is safe for BB/ heart disease patients. very difficult to locate anything in this category

[primadonna22274]

PT, osteopathic manipulation--all forms of manual medicine--acupuncture--topicals etc. Be careful with systemic absorption of topical NSAIDs & aspirin (toxicity has been reported).

Be careful with high-dose APAP and watch hepatic & renal function.

There is a role for opioids in these folks but I think best in an interdisciplinary pain mgmt setting.

Structured and monitored exercise program too!

[discogenic]

While not directly addressing the prescription medicine question, a patient like this might want to address other lifestyle issues as a longer-term approach. Weight loss (specifically fat loss), if applicable, would be top of the list given the pro-inflammatory nature of adipose tissue. Obviously diet is key with this. No-brainer changes would be reducing/eliminating junk carbs/sugars, high-fructose corn syrup, etc.. Upping omega-3 consumption is probably a good idea as well, whether that's eating more oily fish or taking fish/krill oil supplements. Although less agreed-upon, reducing overall consumption of omega-6s may prove beneficial as well, including oils like soybean, cottonseed and corn oils...the kinds of fats found in many processed foods. Which brings up the point of eating better overall, aiming for more 'whole' foods and fewer processed foods. Optimizing vitamin D status isn't a bad idea either.

 

These dietary changes won't have immediate obvious clinical benefit (like a drug) but are worthwhile for the long run.

[primadonna22274]

^^^Discogenic: I like your response.

Anti-inflammatory diet a good idea for any chronic inflammatory disorder. (Google it.)

[Just Steve]

PT, osteopathic manipulation--all forms of manual medicine--acupuncture--topicals etc. Be careful with systemic absorption of topical NSAIDs & aspirin (toxicity has been reported).

Be careful with high-dose APAP and watch hepatic & renal function.

There is a role for opioids in these folks but I think best in an interdisciplinary pain mgmt setting.

Structured and monitored exercise program too!

 

How is this approach utilized when the patient is on Medicade which does not pay for PT or other non pharm related care?

 

I still haven't been able to figure out why the state will pay for chronic narcs and all the sequelae but not the therapies that will prevent the ruination that narcotic addiction brings.

[discogenic]

How is this approach utilized when the patient is on Medicade which does not pay for PT or other non pharm related care?

 

I still haven't been able to figure out why the state will pay for chronic narcs and all the sequelae but not the therapies that will prevent the ruination that narcotic addiction brings.

 

Medicaid pays very little for chiropractic care, but you may be able to find a chiro who accepts it (I do, more as a community service than a money-maker).

[rev ronin]

How is this approach utilized when the patient is on Medicade which does not pay for PT or other non pharm related care?

 

I still haven't been able to figure out why the state will pay for chronic narcs and all the sequelae but not the therapies that will prevent the ruination that narcotic addiction brings.

 

Not my problem; that's between the patient and their insurer. :-)

 

While it's a tongue-in-cheek response, if I'm looking for atypical/edge cases, I put the question back in my patient's court: is this something you want bad enough you're willing to pay out of pocket?

 

I had a multi-allergic patient with chronic UTIs who was allergic to pretty much everything on formulary except TMP--plain TMP, of course, SMX was out of the question--and she was looking for anything else. Fosfomycin isn't covered and was $50 or so for her co-pay, but the patient made the decision to go ahead and try it if the latest culture was TMP resistant (it wasn't, thankfully). Of course, we still don't know if she will react to Fosfomycin, either, because she hasn't tried it yet... But at least we know where she's going next if prophylaxis fails her.

[physasst]

Cymbalta..sometimes...in my practice I rarely write for narcotics. I've written only 3 prescriptions for narcotics since August. And I see back pain all day long. Radics, stenosis, degenerative arthritis, chronic pain, etc. I order more injections than anything, and I often do trigger point injections in the office for myofascial pain.

 

I often try neurontin for chronic MS pain, and although I know it is more effective for neuropathic pain, it seems to work, and to be honest, I tell patients every day that it is probably the safest medication I prescribe. If they can tolerate the side effects, there is very little effect on the major organs, and it is certainly much safer than tylenol or NSAID's.

 

I don't write for NSAID's very often. 100,000 people are hospitalized with GI complications every year from NSAID's and roughly 16,000 die every year.

 

Discogenics answer was spot on. PT, massage, chiro, acupuncture, etc. I tell my patients that the best long term relief for their back pain is PT. Injections-temporary, medications-not good for long term treatment, surgery doesn't often help back pain, at the end of the day....there is no magic. In fact, when patients seem upset by my explanation I show them the magic wand that my six year old daughter made for me......I've tried it about a dozen times...it hasn't worked yet.

 

I have only 5 things that I can offer ANY patient with back pain....and 5 things only. So does every other provider....

[andersenpa]

Question for all, what is a preferred prescription alternative to NSAIDS for musculoskeletal pain / inflammation for a patient with heart disease and on betablockers?

 

What is the specific NSAID/BB interaction you are concerned about?

[Just Steve]

So demographically speaking...

 

clinic is located in County Seat of Skamania County, WA.

 

There is no gym, no public swimming pool, not even a Weight Watchers group.

 

County population 11,000 people. Sq mile 1655 People per sq mile about 6.7

Average income $32,539/yr

20% of population has a bachelors or higher education

50% of the population commutes out of county for employment

25% of the local employment comes from the food/lodging industry but their wages only make up 15% of the income for the county.

Unemployment rate for Oct 2012 is 8.7%

 

In comparison to Portland:

Average income $50,203

4346 people per sq mile

32% of the population have a Bachelor degree or higher

unemployment rate for 10/2012 is 7.5%

 

I tried to hunt down the number of Medicade patients in the county but having a hard time finding it broken down by county.

 

We have one physical therapist in town, they don't take Medicade.

Our formulary is restricted to what Medicade will pay for, which isn't much, or the "$4 dollar list" which is typically associated with Walmart, but the prices will typically be met at the local pharmacy.

 

Nearest X ray is White Salmon, which is 25 miles east. MRI/CT is also about the same distance but across the river in Oregon at Hood River. A large portion of our clinic population rely on friends/family for transportation as they don't drive, can't drive, or can't afford to drive. The gas money for a 50 mile round trip commute is daunting to them.

 

Patients should not have to live in pain. I AGREE COMPLETELY that non pharm interventions provide the most long term, beneficial care for the treatment. But these patients can't pay $150/hr, twice a week for 8 weeks for physical therapy to get them on the road to recovery. They typically can't really afford the gas to get to another PT provider when the local person is booked out. (another 50 mile round trip)

 

I realize sometimes in medicine the answer is "I'm sorry, there is nothing more we can do". I don't mind that answer. What I get bummed about is when the answer is "I'm sorry, there is nothing more that we can afford to do". That just sucks since we live in one of the most advance countries in the world and we have to rely on Big Box Retailers to make medicine affordable.

 

Thanks for letting me vent

[physasst]

I understand your demographic concerns, but they shouldn't need twice weekly visits for 8 weeks for PT...not unless they are being fleeced by the therapist, or they are working in a recovery program (work rehab, post surgical recovery like TKA, or top athletes recovering from sports injuries). For most MSK complaints, therapy should be really be targeted to teaching a home program, which can almost always be done in less than 3 visits total.

 

I order only 1-3 visits, and usually, it is only 2 visits total to establish a home program. THEN, it is on the patient to actually do the therapy on their own at home.

 

Also, there seems to be a cultural misconception here in the US that pain is always bad, and that no one should ever be in pain..which is really bullocks. As long as there isn't a malignant or pathologic cause for pain, sometimes learning to live with it is the best treatment you can offer. That is actually one part of my 5 treatments talk that I give to every patient discussing what I can offer. Pain isn't a horrible thing and is a part of life. Learning to live with it and make it a part of your life instead of becoming a victim is a huge part of treatment and this is one of those talks that I often have with patients. Some understand and appreciate it, many of them are not ready to hear that......

[Guest JMPA]

What is the specific NSAID/BB interaction you are concerned about?

I'm concerned with potentially having a marked rise in blood pressure

[andersenpa]

I'm concerned with potentially having a marked rise in blood pressure

 

There is a technical interaction and patients requiring NSAIDs with BBs tend to have very modest increases in BP (~10 mmhg). Short course NSAIDs with BBs is fine, without strict monitoring. Chronic use is a different story, not sure which time frame you're talking about.

[True Anomaly]

Also, there seems to be a cultural misconception here in the US that pain is always bad, and that no one should ever be in pain..which is really bullocks. As long as there isn't a malignant or pathologic cause for pain, sometimes learning to live with it is the best treatment you can offer. That is actually one part of my 5 treatments talk that I give to every patient discussing what I can offer. Pain isn't a horrible thing and is a part of life. Learning to live with it and make it a part of your life instead of becoming a victim is a huge part of treatment and this is one of those talks that I often have with patients. Some understand and appreciate it, many of them are not ready to hear that......

 

Dude, I can't tell you how many times I've vented that exact same bolded sentence to colleagues or my fiance about my fears of what lies ahead of us in medicine. Success in life can almost be whittled down to the microcosm of those who experience pain and can overcome it, and those who become victimized because of it.

 

 

....reasonable levels of pain, I mean...we're not talking cancer here.....

[andersenpa]

There is a reason pain is the most common reason people seek medical care

Our job is to maximize all the modalities we have to alleviate it

If we fail then we need to consider referral to pain specialists

Our job is not to dispense "tough love" or enforce our own life philosophy on our patients

 

It's about THEM not YOU

[Just Steve]

The sequelae of chronic pain typically leads to eventually being unable to pick up your kids, unable to work, unable to provide for your family, unable to be a productive member of society. Everyone has their breaking point. Some are just at a different level. The medical profession actually depends on these breaking points to keep a revenue stream. If people just sucked t up all the time and learned to live with their ailments they would not be in your office, paying your salary.

[physasst]

There is a reason pain is the most common reason people seek medical care

Our job is to maximize all the modalities we have to alleviate it

If we fail then we need to consider referral to pain specialists

Our job is not to dispense "tough love" or enforce our own life philosophy on our patients

 

It's about THEM not YOU

 

Of course not.....not for all of them. I am a pain specialist of sorts....one of the reasons they are referred to me, and they are all referred as we do not take self referred patients, we're consultative only, is to evaluate and attempt to optimize their spine pain management. I tell every single patient..I have 5 things, and any other doctor or provider in the world has the same 5 things to treat your back pain.

 

1. Surgery....take something out, put something in....fuse something.....Not a great option for most back pain. Works well for a few spine disorders, but won't help back pain for the most part (yes, I know that occasionally someone gets better, but statistically, surgery is not a great option and DEFINITELY won't help mechanical pain)...

 

2. Injections....we love steroids....the Nobel prize sits right across the hallway from me as we invented cortisone....but the injections are generally only a temporary fix whether they be facet, TFESI, ILESI, SI, trigger point, etc....They can be used a few times per year, depending on steroid load....

 

3. Physical Therapy...this is the mainstay...it won't completely prevent pain, but it will make the peaks flatter and lower, and space out the bad days, with more good days than bad.....It's the best long term treatment we have.....

 

4. Medications....I tell patients, I can give you medications and you won't even know you have a back, but most of them are only good for short term pain management......I prescribe and have several patients on regimens of gabapentin, lyrica, or cymbalta, but I only write narcotics for short term management. IE; acute radiculopathy with severe pain.......I tell patients that gabapentin might be the safest medication I prescribe, as NSAID's aren't good for longer term pain, and even tylenol isn't completely benign....

 

5. Living with it......We have a 3 week program, one of the only ones in the country, that is designed to use cognitive behavioral therapy and psych therapy to teach people to learn to LIVE with their chronic pain....

 

That's it...there is no 6th option. Most patients appreciate my candor, some don't. Many of them need a reality check. One of my roles (and that of my partners) is to provide that. We don't have fixes....we can try and make things better....but that isn't necessarily pain free.

 

BTW, you may think of me as cynical or uncaring, but that is far from the truth. I actually do care. I only see about 6-8 patients per day, and I often spend a significant amount of time with each patient talking about all of this, I do care, but as I explain to patients, there is no point in doing therapies that won't likely be helpful and could be harmful. It's about managing expectations.....Having an expectation of being completely pain free is not realistic and won't happen. What we strive for is to make the pain tolerable....

 

You're right...it's not about me...it is about them, but at the end of the day...THEY are the ones with the pain. Most of the chronic ones don't participate in PT, or miss appointments with acupuncture, or won't try chiro or massage......They have to take ownership of their pain, and most do.....but many do not.

[Contrarian]

This state implemented a new law in January 2012 that restricts ANY prescriber (NP/PA/MD/DO) from prescribing opioid pain meds above a certain milligram threshold before consulting a "Pain Medicine SPecialist....

 

Physasst... as a fellow PA who is OFFICALLy considered a "Pain Specialist" by the state of WA. and serving as a community consultant who provides small and large joint injections, oral pain medications above the state mandated threshold, CBT/DBT and addiction medicine...

 

I think your posts above in this thread are SPOT ON and basically parallels my Chronic pain management practice...

 

Pain is a natural human experience and chronic pain is usually a result of some form of pathology...

Not ALL pathology can be cured...

Some of it can be mitigated... but not necessarily cured.

 

I spend a significant amount of our initial and subsequent conversations discusing and trying to dispel the notion that humans are destine to be "pain free" after twenty-fourty-fifty-sixty yrs of poor care, poor maintanence, and wear-and tear on our bodies.

 

At some point... I usually do the pain scale and try in earnest to negotiate a reasonable level of tolerable daily pain.

 

Patient says their pain is a 10/10... well then I try to get them to see/know/under/overstand that if we can get them to a 6/10 or 4/10 on many/most/but not all days.. this is a certifiable WIN...!!!!!

 

Some get it... most have unreasonable expectations shortly after they detail the horrific plane/train/auto/boat accidents/fall from tremendous hights and bounced/post amputation then re-attachment/laminectomy x 8/joint replacement x 4/fusion x 12 stories...

 

There is a clear and cogent reason that my private practice started with Addiction Medicine and eventually morphed to include Chronic Pain Management... and why my phone is ringing off the hook and I'm turning patients away daily.

 

This is mostly due to... surgical "misadventures" (cutting on joints have mostly/historically in all but a few exceptions made things worse in the long term... think scar tissue...!!!!) and the other culprit has been inappropriate, escalating and extended pain med prescribing by well meaning providers....

[Just Steve]

Does your office take DSHS/Medicaid? What are the options for those folks?

[Contrarian]

No... I don't accept any insurance in my private practice.

 

Why...????

Because my Monday thru Friday "day job" is in a outpatient community mental health clinic (I practice Internal Medicine and adult Psychiatry here) and 70% of my patients here are "state-paid" (DSHS/Medicaid/BHAP)...

 

On Tuesdays of each week... I am the county wide (Whatcom County) ECS prescriber and wear my state certified Geriatric Psychiatry specialist hat and visit about 12 -15 patients in about 10 Adult family Homes, Group Homes, Skilled Nursing Facilities. Here I practice Internal Medicine and Geriatric Psychiatry. I medically manage elderly and young/old developmentally delayed adults with assaultive and impule control behavioral issues who are at risk of losing their housing due to these issues. The primary payer is Medicare and DSHS/HCS.

 

If I plan well and am efficient... I leave this job "Day Job" at around 4:30.

 

I then go to my second job which is the community Social Detox/Crisis Respite center. I give them a actual hour each evening examining patients detoxing from various illicit drugs, and/or dealing with their various acute/chronic medical issues. I try to limit my time here to a hour and then I'm on paid call for them until 10pm. Monday thru Friday (excluding holidays)

 

So after working ALL DAY for a pittance... my charity work is done...!!!

 

My private practice is therefore, CASH ONLY and typically open at 5:30-6:00 pm until 9:000pm Wed/Thurs/Fri or by special appointment any evening Mon-Sun. ALL of my private practice patients have my personal cell phone number. Why... because they are paying me between $150-$300 per visit.

 

So NO... I don't accept ANY insurance in my private practice.

 

As I see it, my PERSONAL time and the liability burden... after a long day of accepting minimal state pay from 8am-5:30pm... is worth more than DSHS/HCS/Medicare-caid/or ANY insurance company will pay and just isn't worth the paper-work burden and hassle.

 

ESPECIALLY ... when you consider the accompanying problems, issues, scrutiny and personality disorders many/most addicts and people seeking controlled substances have.

 

Clinic opens at around 6pm...

We accept cash or credit/debit cards... (checks from a select few... as accepting checks from addicts isn't prudent/wise)

No controlled substances on premise

There is a semi-auto in a holster concealed on my hip when the door is unlocked.

Business is good...

 

:heheh: