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A 60-year-old woman presents with chronic low back pain that began many years ago. Her back pain waxes and wanes, and she has taken acetaminophen and ibuprofen with some relief. About 3 months ago, she began to have daily pain. She recalls no trauma. Her examination is unremarkable other than some decreased flexion. Straight-leg raise test is negative. As the patient is older than 55 years of age, radiographs are ordered, and they demonstrate degenerative changes in her lumbar spine (Figure 101-1). She is started on an exercise program and yoga.
A 60-year-old woman presents with chronic low back pain that began many years ago. Her back pain waxes and wanes, and she has taken acetaminophen and ibuprofen with some relief. About 3 months ago, she began to have daily pain. She recalls no trauma. Her examination is unremarkable other than some decreased flexion. Straight-leg raise test is negative. As the patient is older than 55 years of age, radiographs are ordered, and they demonstrate degenerative changes in her lumbar spine (Figure 101-1). She is started on an exercise program and yoga.
A 60-year-old woman presents with chronic low back pain that began many years ago. Her back pain waxes and wanes, and she has taken acetaminophen and ibuprofen with some relief. About 3 months ago, she began to have daily pain. She recalls no trauma. Her examination is unremarkable other than some decreased flexion. Straight-leg raise test is negative. As the patient is older than 55 years of age, radiographs are ordered, and they demonstrate degenerative changes in her lumbar spine (Figure 101-1). She is started on an exercise program and yoga.
This appendix focuses on one of the most common scenarios in primary care—chronic non-cancer pain that does not have an easily identifiable physical source, and therefore is difficult to "fix" with simple interventions. Of course, as needed, arrange treatment for any clearly identifiable source that is not resolving with conservative measures. Examples of these include interventional treatments of severe persistent back pain due to verified disc herniation with clinically consistent exam findings, documented nerve impingements amenable to surgical release, or severe joint disease amenable to surgical repair or joint replacement.
This appendix focuses on one of the most common scenarios in primary care—chronic non-cancer pain that does not have an easily identifiable physical source, and therefore is difficult to "fix" with simple interventions. Of course, as needed, arrange treatment for any clearly identifiable source that is not resolving with conservative measures. Examples of these include interventional treatments of severe persistent back pain due to verified disc herniation with clinically consistent exam findings, documented nerve impingements amenable to surgical release, or severe joint disease amenable to surgical repair or joint replacement.
This appendix focuses on one of the most common scenarios in primary care—chronic non-cancer pain that does not have an easily identifiable physical source, and therefore is difficult to "fix" with simple interventions. Of course, as needed, arrange treatment for any clearly identifiable source that is not resolving with conservative measures. Examples of these include interventional treatments of severe persistent back pain due to verified disc herniation with clinically consistent exam findings, documented nerve impingements amenable to surgical release, or severe joint disease amenable to surgical repair or joint replacement.
A 21-year-old woman is seen by a family physician in a student-run free clinic within a residential chemical dependency program for women. She has just finished withdrawing from intravenous heroin. She is experiencing anxiety and insomnia and is asking for medications to help her sleep at night and function during the day. The young woman has a 10-month-old baby. She had been on a methadone program during her pregnancy. The patient states that her mother is bipolar and often uses various drugs including heroin. Her brother sells heroin but claims to not use it anymore. He does sell heroin to her and her mother at a discount. The patient admits to having been sexually abused as a child and states that the heroin numbs some of the pain from her childhood. Unfortunately, she has bad nightmares (related to posttraumatic stress disorder [PTSD]) that make sleeping difficult. She did return to injecting heroin after the baby was born and lost custody of her child. She is motivated to maintain sobriety so she can be with her baby again. The family physician listens with compassion and empathy and prescribes some non-addicting medications to help her with the anxiety, insomnia, and nightmares. A follow-up appointment is set for the following week, as it is clear that this young woman needs a lot of support in addition to close management of pharmacologic therapy.
A 21-year-old woman is seen by a family physician in a student-run free clinic within a residential chemical dependency program for women. She has just finished withdrawing from intravenous heroin. She is experiencing anxiety and insomnia and is asking for medications to help her sleep at night and function during the day. The young woman has a 10-month-old baby. She had been on a methadone program during her pregnancy. The patient states that her mother is bipolar and often uses various drugs including heroin. Her brother sells heroin but claims to not use it anymore. He does sell heroin to her and her mother at a discount. The patient admits to having been sexually abused as a child and states that the heroin numbs some of the pain from her childhood. Unfortunately, she has bad nightmares (related to posttraumatic stress disorder [PTSD]) that make sleeping difficult. She did return to injecting heroin after the baby was born and lost custody of her child. She is motivated to maintain sobriety so she can be with her baby again. The family physician listens with compassion and empathy and prescribes some non-addicting medications to help her with the anxiety, insomnia, and nightmares. A follow-up appointment is set for the following week, as it is clear that this young woman needs a lot of support in addition to close management of pharmacologic therapy.
A 21-year-old woman is seen by a family physician in a student-run free clinic within a residential chemical dependency program for women. She has just finished withdrawing from intravenous heroin. She is experiencing anxiety and insomnia and is asking for medications to help her sleep at night and function during the day. The young woman has a 10-month-old baby. She had been on a methadone program during her pregnancy. The patient states that her mother is bipolar and often uses various drugs including heroin. Her brother sells heroin but claims to not use it anymore. He does sell heroin to her and her mother at a discount. The patient admits to having been sexually abused as a child and states that the heroin numbs some of the pain from her childhood. Unfortunately, she has bad nightmares (related to posttraumatic stress disorder [PTSD]) that make sleeping difficult. She did return to injecting heroin after the baby was born and lost custody of her child. She is motivated to maintain sobriety so she can be with her baby again. The family physician listens with compassion and empathy and prescribes some non-addicting medications to help her with the anxiety, insomnia, and nightmares. A follow-up appointment is set for the following week, as it is clear that this young woman needs a lot of support in addition to close management of pharmacologic therapy.