A 51-year-old woman is referred for evaluation. She has a 10-year history of chronic pain that she describes as head-to-toe aching, twisting, and sometimes burning that involves several large muscle groups. The pain is constant, and she rates the severity as a 6 on a 10-point scale. She is able to work despite the pain but is constantly fatigued. Her current regimen of oxycodone provides minimal relief. She has tried three other opioid medications as well as gabapentin and milnacipran, all of which provided only minimal improvement in her pain. Medical history is also significant for generalized anxiety disorder treated with sertraline.
On physical examination, vital signs are normal. There is tenderness in multiple large muscle groups. The remainder of the physical examination is normal.
In addition to slow tapering of oxycodone, which of the following is the most appropriate next step in treatment?
B. Physical therapy
C. Transcutaneous electrical nerve stimulation
D. Transdermal fentanyl
MKSAP Answer and Critique
The correct answer is B. Physical therapy. This content is available to MKSAP 18 subscribers as Question 47 in the General Internal Medicine section. More information about MKSAP is available online.
The most appropriate next step in treatment is physical therapy. This patient has a long-standing history of chronic pain that is most consistent with a diagnosis of fibromyalgia. All patients with chronic pain should be referred to a structured physical therapy program for evaluation and treatment. Physical therapy teaches patients safe, self-guided exercises to improve functional status, and there is a clear evidence base to support its use in all patients with chronic pain. Guided/progressive physical therapy programs are associated with a reduction in pain and, perhaps most importantly, improvement in function. No evidence suggests that a specific type of physical therapy is superior to another, and programs should be tailored to patient ability and adherence.
Clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. Epidemiologic studies indicate that concomitant use of benzodiazepines, such as lorazepam, and opioids may place patients at increased risk for fatal overdose. In three studies of opioid overdose deaths, there was evidence of concurrent benzodiazepine use in 31% to 61% of persons.
Trials of transcutaneous electrical nerve stimulation (TENS) for the treatment of fibromyalgia have yielded inconclusive results. Positive trials of TENS are frequently contaminated with concurrent use of an exercise program and massage. On the basis of inconclusive evidence, TENS cannot be recommended as the next treatment modality for this patient.
Opioid rotation would not be an ideal next step in this patient with a long history of chronic pain, particularly in the setting of previous unsuccessful opioid trials. Despite high opioid prescribing rates, no evidence supports the use of long-term opioid therapy in patients with chronic noncancer pain. In one study, patients receiving long-term opioids for chronic pain had more pain, poorer quality of life, and poorer function than a population of patients with chronic pain who were not taking opioids. Given the lack of evidence to support chronic opioid therapy, the continued use of opioids for chronic pain should be justified at every follow-up visit by documenting the patient's sustained functional improvement due to effective opioid therapy. In this patient with pain that has failed to improve with opioid therapy, oxycodone should be carefully withdrawn, and nonpharmacologic therapy should be instituted.
- In patients with chronic noncancer pain, physical therapy reduces pain and improves function.