One in five Canadians live with chronic non-cancer pain (CNCP). Due to the historical role opioids had as a key component of CNCP treatment, a number of patients living with CNCP are on long-term opioid therapy (LTOT). I discuss the off-label use of buprenorphine/naloxone as a distinctive treatment option for CNCP and LTOT.
Degenerative lumbar spinal stenosis refers to the narrowing of the spinal canal that can result in numbness, pain, and weakness of the lower extremities. Atypical presentations are common as are competing diagnoses. Top practice tips: distinguish the source of the symptoms, rule out competing disorders, send for imaging, encourage exercises that place the patient in a flexed position, and consider gabapentin, epidural steroid injections, and a referral for a surgical opinion.
I incorporate this ‘NSAID ceiling’ into my prescribing practice for anti-inflammatory medications. I typically prescribe maximum doses of 400 mg oral ibuprofen TID with meals and 10 mg intramuscular ketorolac. I counsel my patients to limit their NSAID use to a 5-day window when possible and encourage other non-pharmacological and multimodal analgesia.
Otolaryngologists receive many referrals for what is classified as Eustachian Tube Dysfunction, aural fullness, and subjective hearing loss. Practitioners frequently encounter ear fullness or subjective hearing loss, in the face of an otherwise normal exam. It may lead practitioners to “read into” their physical exam with abnormal tympanic membrane (TM) findings.
There is growing recognition that opioid prescribing can lead to prescription opioid use disorder (OUD). It is estimated that nearly 115,000 British Columbians have become addicted to opioids. There is a need to safely reduce the volume of new opioid prescriptions for opioid naïve patients.
Individuals with Chronic Pelvic Pain (CPP) often experience disruptions in multiple aspects of their reproductive health care. Routine pelvic examinations often become extremely challenging due to pain.
I have decreased my frequency of giving steroid injections for decreasing pain of osteoarthritic knees. I educate patients on evidence, placebo effects and risks. I recommend less invasive therapies including physiotherapy, exercise (quadriceps and hip abductor strengthening, Tai Chi), hot compress, antiinflammatory creams, weight loss, TENS machine, orthopedic & orthotic devices, etc.
Appendicitis can often present itself in the black box of abdominal pain. Fortunately at times the history and physical can give practitioners a clear window, straight through the fascia, to an unhappy appendix.
Fatigue, pain, and unexplained symptoms are commonly seen in physician offices, however they are often experienced as “unsatisfying” for doctors. Our patients need an explanatory model to help them understand their illness. If we don’t provide one, patients will create their own or seek one elsewhere.
It has been shown that 55% of pregnant patients reported some form of back pain during their pregnancy when questioned. Studies have demonstrated that if we get pregnant women moving, specifically working their pelvic floor with Kegel exercises and their ‘core’ they may have better pregnancy outcomes.
Endometriosis is a very common condition affecting an estimated 10% of women of reproductive age. Severe dysmenorrhea is the most common symptom of endometriosis and the earliest one to occur.
In the 1970’s if you had a suggestive history, physical exam, and no osteoarthritis you would probably have a complete meniscectomy. Often the knee pain persisted postoperatively. Then complete meniscectomy was shown to be associated with a significantly increased risk of osteoarthritis.
Many people mistake the pain of withdrawal as their usual pain and assume their pain improved because the opioid was relieving their pain, when it was more often just relieving the pain associated with the induced withdrawal.
Somatoform and conversion disorders are common psychiatric presentations in general practice. When chronic, like most psychiatric conditions, they commonly cause leave from work, poor quality of life for patients and supports, and heavy burden on medical practices.
How to manage PVD is an extremely common question. PVD affects 12 -15 % women most of whom are relatively young. The common co-morbidity of PVD strongly supports a chronic pain approach.
It is worth considering OIPS in the differential diagnosis when pain appears to be spreading, especially when features of allodynia and hyperalgesia are present.
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