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Challenging Patients Curriculum Instructor Guide^

The Patient with Chronic Pain



A PGY-2 resident will be able to evaluate and develop a treatment plan for a geriatric patient with several co-morbidities presenting with low back pain.

ACGME Core Competencies:

Patient Care/Interpersonal Communication Skills

  • Demonstrate a comprehensive history and physical examination on a geriatric standardized patient with low back pain

 Patient Care/Medical Knowledge

  •  List red flag signs, symptoms, and findings following a standardized patient encounter on a geriatric patient
  • Write out a plan to work up back pain after seeing a standardized patient who is older with co-morbidities
  • Engage in a group discussion about medications and therapies to be used and avoided in geriatric patients with chronic back pain, as well as in patients with such co-morbidities as liver or kidney failure

Medical Knowledge

  •  Generate a differential diagnosis specific to an older or medically complicated patient presenting with low back pain


Session Guide^


Time Needed: 3-4 hours total. One to one-and-one-half hours for didactic lecture on low back pain, one half hour to review and practice the physical exam, and one hour for discussion.

Equipment Needed:

  • Computer with projector if PowerPoint is to be used in the didactic lecture
  • Room with several chairs and tables which can support residents as they practice the physical exam
  • Examination rooms for the standardized patients during the separate standardized patient interaction (generally scheduled the day after this session is taught)

Suggested online modules:, modules “Common Pain Diagnoses: Fibromyalgia,” and “Common Pain Diagnoses: Neuropathic Pain.” They are free to review “Overview and Assessment,” “Treatment Goals,” “Legal and Regulatory Aspects,” and “Virginia” if they feel they need it.

Instructor Script and Notes

  1. Introduce Pain Management Specialist co-teacher.  Describe a real-life challenging case trying to assess and treat an older patient with co-morbidities and chronic low back pain.
  2. Ask residents about their struggles and successes managing chronic pain in similarly challenging patients.  Elicit questions.
  3. PowerPoint lecture, “How to Prescribe Pain Medications without Killing People” (PainMeds.ppt), followed by 10 minute break.
  4. Demonstrate the LBP physical exam (can refer to PGY1 Word document outline), and have residents practice on one another.
  5. Go over how the differential for low back pain changes with older patients (see Word document handout for PGY2).  Pass out handout “How to Prescribe Pain Medicines without Killing People” (list of medications indicated/contraindicated with geriatric, liver or kidney disease patients – see handout 2).
  6. Group discussion: what questions were left unanswered?  What other questions have come up?  What resources are available if questions arise in the future (people, online references such as the Johns Hopkins Opioid Calculator, VCU Online Modules)?


Open Handout

Medically Complicated Back Pain – Geriatrics,
CKD and Liver Failure – Handout^


  • Geriatric Back Pain
    • What makes assessing and treating back pain in older patients challenging?
      • More time needed to take a history
      • May have a different “pain” vocabulary
      • Difficult to perform and interpret an exam
      • More potentially dangerous causes of back pain
      • Difficulty interpreting imaging
      • Difficulty with choosing medicines for treatment (both because of age and co-morbidities)
    • DDx for an older person presenting with back pain. How do these present?
      • Cancer
        • Hx: constant, unrelated to position, disturbs sleep, progressive despite tx, wt loss
        • Risk factors: 7% of LBP over age 50, hx CA
        • Mets from breast, lung, kidney, prostate. MM. Pancreatic carcinoma, renal cell CA, intrapelvic tumors, lymphoma w/ retroperitoneal LAD
      • AAA (often assoc w/ abd pain, men > women, may radiate to hips/thighs, inc risk w/ PVD)
      • Compression fracture (sudden, severe, minimal trauma, women > men, exam may show kyphosis, can be seen on plain films, bone scans, or MRI. OK when still, painful w/ motion)
      • Osteoarthritis (insidious, worse w/ activity)
      • Polymyalgia rheumatica (sudden, neck/back/shoulder/hip stiffness, high sed rate, responds to prednisone)
      • Spinal stenosis (due to facet jt hypertrophy & disc herniation, bilateral leg pain/numbness/weakness improved with sitting, flexion, check peripheral pulses to distinguish vasc from neuro claudication)
      • Disc disease
      • Fibromyalgia (women > men)
      • Trochanteric bursitis (worse on hip abduction)
      • Paget disease
      • Parkinson’s (increased mm tone/stiffness)
      • Diffuse idiopathic skeletal hyperostosis (ossification of spinal ligaments, usually men > 50)
    • What medicines normally used for treating back pain can be dangerous in an older person?  (See Beer’s List)
      • NSAIDs (GI bleeding risk, possible increased CAD risk, nephrotoxicity in diabetes)
      • ASA – GI bleeding risk, caution if underlying bleeding disorders
      • Tramadol – possible serotonin syndrome with SSRIs
      • Methadone – possible serotonin syndrome with SSRIs, prolonged QT syndrome
      • Opiates – possible altered mental status, constipation, can cause obstruction in BPH, slower clearance of metabolites, may slow respiration and cause CO2 retention in COPD
      • Tricyclic antidepressants – altered mental status, prolonged QT syndrome, constipation, may induce arrhythmias
      • Benzodiazepines – increased fall risk, altered mental status
      • Muscle relaxants – sedation, weakness, anticholinergic side effects, can cause obstruction in BPH
      • Steroids – altered mental status, increased fracture risk with long-term use
      • Anticonvulsants – sedation, ataxia, dizziness
    • Some general principles
      • Meds – start low and go slow
      • Tylenol first
      • Don’t forget non-pharmaceutical treatments
      • Consider x-ray in an older pt whose pain isn’t improving after 4 wks, U/S if you suspect AAA, CT or MRI if you suspect malignancy
  • Back Pain and Kidney Disease
    • Same WHO stepwise guidelines
    • Tylenol first
    • Most narcotics are eliminated hepatically – except methadone, which is both hepatic and renal
    • However, narcs like morphine, oxycodone, propoxyphene and meperidine have active metabolites whose elimination depends on GFR – so dose-adjust and use longer intervals
    • Avoid propoxyphene (Darvocet) and meperidine (Demerol)
    • Tramadol – max 50mg BID due to prolonged elimination
    • Can use NSAIDs, but caution in the elderly
    • Adjust dose and monitor for toxicity
  • Back Pain and Liver Disease
    • For meds taken orally, first-pass metabolism isn’t great – so bioavailability of narcotics and benzos are increased.  Especially bad in pts with viral or alcoholic hepatitis (as opposed to malignant liver dz).  Again, start low and go slow. Opioids can precipitate encephalopathy.
    • Decreased albumin and increasing ascites changes the volume and distribution of meds
    • Tylenol OK in conventional doses – so is amitriptyline
    • Unclear whether NSAIDs are verboten.  Naproxen – decrease dose 50%
    • Morphine CR – accumulates – so decrease frequency
    • Avoid oxycodone (or decrease dose), codeine, tramadol
    • Fentanyl – the opioid of choice?
    • Anticonvulsants – more data needed. Avoid carbemazepine.
    • Benzos – be extremely careful.  If you must, Ativan seems safest.


Open Handout

How to Prescribe Pain Medicines without Killing People – Handout^

Catherine Casey MD☼


Pain Management Pearls and Principles:


  • Believe the patient’s report of pain (but remember: 10/10 pain ≠ narcotics)
  • By the mouth (whenever possible)
    • oral → transdermal → sublingual → rectal/vaginal/ostomy → PCA
  • By the clock
  • By the ladder
  • Add non-drug therapies
  • Differentiate nociceptive from neuropathic pain
  • Try not to prescribe two medications in the same class at the same time (e.g., two short-acting opiates like Percocet and Vicodin). There are exceptions to this, notably in the antiepileptic drug category.
  • When it comes to opiates, titrate by percents rather than milligrams (e.g. go up 25-50% for pain without sedation; go down 25-50% if there is sedation)
  • Convert short-acting opiates to long-acting ones (less risk for overmedication, side effects, euphoria, end-of-dose breakthrough pain)
  • Use equianalgesic doses (, but anticipate incomplete cross-tolerance
  • In liver and kidney patients, dose-adjust and use longer dosing intervals. Even though most opiates are eliminated through the liver, many have metabolites whose elimination depends on GFR.
  • Never be afraid to consult or ask for help, no matter what the hour

ACETAMINOPHEN – nociceptive pain

  • The “starter drug” of choice, even in folks with kidney or liver disease
  • Limit to 2g/d in liver disease, 4g/d in healthy folks
  • Highest risk for acetaminophen-related problems – alcoholic liver disease

NSAIDS – nociceptive pain (but not neuropathic)

  • Ibuprofen has a NNT=2 – the best of any pain med, including morphine!
  • Monitor kidney function frequently. If Cr bumps, check for AIN.
  • Use carefully or not at all in kidney or liver disease
  • Use big, scheduled doses for a limited amount of time (< 2 mos.) – don’t refill 11 times
  • Consider adding a PPI or misoprostol (Arthrotec) to reduce risk of gastric bleeding, esp. in elderly – and don’t use long-term
  • No indomethacin in the elderly – lots of CNS effects
  • No aspirin in kids or teenagers (risk of Reye’s Syndrome), or pregnant or breastfeeding moms

TRAMADOL – nociceptive or neuropathic pain, fibromyalgia

  • SEROTONIN SYNDROME HAPPENS. Treatment: hospitalization, d/c offending drugs (tramadol, methadone, SSRIs), start benzos.
  • Reduces seizure threshold
  • Start 50mg Q6h; can titrate to a total of 300mg daily in elderly (cautiously), otw 400mg daily
  • Don’t believe the hype – some people are genetically predisposed to get addicted to this drug
  • Avoid in liver disease
  • Max 50mg BID in kidney disease due to prolonged elimination

OPIATES – nociceptive > neuropathic pain (methadone does both well)

  • Reassess frequently after increasing dosage (1hr on the inpatient service for IV pain meds, 1 wk for outpatients on methadone)
  • Don’t forget the bowel regimen (colace, senna, bisacodyl)!
  • Dicey in liver patients. Avoid oxycodone and codeine. Use Fentanyl.
  • No meperidine (Demerol) or propoxyphene (Darvocet) in kidney patients. In general, avoid morphine, but Pain docs can sometimes get away with this.
  • Avoid codeine and meperidine in general. Codeine sucks as a pain medicine and has lots of active metabolites that hang around forever (so does Demerol).
  • Consult a specialist before switching around methadone and fentanyl
  • Starting methadone in an opiate-tolerant patient: 5 mg BID x 7 d, then 5 mg TID.  Doesn’t really matter whether they were on whomping doses of other pain medicines previously – there is no good equianalgesic conversion ratio (roughly 20:1). Have a low threshold to ask a specialist to help you. In an opiate-naïve or elderly patient, start with 2.5mg QHS, then BID after 7 d.
  • Methadone has a super long half-life and variable clearance – don’t titrate more frequently than once a week. And don’t give it to folks you don’t trust to understand the directions.
  • Fentanyl patches are contraindicated in patients < 110 lbs

MUSCLE RELAXANTS – muscle spasm, fibromyalgia, neuropathic pain (selected)

  • Baclofen also works for lancinating, paroxysmal neuropathic pain. Start 5mg QHS, titrate up to 20mg QID.
  • Tizanidine (Zanaflex) works for neuropathic pain also, and fibromyalgia. Start 2mg QHS, titrate up to 4-8mg TID.
  • Avoid carisoprodol (Soma). Metabolizes to a sedative. Very addictive.

BENZODIAZEPINES – muscle spasm

  • BENZOS + OPIATES = INCREASED RISK OF RESPIRATORY DEPRESSION.  Implicated in many overdoses in the state of Virginia.
  • Avoid in liver disease. If you must in a liver pt, use Ativan.
  • Taper slowly. 30 days of QD use is enough to generate physical dependence. Cold withdrawal can cause seizures and death.

TRICYCLICS – neuropathic pain

  • Trazodone 10-25mg is great for sleep in the elderly. Avoid amitriptyline in old folks.
  • Get EKGs when titrating up either tricyclics or methadone in someone on both, with attention to the QT interval. If it’s prolonging, STOP.
  • May take a few weeks to fully kick in

ANTIEPILEPTICS – neuropathic pain, postherpetic neuralgia

  • Sudden discontinuation of gabapentin (Neurontin) can cause seizures
  • Titration schedule for gabapentin: 300 QHS x 3d, 300 BID x 3d, 300 TID x 3d, then increase by 300mg q3d until you get to relief or side-effects (usually drowsiness). Max: 3600mg/d divided TID.
  • Check electrolytes frequently for hyponatremia and hypokalemia on topiramate (Topamax)
  • No carbemazepine (Tegretol) in liver disease

TOPICALS – muscular or neuropathic pain

  • Lidoderm patch or capsaicin for periphereal neuropathic pain, menthol-containing ointments for MSK pain, compounded ointments/gels containing NSAIDs, TCAs, and AEDs also available

ADJUVANTS – steroids, heat/ice, TENS, acupuncture, massage, addressing accompanying depression/anxiety/insomnia