management of OA pain in the primary care setting and other assorted questions

[stoic]

What's up guys -

I'm a long time SDN'er and current MS1. I'm doing a 6 week rural preceptorship this summer where we function as 3/4th years students seeing patients and trying our best to Dx and come up with appropriate treatment plans.

Anyway, one thing I've noticed is that there is a TON of variation between primary care physicians in terms of how they manage pain (usually it seems they are not quite up to speed with the current standards in pain management). So if you all will put up with me, I'd like to spend the next few weeks picking your brains before my internship starts up.

One area that I've seen a lot of variation in is the treatment of osteoarthritis when NSAIDS either fail to completely control the pain or are contraindicated.

For example, lets talk about a pt. I saw in the FP clinic earlier this year. This patient come into the practice from a physician who practiced in the same building, but had recently retired. We did have records confirming the history. 65yo overweight female with severe OA of knees/hips/hands. X-ray confirmed. Ambulates w/a cane, does have quite a bit of difficulting getting around. Has HTN also NIDDM. NSAIDS not an option b/c of several GI bleeds. She's been taking 8-10 darvocet N50 a day for several years (400-500mg propoxephene/day, 2600-3250mg APAP/day.) We decided very quickly that we should change the pain med for two reasons: A)propoxephen (sp?) sucks as a pain killer and can be toxic and B)lates a fair amount of APAP.

So neither one of us had any idea how to convert from propox. to a different opiate... Ended up going MSContin 30mg BID, and the patient was happy with the increased pain relief and decreased dosing frequency.

What would you guys have done differently in this case?

It seems a lot of people used to take Darvocet for OA. I know darvocet isn't really used anymore (for good reason), but a lot of older docs are still writing for it, particuarly it seems for OA (though this could be a regional thing). Do you guys move someone with well controlled pain on Darvocet to a different med? Which one? How do you convert?

In general, it seem that unless there are contraindications, the treatment ladder for OA is as follows:

1. APAP
2. NSAIDS if APAP fails
3. Low dose opioid or tramadol +NSAID if tolerated or w/o NSAID if not tolerated
4....
5...

Past that I don't really know; if moderate doses of hydrocodone aren't doing the job, do you go to moderate doses of more powerful opioids like oxycodone in a immediate release prep? or do you go right to the long acting drugs?

Is there a role for vicoprofen in OA management at all? It seems to me that it would be a better drug than hydrocodone/apap (personally, i've found - for me - that ibuprofen is like magic; it can cure anything; while APAP is basically useless). However, I rarely encounter pt's who take it. Is there a reason for this?

Finally, in general, what do you wish you could brand into primary care physicians's brains when it comes to treat OA? Treating pain in general?

I'm sure I'll be asking a bunch more questions, but thanks for your help in advance. I've really enjoyed reading this forum... hopefully we can get some good discussions going.

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[jsaul]

What's up guys -

I'm a long time SDN'er and current MS1. I'm doing a 6 week rural preceptorship this summer where we function as 3/4th years students seeing patients and trying our best to Dx and come up with appropriate treatment plans.

Anyway, one thing I've noticed is that there is a TON of variation between primary care physicians in terms of how they manage pain (usually it seems they are not quite up to speed with the current standards in pain management). So if you all will put up with me, I'd like to spend the next few weeks picking your brains before my internship starts up.

One area that I've seen a lot of variation in is the treatment of osteoarthritis when NSAIDS either fail to completely control the pain or are contraindicated.

For example, lets talk about a pt. I saw in the FP clinic earlier this year. This patient come into the practice from a physician who practiced in the same building, but had recently retired. We did have records confirming the history. 65yo overweight female with severe OA of knees/hips/hands. X-ray confirmed. Ambulates w/a cane, does have quite a bit of difficulting getting around. Has HTN also NIDDM. NSAIDS not an option b/c of several GI bleeds. She's been taking 8-10 darvocet N50 a day for several years (400-500mg propoxephene/day, 2600-3250mg APAP/day.) We decided very quickly that we should change the pain med for two reasons: A)propoxephen (sp?) sucks as a pain killer and can be toxic and B)lates a fair amount of APAP.

So neither one of us had any idea how to convert from propox. to a different opiate... Ended up going MSContin 30mg BID, and the patient was happy with the increased pain relief and decreased dosing frequency.

What would you guys have done differently in this case?

It seems a lot of people used to take Darvocet for OA. I know darvocet is really used anymore (for good reason), but a lot of older docs are still writing for it, particuarly it seems for OA (though this could be a regional thing). Do you guys move someone with well controlled pain on Darvocet to a different med? Which one? How do you convert?

In general, it seem that unless there are contraindications, the treatment ladder for OA is as follows:

1. APAP
2. NSAIDS if APAP fails
3. Low dose opioid or tramadol +NSAID if tolerated or w/o NSAID if tolerated
4....
5...

Past that I don't really know; if moderate doses of hydrocodone aren't doing the job, do you go to moderate doses of more powerful opioids like oxycodone in a immediate release prep? or do you go right to the long acting drugs?

Is there a role for vicoprofen in OA management at all? It seems to me that it would be a better drug than hydrocodone/apap (personally, i've found - for me - that ibuprofen is like magic; it can cure anything; while APAP is basically useless). However, I rarely encounter pt's who take it. Is there a reason for this?

Finally, in general, what do you wish you could brand into primary care physicians's brains when it comes to treat OA? Treating pain in general?

I'm sure I'll be asking a bunch more questions, but thanks for your help in advance. I've really enjoyed reading this forum... hopefully we can get some good discussions going.

man, you are an ms1 and you have 4000+ posts!!!
what do you do in your free time?

 

[stoic]

man, you are an ms1 and you have 4000+ posts!!!
what do you do in your free time?

lol... i've been a member here at SDN since the good old days. i started posting in november of 2000 - when i was a senior in high school (isn't that nuts? started in high school, all through undergrad, and now in med school with now end of posting in sight). the VAST majority of my posting came before med school started.


and now... on the topic at hand!

1) conversion from propox. to other opiods?
2) management of OA pain in the primary care setting?

Thanks a million.

Dave

 

[stonemountain]

1) For OA, if not tried before, would suggest the patient try glucosamine/chondroitin/MSM supplement for 2-3 months.
2) there is a newly approved subthreshold e-stim device by Bionicare for knee OA. So new I haven't tried it yet.
3) I don't think there is any data proving one strong narcotic medication is any better than another. I do tend to use Fentanyl patch more since it is less likely to be abused and it has less constipation side effects (although many patients still get it).
4) to convert narcotic medications, you should be able to find tables in small reference books such as the pocket pharmacopoeia, scut-monkey, and washington manual, as well as many others.
5) If the pain is in a large joint such as the knee, you could consider injecting it. I don't much experience with small joints so I leave those to rheumatology.

Now for my million