A Recommendation from Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from ACOP and APS By Rhys Dela Cruz, Angela Hickey, and Mit Patel The purpose of the guideline is to present the available evidence for evaluation and management of acute and chronic low back pain in adults that is not associated with major trauma. The guideline grades its recommendations by using the ACP’s clinical practice guidelines grading system.

Recommendation: Treatment of Low Back Pain Recommendation 6 states: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs).

Summary of Evidence 1) Medications with Proven Benefits Treatment for Acute or Chronic Pain: 1st Line therapy: Use Acetaminophen or NSAIDS - Both are Grade B (good level of evidence with moderate level of benefit). Acetaminophen is slightly weaker analgesic than NSAIDs, but more favorable safety profile and low cost. Tylenol has asymptomatic liver enzyme elevation of uncertain clinical significance whereas NSAIDs have GI and renovascular risks and increase risk for MI. Benzodiazepines, Opiates and Tramadol- all are Grade B (fair level of evidence with moderate net benefit)- Benzos have short-term relief but come with risk for abuse, addiction and tolerance and if used, a time-limited course therapy is recommended. If opioids are administered and failure to respond occurs, reassessment and consideration of alternatives must happen. Evidence is insufficient to recommend one opioid over another. Also recommended for Acute Pain: Skeletal Muscle Relaxants- Grade B (good level of evidence and moderate level of benefit). No compelling evidence they differ in efficacy or safety however risk-benefit profiles can substantially vary. Also recommended for Chronic Pain: TCAs- Grade B/C (good level of evidence and small to moderate net benefit) for providing pain relief. Antiepileptics- Grade C for gabapentin (fair level of evidence and small net benefit for patient with radiculopathy for the short term) 2) Back Care Information and Self-Care: Grade B (fair level of evidence and small net benefit)

Strategies

RR5. Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable. Setting: hospital Audience: nurses, medical residents, physician assistants, physicians & pharmacists How: A charting requirement will be utilized as part of pain protocol for each particular patient. The RN documents medication assessment & treatment plan (education, pharmacological & non-pharmacological). The MD documents medication assessment, reconciliation & treatment plan (pharmacological). Pharmacy review of treatment plan (pharmacological & non-pharmacological) & medication reconciliation. Outcome: Interprofessional review of treatment plan and equal collaboration among health professionals to provide the safest and most effective treatment. With every patient file, a prompt signals the health care provider once the patient is admitted to the system, prior to transfer, prior to the OR and before discharge. This makes sure that pain is addressed and a regimen is created and tailored to the patient. Nurses typically assess the patient first and create a plan of care. Then the physicians create their plan of care using their own assessment and provide orders. The prompt would require each provider to compare their plan of care to each other. Once medication orders are placed, the pharmacy are then required to review the orders along with other treatment modalities provided by the nurses and physicians. The pharmacists will now have a bigger picture to consider because they are being notified of the actual clinical care along with the pharmacological interventions. Everyone is in equal involvement.

RR3. Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. Setting: hospital Audience: nurses, medical residents, physician assistants physicians & pharmacists How: Seminar led by medication experts such as pharmacists evaluating medical literature and research in order teach the most appropriate medication therapies Outcome: Healthcare professionals who are well-informed about appropriate medication selection based on evidence and patient presentation

RR8. Engage in continuous professional and interprofessional development to enhance team performance Setting: hospital Audience: nurses, medical residents, physician assistants, physicians & pharmacists How: Simulation exercises for healthcare professionals to teach appropriate methods of assessing severity of lower back pain & selecting non-pharmacological / pharmacological interventions while at the same time dispelling inappropriate methods currently in practice. Simulation scenarios are to be created by an interprofessional team with several years of clinical experience and current evidence-based knowledge. Outcome: Promote teamwork to implement current evidence-based pain assessment and management strategies for better patient outcomes