Tania is a 52-year-old project manager with a 30-year history of chronic lower back and buttock pain. She recently changed primary care doctors and her new primary care doctor suggested that she come to this office. Tania reports that her pain began shortly after she had her first child at the age of 22. Since then, Tania has had another child and slowly over the last 30 years the pain in her lower back and buttock has gotten worse.

In the last 10 years, Tania’s pain has been relatively constant. The pain is sharp and burning and drives Tania “crazy all the time.” The pain is worse with any static position but is particularly worse with sitting and with transitioning from sit to stand after she has been sitting for more than a few minutes. Tania’s pain does not radiate into the legs. She denies any numbness, tingling, or burning in the lower extremities and she does not believe that she has any weakness in the lower extremities.

Over the years, Tania has seen many doctors about her lower back pain. She has been to physical therapy for several months in the past but did not feel that was helpful except she liked the massages and the electrical stimulation “but the relief never lasted.” She has been to chiropractors through the years and has found that manipulations sometimes help “for a couple of days” but the pain always returns.

Tania has had three epidural steroid injections that did not help at all. She is not sure what type of epidural steroid injections they were (interlaminar versus caudal versus transforaminal) and she is not sure at what level they were performed. Her last epidural steroid injection was 4 years ago. She has had “lots of trigger point injections” over the years and she usually finds that they help “for about a week” but the pain has always recurred.

Tania has had facet joint injections that did not help and she has had non-image-guided sacroiliac joint injections that did not help. Her last injection of any sort was 4 years ago. She does not remember ever being given a pain diary after any injection and is not sure what a pain diary means as no one has ever discussed it with her.

Over the last 4 years, Tania has been taking oxycodone 10 mg PO QID. She says that she hates needing pain medication and would love to get off of it but the oxycodone is the only thing that helps her get through the day. At night, she often takes cyclobenzaprine 10 mg in addition to the oxycodone to help her sleep. Without the medications, she says that she could not function. Tania has tried various nonsteroidal anti-inflammatory medications, both over the counter and by prescription, but she says that the only one that ever helped was Vioxx and that is unfortunately no longer available.

Tania’s last imaging study was 5 years ago. She had an MRI at that time that revealed diffuse disc bulges and multilevel facet joint arthropathy. She has been to three different spine surgeons 4 years ago when she thought she could not take the pain anymore and just wanted “to fix the problem.” Each surgeon that she saw recommended against any surgical intervention. After talking to the last spine surgeon, and after all of the failed previous treatments, she says that she basically accepted the status quo of pain and takes the pain medications to help get through her days and nights. She is very unhappy with the way her pain affects her and the way it limits her life and diminishes her quality of life, but from the conversations she has had with her doctors, she believes that there is nothing else that can help her. As she discusses it, Tania begins to cry. She says that her previous primary care doctor told her that she needs to accept the pain and take the pain medication as little as possible to get through the day.

Tania used to see a pain management specialist but she has been stable on her medications for 3 years and so for the last 2 years it is her primary care doctor who has written her pain medication prescriptions. Her new primary care doctor said that he was okay with writing the pain prescriptions if necessary but that hopefully something better could be found to treat her pain.