Chronic non-cancer pain and opioid stewardship — KFP-style written assessment

KFP 1 (10 marks)

A 52-year-old labourer has six months of low back pain despite eight weeks of graded physiotherapy. Sleep is broken; he has missed work twice this month. He requests 'strong painkillers'. Pain score 7/10. ^[1]

1. Set a functional goal for him — give two examples of what you would write down. (2)
2. Which non-opioid medication steps would you try first, with honest effect sizes? (4) ^[1]
3. He asks to start morphine now. What does SPACE show about that plan? (4) ^[1]

Model answers

1. Examples: walk 30 minutes without stopping; sleep at least six hours; return to full work duties within eight weeks. Function is the goal, not a number out of ten.
2. NSAIDs first-line for nociceptive back pain (modest benefit, watch renal/GI); then consider duloxetine (proven in chronic low back pain). Paracetamol adds little in spinal pain - say so honestly. ^[1]
3. SPACE randomised 240 veterans with chronic back or hip/knee OA pain: pain-related function did not differ between opioid and non-opioid strategies at twelve months (BPI interference 3.4 vs 3.3), and pain intensity was actually better on non-opioids (3.5 vs 4.0). Opioid starts are not supported by this evidence. ^[1]