Event 1: Meet Catherine

Catherine is a 46-year-old woman with Chronic Low Back Pain (CLBP), obesity, poorly controlled diabetes with peripheral neuropathy, and ankle pain on high dose opioids for past 4 yrs.

Catherine, a 46-year-old woman
  • Pain present for 12 yrs
  • Midline and paraveterbral without sciatica.  
  • Bilateral neuropathic pain in both feet for 3 years
  • Persistent right ankle pain despite a fusion after she fell and fractured her ankle 9 months ago. 

Psychiatric History

History of anxiety and depression, had seen a counselor ten years ago after last divorce.

Substance Abuse History

She smokes 1 pack of cigarettes per day, since age 13. She used to drink “a lot” as a “teenager”, but has not used any alcohol for the past “few years”. She attended Alcoholics Anonymous (AA) “a few times” many years ago.

Review of Systems

Weight “always too much, hard to lose.” Always fatigued.  Snores.  Coughs every day and dyspnea with walking short distances. Can’t walk much because it hurts “too much.” “Everything hurts”: neck, upper and lower back. Pelvic pain and urinary frequency/urgency “but they can’t find any infections.”  Feet numb and painful.

Physical Exam

Obese, with moaning and grimacing pain behavior. Pain intensity 9/10. Anxious and tearful.

Back was tender in the midline. Straight leg raising causes only back pain, no referral into her legs. Hip range of motion normal. Ankle tender to palpation and movement, but not red and no effusion.  Normal lower extremity pulses.

Reduced resistance to strength testing due to pain. Numbness to touch and pin prick, most dense distally, up to midshins, with tactile and mechanical allodynia of both feet.  Vibration and proprioception were normal.  Romberg was positive. She could barely walk. 


Recent Spine MRI

Recent spine MRI reveals no structural lesions.  Expected age-related “degenerative” changes of discs and facets are noted.

MRI image of a spine
Spine MRI

Ankle Plain Film

Ankle plain film, with solid talocalcaneal fusion.

Ankle plain film
Ankle plain film

Current Medications

  • Methadone 10 mg - four time a day
  • Oxycodone 5 mg  - eight times a day
  • Carisoprodol 350 mg - four times a day
  • Lorazepam 2 mg every 4 hr PRN 
  • Metformin 1000 mg  - twice daily
  • Simvastatin 20 mg  - daily
  • ASA 81 mg - daily

Lab Results

Urine Drug Toxicology (Qualitative)

Positive for methadone, oxycodone, and benzodiazepines


Compliant with prescribed drugs.

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University of Washington