Low Back Pain Diagnosis Problems – Acute And Chronic Pain
Low Back Pain Diagnosis Problems
The opioids are the most common class of drugs that are currently prescribed for back pain, neck pain and low back pain, As a matter of fact, we know that probably about 50% of the people who regularly use opioids are doing it because they have back pain. In spite of the fact there is little evidence that the medicines work and that they get you back to work and that they helped you.
Are the medicines appropriate? Well, it's tough to say. But the answer appears to be NO! The drugs are used in the United States right now are used inappropriately.
How common is a back pain? If we look at the back pain we, find that about one in four people on surveys, all are adults. Over the period of the past three months, they are going to complain that they had at least one day of a back pain. And if we survey them for a year, we find that about 50% of the people are going to complain that they have some sort of back pain. And 20% people going to report that the back pain is chronic, it frequently reappears and they don't seem to be able to shake it for long period of time.
Within a month 60% of people going to get better almost irrespective of what was done. We could do nothing and 60% of the people are going to get better. We can use back manipulation, chiropractic manipulation – 60% of people are going to get better. Almost anything - 60% of people are going to get better.
10% of the people going to go on to develop chronic pain. Chronic pain is going to be defined as pain for more than about three months. A small percentage of the people are going to have some issues that are intermittent.
The diagnosis of back pain is a real problem. In order to treat something we have to know what we're treating. And the question is with back pain - what is it?
A lot of people say it's my degenerative disease. For the overwhelming majority of people if we were lucky enough to do an MRI before they suffered from pain and then one after they suffered from pain, we find that there isn't any difference between the two.
Yet, if we only do the MRI after a person complains of pain we say that it looks abnormal, this must be the problem. On the other hand, we know that the problems often time and to date they come before the pain. So, if the only test we have is afterward the test it is abnormal then we think it is the cause of the pain.
However, the older you get, the worse your spine is going to look on an MRI or any other kind of imaging test. The studies are often unnecessary and provide not just false information, they provide misleading information. Because we simply assume that the abnormality we see on the MRI or on the x-ray is the cause of the problem, When indeed, it existed long before.
Is it the disc? Is it the vertebrae? Is it some problem with musculoskeletal system? We just really don't know. And since the cause of the pain is unknown, it is difficult to go and use a medicine that is just a painkiller to treat a disease.
We don't really know why the person has the condition and, as a matter of fact, there's considerable evidence that maybe it doesn't have anything to do in many cases, with some structural abnormality.
It is a well known fact that mood disorders people who have depression, people have anxiety are much more prone to develop back pain. And then the question is - is it really back pain or is it a manifestation of the mood disorders?
We also have some workplace issues. A happy workplace seems to have less back pain then an unhappy workplace. More stress, more strife in the workplace, more uncertainty in the workplace, less ability to control what's happening in the workplace are greater incidence of pain.
It seems that the concept of low back pain has to be taken with the grain of salt. Now we really view the whole problem as a biopsychosocial problem. A problem well beyond simply some sort of an abnormality in the bone or in the joint.
A lot of people worry maybe the back pain is something serious, it's got some sort of major medical issue. Maybe the back pain is caused by metastatic cancer, maybe it's caused by an infection in your spine. It also maybe caused by something like that.
The Increase In The Prescriptions Of Opioid Medications
If we look at sales of narcotics in the United States, the medicines that the doctors prescribed for people who have pain in the past period of about 10 years has increased by about four fold.
Interestingly, the reason that prescription started to increase was that they weren't used enough. Back in the 1960s, 1970s early 1980s there was a problem. People who had legitimate reasons to take these medicines were dying, had cancer, were in the final stages of cancer, had acute pain. There was the fear that they would become addicted and a lot of people did not prescribe the medicines appropriately. They were used too sparingly.
As a result, because of the lack of medicine, a lot of societies came and said: "that's inappropriate, you have to go and treat pain more humanely". And then all of a sudden there was a massive upsurge in the number of prescriptions being written.
Now, in the period of the past 10 or 15 years the expenditure on these drugs has increased by more than six hundred fold. Increase because of the price of the medicines. Everything seems to have gone up, they've gone up a whole heck of a lot.
The use has also gone up. The percentage of people who have either neck pain or lower back pain who got prescriptions for narcotics back in the 70s, 80s and even 90s was 20%. Now it is 30% or 40%.
There's a matter of fact, if you have back pain chances are probably about forty percent that you're going to get a prescription for a narcotic if the pain goes on for a period of six months to a year.
Probably, close to 90% of all of the narcotic medicines that are prescribed to people who have long-term back pain. Not only are they prescribed for these patients, the dose that the patient is taking gets higher.
You have a certain amount of pain. It is controlled initially with a certain dose, but later on, you have that does that might be doubled, tripled or quadrupled. There's a problem - the pain isn't getting worse, but you're taking more medicine.
If we look at the likelihood of prescriptions here in the United States versus prescriptions in Europe, we can see the different approach. Fox instance, English doctors issue 2 times less opioid prescriptions than their collegues in the United States. It is even 3 times less in Holland.
If we look at the comparison of the United States to Japan we can see that it is 26 times more narcotics that are prescribed in the US on a per capita basis then in Japan.
If we look at some of the insurance plans for low-income individual in the US. there's about a 23 fold variability throughout the country on the likelihood of receiving the medications.
In the 90s of the sudden pain experts told us that, well, we should really prescribe the medicines more frequently. And not only should we prescribe them more frequently but more freely! They said that there wasn't really a problem. If you didn't have any kind of pain or you didn't have any kind of problem, you wouldn't take the medicines. That proved to be false, unfortunately.
In the 1990s there was a massive increase in advertising from the pain medicine manufacturers. They would sponsor different events, CME credits, would help institutions write guidelines that would tell other doctors how to prescribe the medicine. Unfortunately, that wasn't at arm's length.
It sort of culminated when the makers of Oxycontin were charged with criminal conspiracy and criminal events. They were claiming that the drugs really had a lower abuse than their competitors, when indeed they didn't. They were misbranding the drug.
When it gets right down to the issue, there's a lack of evidence of safety and efficacy of these drugs. And we also don't know how much to prescribe, we don't know what the appropriate dose is for any given individual.
An Approach To Prescribing Opioids In Case Of Acute And Chronic Back Pain
Let's divide back pain into two groups: acute low back pain and chronic low back pain.
Acute low back pain - you would say that would be relatively easy, when all of a sudden you have pain.
Actually, we don't have any great long-term studies or even short-term studies that show that these medicines that are so widely prescribed are really any better than Tylenol or non-steroidal anti-inflammatory drugs like Aspirin, Ibuprofen or Naprosyn or one of the similar prescription medicines.
Is there any evidence that the narcotics are really better? Are they better than muscle relaxants or antidepressants? We don't know that.
It isn't just how we treat the pain, it's how we treat the person. So, the person is not able to work. Are we able to get the person back to work better if we use a narcotic drug than with we use a non-steroidal anti-inflammatory drug? The answer is - it doesn't seem so.
Actually, the narcotics like Oxycodone or Hydrocodone and drugs like that might actually inhibit some of the ability of the person to go back and function normally.
If a person receives opioids for more than seven days, he or she has relatively good chance of being disabled after a year and still being on the drugs. And if we see people who have been taking the drugs for more than a couple weeks, those people have a longer likelihood of being disabled from work.
The bottom line is - are these drugs really providing an appropriate function? Are they benefiting or are they causing problems?
People were going to have a longer disability with the higher dose that they take. The opioids can worsen the outcome. We know that people who are taking the opioids seem to suffer from inactivity. When they become inactive or relatively inactive, then their muscles can become weak, they're going to become relatively deactivated, the mood is going to be somewhat more apathetic.
And as that happens then the people are going to be negatively impacted, not positively impacted,
Chronic Low Back Pain
Now, let's talk about the chronic low back pain. Again, the evidence that the opioids are going to be helpful is very meager. We have no trials that have lasted a long period of time and the trials that have been ongoing.
They suffered from high dropout rates and the high dropout rates were because people didn't see any benefits and they had some side effects of the medicines.
The kind of people who were taking the medicines aren't the kind of people who were in the studies. The kind of people who are given the medicines in our society are completely different.
They are psychologically different. These are people who have a higher incidence of other symptoms, mental symptoms like depression. They have a higher incidence of using hypnotics, the anti-anxiety medicine, sleeping pills.
We know that there's an adverse selection of the people. These people are not those pure people who are otherwise unencumbered by medical problems. People who are taking these pain medicines are taking an awful lot of other medicines as well oftentimes.
The question is, how do they react with one another? Well, that hasn't been studied.
As we have already mentioned, that people, who are taking the pain medicine, are going to have some reduction in the pain, but they're not going to have a complete elimination of the pain.
If we look at what happens overall in observational studies, we find that a significant number of the people who are taking the drugs are going to have a little bit of improvement as far as the pain and function are concerned. The longer time goes on. the higher the dose of the medicine that they're taking.
In a Danish study concerning opioids like Oxycodone and Hydrocodone, scientists looked at the people who were taking non-narcotic medicines. The people who were taking the narcotic medicines seem to have a higher incidence of pain, increasing pain and decrease in quality of life in spite of the fact that the people, at least when they started, had about the same amount of pain.