Study: Don't Avoid Opioids to Treat Back Pain

WMUR-TV ^ | March 14, 2003 | By Holly VanScoy

[AlwaysLurking]

Study: Don't Avoid Opioids to Treat Back Pain

By Holly VanScoy HealthScoutNews Reporter

(HealthScoutNews) -- Doctors and pharmacists tend to avoid prescribing them, patients are afraid of becoming addicted to them, and government officials are concerned about their abuse. It's little wonder that opioids have acquired something of an unsavory reputation in medicine. But is it all deserved?

A new study suggests it's a mistake to ignore the potential value of these powerful pain relievers for chronic conditions, including musculoskeletal pain and lower back pain.

There's evidence that opioids such as morphine, oxycodone, and fentanyl can help and should be the treatment of choice for some patients, says Dr. J.D. Bartleson, a Mayo Clinic neurologist and lead author of the study. It appears in the latest issue of the journal Pain Medicine.

"The prejudice against the use of analgesic opioids is unfortunate," Bartleson explains. "Especially since it results in their being underutilized in situations where they can contribute to improving patient outcomes. Opioids can provide significant relief for patients experiencing severe pain. I believe physicians and patients should be considering them more often than they presently do, including use in the management of chronic, nonmalignant pain."

Bartleson bases his conclusion on extensive analysis of all studies of opioid use in the treatment of chronic lower back pain. Despite longstanding controversies over opioid misuse and potential dependence, Bartleson found there is a place for their carefully considered and closely monitored use in treating this persistent, debilitating condition. In particular, he says, opioid use may provide a better alternative than back surgery and other pain medications for many patients whose lower back pain is persistent.

"Fewer than half of all back surgeries are successful in relieving chronic back pain," Bartleson says. "Other medicines for pain -- including aspirin and acetaminophen -- can cause permanent adverse effects. Opioids have been demonstrated to provide pain relief, without long-term side effects."

John Giglio, executive director of the American Pain Foundation, concurs. He adds the recent controversy over the opioid OxyContin has further muddied the waters over the benefits of this entire class of prescription medications.

"There is mounting evidence that physicians are being deterred from using opioid drugs for patients in pain, not only because of the bad publicity about certain ones of these medications, but also because they are concerned they will be investigated by the U.S. Drug Enforcement Agency if they prescribe them," Giglio says. "Even where there is no arrest, no indictment, no evidence of physician or pharmacist wrongdoing, an investigation sends a strong negative ripple through the medical community."

Giglio says chronic back pain is only one of the conditions for which negative publicity has overshadowed opioids' legitimate and proven medical benefit. Even in the treatment of serious malignant conditions, doctors and patients tend to shy away from the powerful drugs.

"In a recent survey of cancer specialists in California, for example, only about 60 percent of the oncologists reported being certified to prescribe opioids," Giglio says. "Of these, only 40 percent had ever done so -- which means that only one in four physicians specializing in cancer treatment in California are presently using the most powerful painkillers available in their practice."

Giglio and Bartleson agree that additional, longer-term and better-designed studies are needed to study how opioids can be best used in medical care.

Although Bartleson now counts himself among believers in opioids' benefits in the treatment of chronic back pain, he doesn't advocate their use for every back pain patient. "Opioids definitely have a role to play," Bartleson says. "But a physician has to make sure that whatever treatment is pursued is the best for the individual patient. Opioids aren't for everyone."

Bartleson adds that, more than anything else, his study points out the need for additional well-designed studies on treating back pain, including the role opioids can legitimately play in such treatment.

Copyright © 2002 ScoutNews, LLC. All rights reserved.

[not_apathetic_anymore]

only about 60 percent of the oncologists reported being certified to prescribe opioids,"

I don't understand that statement. When applying for a DEA certificate don't all MD's check all the boxes. If one checks all the boxes you can prescribe all the opioids. (There are some opioids that can't be applied for - like heroin. Though some argue that it's a far more effective pain killer than other available opioids - maybe the euphoric side effect, and should be available to those who are terminal and don't have pain control with other drugs.)

So who are these 40 percent who aren't certified?

Other thoughts from someone who has spent some time awhile back learning about pain medicine from a pain clinic. Pain Medicine is a relatively new field where docs can become board certified, and it's a booming field. They can essentially write their own ticket. But it's also a field with relatively high liability. Patients by the time they get to a pain doc are hurting, frustrated and angry at having to endure pain. They see the pain doc as a last resort and often sue when they aren't cured.

• pain is what the patient says it is and it has the intensity they report. It's very subjective and everyone experiences pain differently. There are physical components with emotional/psychological overlay. Some people report a hangnail as 10/10 intensity. Others give post op abdominal surgery 5/10.
• JACHO - the hospital accreditation group is pushing pain as a 5th vital sign. There will be more effort(certainly more documentation) within the hospital to try and evaluate and treat pain
• people with chronic pain do develop a tolerance and can take and function while taking incredible numbers of meds. When this starts to happen most docs do get uncomfortable. Unless they can find a pain doc/pain clinic to take the patient and manage the meds everyone starts to get unhappy. The patient becasue they hurt and are frustrated, and the doc because of concerns about prescribing and addiction.
• Things may have changed, but years back when the pain docs were teaching me they tried VERY hard to avoid opioids. They'd use other drugs and coping mechanisms, and treatment modalities (TENS units etc) and use narcs only as a last resort and under 'blinded' conditions like using a 'pain cocktail' for the patient, with agreements from all docs involved in caring for the patient that only ONE of them would prescribe sedative/opioid/hypnotics.
• medical care in the US is very fragmented. The exception is if a patient gets all care from a multi-specialty clinic type set up. If a patient doesn't disclose that they go to another doc and get prescriptions - pain meds or other - the 'current' doc likely won't have any idea what the patient is taking. Occasionally with really blatant cases a phamacist will raise red flags. But saavy patients doctor shop and use multiple pharmacies.

enough flight of ideas for now!

[Grenada]

I am glad you were finally able to find someone who would treat you. Sometimes people never do and it is devastating. The medical community needs to move into 2003.

[Grenada]

Things may have changed, but years back when the pain docs were teaching me they tried VERY hard to avoid opioids. They'd use other drugs and coping mechanisms, and treatment modalities (TENS units etc) and use narcs only as a last resort and under 'blinded' conditions like using a 'pain cocktail' for the patient, with agreements from all docs involved in caring for the patient that only ONE of them would prescribe sedative/opioid/hypnotics.

The pain clinics I have been to(moved once) all REQUIRE that you sign a contract stipulating that you only get meds from that clinic. If you break the contract, you are out.

[kenth]

Last summer I had some dental work done, which included having to have a molar cut out. In addition to it feeling like the dentist had busted my jaw getting the tooth out, I ended up with a dry socket.

I was originally prescribed large dose ibuprofen that didn't even begin to touch the pain. When I asked the dentist for something stronger, he looked at me like I was a junkie and told me he didn't like to prescribe narcotics. I spent a few sleepless nights trying to ignore the vice-grips attached to my jaw (what it felt like).

[Sally'sConcerns]

I had to sign a contract with the current pain clinic and also agree to random blood testing. I had no problem with that since the main reason I had my original PCP was because I wanted one physician who knew everything medically about me.

I don't know what people do who can't find medical treatment for their pain. It boggles my mind!

[hobson]

Have any of your doctors ruled out fibromyalgia? I was diagnosed 7 years ago. I suffered 3 months with excruciating pain in my arm and shoulder. That kind of pain makes you want to crawl out of your body for just a few minutes of relief. Once my doctor diagnosed fibromyalsia and prescribed the right medication I began to improve. Now, I only experience the pain when I've been under alot of stress.

[Sally'sConcerns]

I have fibromyalgia as a result of the surgery they performed on my neck in 94. Normally it doesn't bother me unless I get extrememly stressed.

No, my pain is from a botched 3 level cervical fusion. Thankfully it wasn't botched to the extent I'm paralyzed but that's about the only way it wasn't 'botched'.

BTW, what type of medication do they prescribe for your fibro? Since it rarely bothers me, I haven't kept up with new treatments and last I had heard, pain meds don't help.

[hobson]

I'm taking Amitriptyline 25mg, sometimes 35. The medication helps me get the much needed sleep that staves off symptoms. Getting quality sleep is the key for me.

[WoofDog123]

Using the colored scale in the middle of this page

http://pudendal.info/info/documents/ComparativePainScale.htm

I have never been above a 6, and then only for brief spaces of time (30 minutes). If I were at 8 or 9, from what I was reading, I cannot imagine what reason I would see NOT to take just about anything, if it would help reduce it and not kill me too quickly.

[texasbluebell]

It is not acceptable to tell people "you should be in pain, because drugs are bad", this is puritanism at its worst.

I remember when my dad was dying of cancer back in the 70s, he was at the Mayo Clinic. He had at that point about one month to live. He was in desperate pain, but the nurses wouldn't give him his meds just yet, not till it was the right time to do so, because of course the thinking was that he would become addicted to the drugs even though everyone knew he had very little time left.

I spent some time chewing them out, not that it did much good. Simply ridiculous to worry about people becoming addicted when they're so close to death as he was.

Pain management has got to change.

[jocon307]

"Simply ridiculous to worry about people becoming addicted when they're so close to death as he was."

Yes, it is ridiculous. I'm sorry about your dad.

[texasbluebell]

Thanks, it was over very quickly for him.

I hate reading how people still suffer so much. What's wrong with our medical community that this can be allowed?

I'll pass along something that helped me when I was in severe pain due to a neck injury, for over a year. I don't know if it will help some people's suffering, but if anyone wants to try this, it helped me very quickly.

There's something called Arniflora (Arnica gel) which is a homeopathic remedy, and even though I couldn't turn my neck, even while driving sometimes, and would wake up during the night unable to sleep because of this, after starting to use this gel, the pain was relieved after only a few days, and then after 3 weeks, there was almost no pain remaining.

The gel seems to help with any muscular problems, which prevent the limbs from moving in their regular patterns, so it may not help many problems, but it may be worth trying for those who want to try something that's pretty mild on the system.

It's been used for centuries, comes from a mountain flower, and is even used by coaches for various injuries to athletes.

As I said, it won't help everyone, but I was one of the lucky ones that time.

[wardaddy]

His mistake was to self medicate to such a degree.

Agreed but why did he not simply use a doc like you and many do...including myself at times. He could be on a fentanyl patch or morphine etc if it's that bad. Why buy this ALLEGED huge doses of hydrocodone and oxycodone which from my experience are not quite up to the Class A narcotics level for severe pain....maybe Oxycotin is due to the large time release. I assume he was afraid a doc would not keep him on the level he needed or enjoyed (I know you don't like that but a lot of folks DO use these drugs to get high ...yes...even some folks with pain)

I would like to know more about how much he took and bought and what his medical condition is. Herniated disc is likely to merit a schedule II narcotic either of opiate nature or synthizised like Talwin, a muscle relaxer like Soma or Flexaril or Parafon-Forte and a kicker-anti-emitic like Promethiazine. Myself, I have found that any strong narcotic somewhat under the dialaudid or morphine sulfate level with the Promethiazine kicker works for me. However, folks with certain malignancies such as stomach or bone, need much much more.

If Rush's pain was so bad, most docs would have insisted on more surgery. Mine would. Therefore, I would not discount that his medication initially for pain grew into something beyond that and that is where he is in trouble. If it is simply about pain, then why is he detoxing? He needs to continue and just reduce his dosage or change it to less of something stronger. You know some addicts...particularly heroin...will purposely withdraw a bit so they can get back to getting high again. Once one is super addicted, it's not about getting high, it's about not being sick. Sad...he's not the first but he sure shocked me.

[wardaddy]

You and my mom would get on well....she swears by alternative meds.

[wardaddy]

BTW...folks should realize that buying the amounts Rush is alleged to have bought ..if documented by the DEA could mandate criminal prosecutions and minimum mandatories.

It doesn't matter if it's prescription or heroin. The dosage weight is the same when accounted for the charge. 1000 milligrams of oxycodone is treated the same as 1000 milligrams (one gram) of heroin.

If I bought 50-100,000 dollars of these narcotics from a snitch in an ongoing investigation and even if I claimed I was self medicating...I can bet you I would still be looking at charges and for sure jail time by the Feds or maybe if I got lucky, the judge might find mitigating circumstances and get the prosecutor to file for a rule 5k1 or rule 35(both of these departures are usually due to cooperation) and reduce my sentence to mandated in-house drug treatment of at least a year or so followed by probation. Likely, I would get the min-man sentence.

[expatguy]

On occasion I take codiene for a bad cough I have.

I normally take around 100mg and I dont have a cough at all.

I have met doctors who would not prescribe it at all, I simply find another doctor.

[Aracelis]

About the third day I was talking to the cat -- and he was talking back.

I was given Demerol post-op, and had the same reaction. Hate the danged stuff. Just give me aspirin and a heating pad for my back. I'll deal with the pain.

[capocchio]

a better alternative than back surgery and other pain medications

good and honest discussion in this country on how to help people in pain

"Fewer than half of all back surgeries are successful in relieving chronic back pain"

Chiropractors are a solution rarely suggested by doctors. That's too bad, because often they are completely effective in relieving back pain without surgery or medication. Let me illustrate.

My wife first had lower back pain from two herniated discs over 25 years ago. Like many, she first went to see her doctor. He checked her into a hospital and prescribed an endless stream of painkillers (valium back then). The only other treatment he tried was physical therapy, which was not effective at all.

After putting up with his mindless efforts for a week yet still hurting as badly as when she came in, she finally tired of being doped up. She screwed up her courage, convinced him she was cured and got herself checked out of the hospital.

Then we directly to a chiropractor. Thirty minutes later she walked out of his office completely free of pain. Got that? 30 minutes and no pain She's never looked back. Sure, she returned for a gradually diminishing program of treatments over several weeks to get her spine back into alignment. He then prescribed a simple regime of walking and stretching exercises which kept her out of pain and not needing to come back to his office.

Over the years, she's occasionally had new episodes which required another visit to the chiropractor, but nothing as extensive as originally. Nearly every one she talks to about their similar problems express an unwillingness to go to see a chiropractor. Often it is for as idiotic a reason as that their insurance doesn't cover the visit! Others claim horror stories of permanent damage or being milked for all of what their insurance will pay.

Whatever, she has never had such things happen to her or to anyone whom she knows who has actually gone in. All report relief. Not just relief, but RELIEF. Immediate, complete, walk out of the office free of pain relief. No doctor has ever, ever, EVER been able to provide the same.

Chiropractors may not be the solution that works in every instance, but aren't they worth the try before going under the knife or becoming addicted to drugs? They are usually absolutely, positively effective. My dad was a doctor and he always said that for what they do, chiropractors should be consulted, that medicines don't address the problem, just the symptoms. Maybe if ER included an example people would be less blind.

We don't argue much any more with those who complain of back pain but won't go see a chiropractor. We have no patience with them if they refuse to try that option and they know it, so they just don't mention their back pain around us.

[jazzlite]

Oh, so do I. Pain is just as disabling to people as paralysis. Overwhelming pain stops living and life as people know it and our doctors have been hogtied by insane laws surrounding the prescribing of the opiate drugs to relieve much of this pain. Therefore, sometimes people will get the drugs illegally because it is the only way to get rid of the pain. Some of this pain is almost as severe as having a surgical or dental procedure without anesthesia. How would any of us like to experience that? When I think of how much power has been taken from physicians to make decisions about the well-being of their patients on an individual basis, I cringe. It has been brought about through illogical laws and lawsuits against doctors. Threatening Drs. with criminal consequences for taking care of their patients has it's effect on society. If discussion about this will awakening some of the thoughtful legislators in the area of healthcare, perhaps great benefit will come to our people through Rush's suffering..If I know Rush, he would willingly choose his current suffering if it could result in a positive outcome for his people. God bless you, Rush..We are praying..

[jazzlite]

Oh, so do I. Pain is just as disabling to people as paralysis. Overwhelming pain stops living and life as people know it and our doctors have been hogtied by insane laws surrounding the prescribing of the opiate drugs to relieve much of this pain. Therefore, sometimes people will get the drugs illegally because it is the only way to get rid of the pain. Some of this pain is almost as severe as having a surgical or dental procedure without anesthesia. How would any of us like to experience that? When I think of how much power has been taken from physicians to make decisions about the well-being of their patients on an individual basis, I cringe. It has been brought about through illogical laws and lawsuits against doctors. Threatening Drs. with criminal consequences for taking care of their patients has it's effect on society. If discussion about this will awakening some of the thoughtful legislators in the area of healthcare, perhaps great benefit will come to our people through Rush's suffering..If I know Rush, he would willingly choose his current suffering if it could result in a positive outcome for his people. God bless you, Rush..We are praying..