Are Opioids Beneficial for Chronic Back and Osteoarthritis Pain?


Although most clinical guidelines recommend against opioids for patients with chronic back and musculoskeletal pain, opioids still are prescribed frequently for these conditions. In this randomized trial, conducted in the Minneapolis Veterans Affairs system, researchers randomized 240 patients (mean age, 58; mostly men) with moderate-to-severe chronic back pain or hip or knee osteoarthritis pain to flexible opioid or nonopioid regimens. Patients who were receiving long-term opioid therapy were excluded, as were those with substance abuse disorders or poor prognoses.

Opioid regimens started with immediate-release morphine or oxycodone or hydrocodone/acetaminophen and progressed to sustained-action morphine or oxycodone or transdermal fentanyl, all titrated to 100-mg morphine-equivalents, as needed. Nonopioid regimens started with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) and progressed to tricyclic antidepressants, gabapentinoids, topical analgesics, serotonin-norepinephrine reuptake inhibitors, and tramadol as needed. Patients pursued nonpharmacologic treatments as desired. Both groups were monitored in-person monthly until stable; subsequently, patients were monitored every 1 to 3 months (usually by telephone).

At 12 months, improvement in pain-related function was similar between the two groups. Pain intensity was significantly lower in the nonopioid group than in the opioid group, although this improvement was of borderline clinical significance. The opioid group had significantly more medication-related symptoms; adverse events did not differ between groups.

Comment

This nonblinded trial mimics real-life practice with its patient heterogeneity and wide range of medication choices. No benefit, and some potential harm, seems to be associated with use of opioids in patients with chronic back or osteoarthritis pain. Note, however, that several of the medications used by patients in this study’s control group — including acetaminophen, NSAIDs, and gabapentinoids — also are ineffective or minimally effective in patients with chronic low back pain

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Where pain lives


Fixing chronic back pain is possible only when patients understand how much it is produced by the brain, not the spine,

For patient after patient seeking to cure chronic back pain, the experience is years of frustration. Whether they strive to treat their aching muscles, bones and ligaments through physical therapy, massage or rounds of surgery, relief is often elusive – if the pain has not been made even worse. Now a new working hypothesis explains why: persistent back pain with no obvious mechanical source does not always result from tissue damage. Instead, that pain is generated by the central nervous system (CNS) and lives within the brain itself.

I caught my first whiff of this news about eight years ago, when I was starting the research for a book about the back-pain industry. My interest was both personal and professional: I’d been dealing with a cranky lower back and hip for a couple of decades, and things were only getting worse. Over the years, I had tried most of what is called ‘conservative treatment’ such as physical therapy and injections. To date, it had been a deeply unsatisfying journey.

Like most people, I was convinced that the problem was structural: something had gone wrong with my skeleton, and a surgeon could make it right. When a neuroscientist I was interviewing riffed on the classic lyric from My Fair Lady, intoning: ‘The reign of pain is mostly in the brain,’ I was not amused. I assumed that he meant that my pain was, somehow, not real. It was real, I assured him, pointing to the precise location, which was a full yard south of my cranium.

Like practically everyone I knew with back pain, I wanted to have a spinal MRI, the imaging test that employs a 10-ft-wide donut-shaped magnet and radio waves to look at bones and soft tissues inside the body. When the radiologist’s note identified ‘degenerative disc disease’, a couple of herniated discs, and several bone spurs, I got the idea that my spine was on the verge of disintegrating, and needed the immediate attention of a spine surgeon, whom I hoped could shore up what was left of it.

Months would pass before I understood that multiple studies, dating back to the early 1990s, evaluating the usefulness of spinal imaging, had shown that people who did not have even a hint of lower-back pain exhibited the same nasty artefacts as those who were incapacitated. Imaging could help rule outcertain conditions, including spinal tumours, infection, fractures and a condition called cauda equina syndrome, in which case the patient loses control of the bowel or bladder, but those diagnoses were very rare. In general, the correlation between symptoms and imaging was poor, and yet tens of thousands of spinal MRIs were ordered every year in the United States, the United Kingdom and Australia.

Very often, the next stop was surgery.  For certain conditions, such as a recently herniated disc that is pressing on a spinal nerve root, resulting in leg pain or numbness coupled with progressive weakness, or foot drop, a nerve decompression can relieve the pain. The problem is that all surgeries carry risks, and substantial time and effort is required for rehabilitation. After a year, studies show, the outcomes of patients who opt for surgery and those who don’t are approximately the same.

More invasive surgeries carry greater risks. Lumbar spinal fusion – surgery meant to permanently anchor two or more vertebrae together, eliminating any movement between them – is recognised as particularly hazardous. Even when the vertebral bones fuse properly, patients often do not get relief from the pain that sent them to the operating room. Beyond that, fusion surgery often results in ‘adjacent segment deterioration’, requiring a revision procedure.

In the US, about 80,000 spine procedures fail each year , and one in five patients returns for another operation. Typically, second, third and fourth attempts have an even lower chance of success, and patients continue to require painkillers over the long term. Even the procedures that surgeons deem successful, because the bones fuse and look perfect on a scan, are often unhelpful to patients. In one study, two years after spinal fusion, patients’ pain had barely been reduced by half, and most patients continued to use painkillers. Given such unimpressive outcomes, the cost of treating back pain is unacceptably high. Spine surgery costs a fortune, but otherapproaches, including epidural steroid injections, physical therapy and chiropractic treatment, are also expensive.

Including direct medical expenses and indirect expenses such as lost earnings, spine care costs the US about $100 billion a year. In the UK, that tab is about £10.6 billion (c$13.6 billion). In Australia, it’s A$1.2 billion (c$950 million). Many of these costs derive from the loss of productivity, as people take time off from work. Others result from the devastation wrought by addiction to prescription opioids. In Australia, between 1992 and 2012, prescription opioid dispensing increased 15-fold, and the cost to the Australian government increased more than 32-fold.

Pain falls into four basic categories. There’s nociceptive pain, the normally short-lived kind you feel when you accidentally slam your finger in the car door. There’s inflammatory pain, a response to damage or infection, resulting in a rush of small proteins called inflammatory cytokines to the site of the casualty. That pain has a habit of spreading, to affect everything in the vicinity. Beyond that, there’s neuropathic pain, known as ‘radiculopathy’. It results, usually, from an insult to a nerve, culminating in burning, tingling or shock-like sensations that travel the length of the affected nerve (sciatic pain is a good example).

‘As pain becomes more centralised, it becomes increasingly more difficult and less relevant to identify the initial source’

When any of those three types of pain sticks around long after the inciting injury has healed – or in the absence of any noxious stimulus – the patient can be said to be suffering from ‘central sensitisation’. Central sensitisation is a condition in which even mild injury can lead to a hyperactive and persistent response from the central nervous system.

The CNS includes the dorsal root ganglia, containing the cell bodies of sensory neurons that allow information to travel from the peripheral sites to the spinal cord and the brain. The peripheral nervous system (PNS) consists of the nerves beyond the brain and the spinal cord, serving all parts of the body that the CNS does not, comprising roughly 40 miles of nerve fibres, if they were laid out, end to end.

‘As pain becomes more centralised,’ wrote Clifford Woolf, a neurologist and neurobiologist at Harvard Medical School, ‘it becomes increasingly more difficult and less relevant to identify the initial source.’

More than three centuries ago, the French philosopher, mathematician and natural scientist René Descartes advanced the heretical idea that pain was not a punishment from God, nor a test or trial to be endured, for which prayer was the only intervention. Instead, he said, pain existed as a mechanical response to physical damage. His work Treatise of Man would not be published until after he died (some say because he feared persecution by Christian authorities, for whom the threat of pain was a useful recruitment tool). But when the volume finally emerged, Descartes posited the existence of ‘hollow tubules’ that allowed messages he described as ‘animal spirits’ to travel on a dedicated somatosensory pathway, from the afflicted site to the brain. The intensity of pain, Descartes believed, rose with the severity of tissue damage. In the absence of such damage – a shattered bone, a wound, a burn – pain ought not to exist.

But of course, it did.

In the mid-1960s, two scientists, the Canadian psychologist Ronald Melzack and the British neurobiologist Patrick Wall, both then working at the Massachusetts Institute of Technology, set out to answer the question of how pain could persist in the absence of an injury. It was mostly guesswork. It would be years before neuroimaging would allow them to view the structure of a living human brain.

In their landmark article ‘Pain Mechanisms: A New Theory’ (1965), published in the journal Science, they considered the pathophysiology of chronic pain, based on post-mortem studies, surgical notes, neurofeedback and patients’ reports of their experiences. Ultimately, the two scientists described the ‘gate control theory of pain’, hypothesising that nerve cells in the spinal cord acted as gates, flipping open to allow pain messages to pass through, or closing to prevent such messages from reaching the brain. At times, the scientists posited, the gates became stuck in the open position, allowing pain messages to flow unabated. It was that last little bit – the notion that messages would travel unceasingly, from the PNS to the CNS – that sparked Clifford Woolf’s interest in how pain was generated, and how it could be silenced.

In 1983, Woolf was a young anaesthesiologist with a PhD in neurobiology. As a post-doc, he had worked in Wall’s laboratory, which by that time had moved to University College London. There he observed post-mortem cellular and molecular changes in brain tissue in subjects who had suffered from chronic pain when they were alive.

Instead of responding to externally generated discomfort, under siege the brain itself begins to generate the pain

Later, he had access to high-powered neuroimaging in the form of functional magnetic resonance imaging, or fMRI. This neuroimaging could measure changes in the brain’s blood flow, volume, oxygen or glucose mechanism, allowing Woolf to see how the brain responded to pain in a living subject. Woolf thus began to explore the many ways in which neurons in different brain regions communicate; how they form a greater number of synapses, linking regions that are not normally hot-wired to work in concert; and how those neural changes lead to the perception of pain. He saw that the regions of the brain that responded to acute, experimental pain were different from the regions that were involved in chronic pain. Over the next three decades, Woolf explored the relationship between specific gene phenotypes and chronic pain, looking for potential targets for drug therapy. It would be slow-going, in part because pharmaceutical companies were profitably selling opioid analgesics. When, in the mid-2000s, the efficacy and safety of opioids began to be questioned, Woolf’s work took on new vigour.

By then, the neuroscientist A Vania Apkarian, a professor of physiology, anaesthesiology and physical medicine at Northwestern University’s Feinberg School of Medicine in Chicago, was well into his own study of what happens to specific regions of the brain under the onslaught of chronic pain. For two decades, in his provocatively named Pain and Passions Lab, where his group works with both rodents and humans, Apkarian’s focus has been on pain’s cognitive consequences.

‘When we started this research in 1999,’ Apkarian said, ‘very few people believed that pain was more than nerves sending a signal into one part of the brain.’ With grants from the National Institutes of Neurological Disorders and Stroke – part of the National Institutes of Health (NIH), Apkarian demonstrated that instead of simply responding to externally generated discomfort, under siege the brain itself would begin to generate the pain. ‘The official definition of chronic pain,’ Apkarian wrote in the journal Pain Management, ‘is that it persists past the completion of injury-related healing processes.’

Brain activity in subjects with chronic pain was different from the nociception (perception of harm) evident in patients with experimentally induced pain, for instance, a hot poker placed on a sensitive part of the arm. While nociceptive-provoked pain activated primarily sensory regions – the ones that would cause you to yank your arm out of harm’s way – Apkarian’s group observed that chronic pain activated the prefrontal cortex and the limbic regions of the brain. The prefrontal cortex dictates higher-level thinking, including goal-setting and decision-making, while the limbic regions, including the hippocampus and the nucleus accumbens, govern memory, motivation and pleasure.

In a revelation that set the international media abuzz, Apkarian’s group found that the anatomy of the human brain in patients who suffered from chronic pain was abnormal. In those who had suffered for five years, both the hippocampus and the prefrontal cortex were structurally transformed, sacrificing 5 to 11 per cent of their grey matter density. That was important because the prefrontal cortex, in concert with the hippocampus, dictates how optimistic or depressed patients feel about their prospects, how well they can cope and make decisions about treatment. There’s still a great deal of work to do in this area but, wrote Apkarian, ‘the concept is that the continued, unrelenting pain impacts limbic structures in the brain that in turn entrain the cortex to reflect both the suffering and coping strategies that develop in chronic-pain patients.’

The brain of a person with lower-back pain looks different from that of a person with a repetitive-stress injury

Subsequently, more than 50 studies, most from other investigators, have documented regional decreases in grey matter density, volume or thickness. Beyond that, the neuronal network of the remaining grey matter is rearranged, in patterns that are specific to chronic-pain conditions. That means, for instance, that the brain of a person with lower-back pain will look different from that of a person with a repetitive-stress injury. It’s still unknown, Apkarian adds, ‘the extent to which the observed brain reorganisation is a causal response to the condition or a predisposing factor’.

At least one other aspect of brain activity is transformed in people with chronic pain. The nucleus accumbens’ role is to monitor the brain’s reward circuit, thus governing feelings of pleasure and motivation. According to the scientists at Stanford University who studied the nucleus accumbens in mice, the brain structure is involved in ‘computing the behavioural strategies that prompt us to seek out or avoid things that can affect our survival ’.

In chronic-pain patients, Apkarian’s researchers observed, the nucleus accumbens and the medial prefrontal cortex (which, once again, mediates decision-making) become unusually chatty.

This much-enhanced level of communication between the two regions represents a profound reorganisation of neuronal connections. It’s possible that this chattiness might correspond with chronic-pain patients’ reluctance to follow self-care protocols such as exercise. The heightened communication might also drive a tendency to select interventions that seem ‘easy’, but often are not, and in hindsight might be damaging. It’s easy to see why that would be. In the absence of any sense that hard work will be rewarded, or that things will get better, it’s difficult to summon the energy to follow through.

There’s much debate about what sparks the complex neurobiological sequence that results in central sensitisation and, puzzlingly, why this occurs in some people but not in others. Both environmental and hereditary factors are likely involved, Woolf has found. His lab at Boston Children’s Hospital is focused on identifying human genes with a link to ‘dramatic familial pain phenotypes’ – extreme pain disorders that run in families – and could offer insight into more typical chronic-pain conditions.

Woolf’s lab has identified a haplotype (an inherited DNA variation) that matches up with high sensitivity to pain from sciatica, osteoarthritis and lumbar disc degeneration. ‘It is becoming clearer,’ observed Woolf and his co-authors in a paper in the Journal of Pain in 2016, ‘that the development of chronic low back pain may occur because of a combination of genetically based susceptibility factors as well as local pathological risk factors.’ In other words, whether your intervertebral disc is going to rupture has much to do with your physiology and physical condition. But how much it’s going to bother you, and for how long, is likely to be a matter of genetic predisposition. Woolf’s group is currently working on a process that allows them to genetically reprogram skin cells to turn into pain-sensing nerve cells, which can be studied in a petri dish. Woolf hopes that once the nerve cells are established, they will be valuable for pre-screening patients to see who has the physical and biochemical traits that make it likely they will develop chronic pain.

Scientists suspect that shared genetic background is the reason that pain hypersensitivity often runs in families

Scientists now recognise that there are gene variations that ‘wire’ certain people for suffering, and variations that leave others unscathed. The enzyme catechol-O-methyltransferase (COMT) is essential to the production of several stress-related neurotransmitters, including dopamine, norepinephrine and epinephrine, each of which is involved in modulating mood and cognition. One variant of COMT produces a slower-acting enzyme that leaves a flood of dopamine intact within the synapse, a condition that is associated with a very high level of stress. People who inherit that slow-acting COMT variant can be especially emotional and pain-sensitive. Intriguingly, unless they choose more even-keeled partners, it’s likely that their progeny will share their tendency towards pain sensitivity.

Research on this topic is still sparse, but scientists suspect that this shared genetic background, rather than any identifiable pathology, is the reason that pain hypersensitivity often runs in families, and it’s common to hear stories of multiple family members who suffer from similar chronic back-pain conditions. Woolf’s lab found that the gene GCH1 controls the production of the chemical BH4, a precursor of serotonin. Those without the protective variety of BH4 feel a great deal of pain, but about 15 per cent of the population carry the ‘bulletproof’ version of the GCH1 gene, which leaves them remarkably impervious to pain. At least one study has shown that patients with this pain-busting biology recover much more successfully from spine surgery than their ultrasensitive brethren.

An excellent article on Mosaic, a digital magazine produced by the Wellcome Trust in the UK, quotes professor Irene Tracey, head of the Nuffield Department of Clinical Neurosciences at the University of Oxford. The most significant change in evaluating chronic pain, observes Tracey, is the understanding that chronic pain is a different animal from nociceptive pain. ‘We always thought of it as acute pain that just goes on and on – and if chronic pain is just a continuation of acute pain, let’s fix the thing that caused the acute, and the chronic should go away,’ she said. ‘That has spectacularly failed. Now we think of chronic pain as a shift to another place, with different mechanisms, such as changes in genetic expression, chemical release, neurophysiology and wiring. We’ve got all these completely new ways of thinking about chronic pain. That’s the paradigm shift in the pain field.’

One explanation for the phenomenon of central sensitisation is that when an injury has afflicted some aspect of the peripheral nervous system, neurons in the central nervous system can also become agitated. This bumped-up signal-to-noise ratio can result in increased activation of calcium channels, the molecular pores that govern the flow of calcium ions across the cell membrane. This boosts the number of chemical messages travelling between nerve cells. Certain vulnerable neurons can also get a dose of NMDA (N-methyl-D-aspartate), opening more calcium channels, and sending even more messages whirling around the CNS. One class of drug now being evaluated in laboratory studies, an NMDA antagonist, could one day be useful in treating central sensitisation by blocking the excess ‘chatter’ that flies between overwhelmed neurons.

A final hypothesis suggests that central sensitisation reflects a type of neurobiological learning disorder: essentially, the brain is misinterpreting pain messages, which are never dismissed, but continue to travel endlessly from PNS to CNS, leaving the brain unable to set a new course. Some researchers have remarked that central sensitisation can be understood as a form of classical conditioning: just as the Russian physiologist Ivan Pavlov conditioned his dogs to salivate when a bell was paired with food, and then to salivate when the bell alone was heard, the body that has learned to experience pain in response to insult or injury continues to experience it in response to inconsequential stimuli.

Recent research has revealed what many patients know all too well: chronic back pain is often accompanied by other types of pain, including headaches, other musculoskeletal disorders, temporomandibular joint disorders, fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome. People who develop central sensitisation can also find light, noise or smells unusually disturbing, or display hypervigilance. Anxiety, stress and depression are problems for an estimated 30 to 45 per cent of patients with chronic back pain, and an even higher percentage of back-pain patients who experienced early childhood adversity.

If you wish to get past the terror, you are going to have to follow pain deep into its lair

One would think that opioid analgesics would be helpful in calming an agitated and dysregulated nervous system, but this premise has been debunked. In fact, to the contrary, long-term use of opioid analgesics, especially high-dose extended release drugs such as OxyContin and methadone, have been associated with the development of a particular type of central sensitisation called ‘opioid-induced hyperalgesia’, resulting in abnormal sensitivity to pain.

Despite Apkarian and Woolf’s decades-long efforts, it is likely to be years before physicians can use targeted compounds to treat the neurobiological mechanisms that lead to central sensitisation. ‘A huge clinical challenge remains to identify these mechanisms from the individual pain patient phenotype and to then target the molecular mechanism with a specific treatment,’ Woolf says.

It’s easy to see why progress has been slow: to make money in medicine, the common wisdom holds that it’s necessary to incise, prescribe, implant or inject. Pain science, dealing with complex neurological function, doesn’t readily allow for those kinds of interventions.

Historically, NIH has dedicated only 1 per cent of its research budget to pain science-related investigations. And until recently, painkiller manufacturers saw no reason to invest in very speculative research, thus unwisely diluting their shareholders’ earnings. But with opioid treatment on the skids, and profits sinking, finding new therapeutic targets is suddenly very attractive.

Drug targets are still on the horizon. But many pain psychologists and rehab specialists believe that central sensitisation can be successfully treated with a combination of cognitive behavioural therapy (CBT) and graded, non-pain-contingent exercise. The good news is that several labs have now shown that, after a patient’s pain has been properly treated, three months of CBT can substantially reverse pain-induced changes in grey matter.

While researching my book Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery (2017), I listened to hundreds of back-pain patients explain their chronic pain: they spoke of degenerative disc disease, herniated discs, pinched nerves, sciatica, spondylolisthesis, scoliosis and spinal stenosis. But I never encountered a single patient who described his or her struggle in terms of central sensitisation, or had heard of terms commonly used in behavioural psychology, such as ‘guarding’ (walking with an attention-getting limp) or ‘fear-avoidant behaviour’ (eschewing activities that might tax back muscles, thereby making them progressively weaker) or ‘pain catastrophising’ (ruminating over how severe the condition is likely to become, ruining any hope of a productive future).

As a practice, CBT provides graded exposure to feared stimuli. That means if you’re afraid of spiders or flying, you dull your terror by facing down the arachnid or the take-off and landing, safely and repetitively. With back-pain patients, the fear of pain might seem life-threatening. This idea is often implanted by healthcare practitioners who caution patients, unnecessarily, to ‘be careful,’ and to ‘spare their backs’. The job is to let patients know that, in the case of chronic back pain, hurt does not typically mean harm; that in fact, if you wish to get past the terror, you are going to have to follow pain deep into its lair.

Depending on the kind of chronic-pain rehab programme you enter, you might find yourself hauling around a plastic milk-crate filled with steel bricks, or engaging in water aerobics, or doing reps with free weights, or pushing an industrial sled (a heavy aluminium rectangle equipped with sliders on its base and sturdy handles on either end) or playing a game of beach volleyball, all under the close but generally unsympathetic supervision of someone who understands how bodies work and has seen it all before. The grimacing, the groaning, the odd body mechanics – all of them must go. Strengthening must follow. And when it does, the patient is rewarded with a sense of mastery over his or her own body, and no longer feels like a helpless victim.

Opioid Analgesics Subpar for Chronic Back Pain


Despite the prevailing public view, opioid medicines are not powerful analgesics for low back pain, according to a meta-analysis of 20 randomized controlled trials.

The drugs are commonly prescribed for chronic low back pain, but the review finds that they give only modest short-term relief and that the effect is not likely to be clinically important within current recommended doses.

In addition, they are commonly associated with several adverse effects. The findings were published online May 23 in JAMA Internal Medicine.

Christina Abdel Shaheed, PhD, from the George Institute for Global Health in Sydney, Australia, and the School of Medicine at Western Sydney University in Penrith, and colleagues say evidence on long-term efficacy is lacking, and the efficacy of opioid analgesics in acute low back pain is unknown.

“We found some evidence of a greater effect of opioid analgesics with larger doses; however, the effects are not likely to be clinically important even at high doses,” they write.

Doctor Argues Cutoff Is Arbitrary

Pain and disability were the primary outcome measure, and the researchers converted pain and disability outcomes to a 0 to 100 scale. They considered effects greater than 20 points clinically important.

Kenneth Nguyen, DO, assistant professor of physical medicine and rehabilitation and pain medicine at The Ohio State University Wexner Medical Center in Columbus, told Medscape Medical News that the number is arbitrary and would be different for each patient. He disagrees with the authors’ conclusion that the relief is not clinically significant.
“The way I interpret this study is that opioids do have a favorable outcome for chronic low back pain, but the effect is small. Higher dosages of opioids will offer a very small increase in pain relief with more potential side effects, so dose escalation should be done with caution.”

If a patient is in severe intractable pain, doctors should still consider opioids, Dr Nguyen said, adding that even small relief may be worth the adverse effects for some patients.

“I consider opioid and nonopioid medication, physical therapy, injections, spinal cord stimulators, medical massage therapy, acupuncture, etc., as potential treatment options. Opioids are just another tool that pain physicians have to offer patients,” he said.

Partial agonists, such as buprenorphine, are proving to have some of the pain-killing effects of the opioids without some of the adverse effects, he noted.

He acknowledged that he uses a numerical pain scale as part of a requirement for insurance, but the better measure is what the patient can do while receiving the medication as compared to what they are able to do without it, he said.

He added that the study does illustrate that physicians need to curb the “magic bullet” expectations of patients and emphasize it is a small part of the treatment plan.

A question that is “above my pay grade,” he said, is do we move toward a society where opioid analgesics are highly restricted, as they are in some other countries that have found benefits do not outweigh the risks.

Back Pain Is the Number 1 Reason for Disability

Low back pain is the leading cause of disability worldwide. Although guidelines encourage prescribing simple analgesics, such as paracetamol or nonsteroidal antiinflammatory drugs (NSAIDs), many people with low back pain are prescribed opioids.

Researchers found that was common in Australia and the United States. In the United States, more than half the people regularly treated with prescription opioid analgesics have chronic low back pain. In Australia, the three most commonly prescribed drugs for the condition are opioid analgesics or opioid analgesic combinations: oxycodone (11.7%), tramadol (8.2%), and paracetamol and codeine combination (12.1%).

They also found that the ability of people with low back pain to tolerate opioid analgesics is not well-studied. Many trials exclude participants who do not tolerate or adequately respond to the opioid analgesic in the run-in phase. Also, some trials exclude participants who do not respond to or tolerate the opioid analgesics in the randomized phase, so the estimate of treatment efficacy comes from only a proportion of participants who were enrolled to receive opioid analgesics.

Of the 20 trials (with a total of 7925 participants), 13 trials (3419 participants) evaluated short-term effects on chronic low back pain. In half of the 13 trials, at least 50% of participants withdrew because they did not tolerate or respond to the medicine. Moderate evidence showed opioid analgesics reduce pain in the short term (mean difference [MD], −10.1; 95% confidence interval [CI], −12.8 to −7.4). Meta-regression revealed a 12-point greater pain relief for every 1 log unit increase in morphine equivalent dose (P = .046).

Clinically important pain relief was not observed in doses of 40 to 240 mg morphine equivalents per day.

The latest opioid prescribing guidelines caution against exceeding 200 mg of morphine equivalents per day to lessen the risk for opioid-related complications, such as life-threatening respiratory depression. Higher doses of opioid analgesics have also been associated with misuse and dependence, hyperalgesia, and clinically significant hormonal changes.

In 2010, there were 16,651 opioid-related deaths reported in the United States, the authors note.

Dr Nguyen said he sees a trend in the last 10 years toward less prescribing of the opioid analgesics and more use of partial agonists.

“With the awareness of the dangers of pain medication…and with new laws and regulations, I don’t think opioids are overprescribed now,” he said.

Need a Nerve Block? 4 Things You Should Know.


For many people who suffer with severe pain, nerve blocks have become part of their treatment. These injections of local anesthetic and steroid directly to the area of the affected nerve can help with pain control and improve function and quality of life. Often, the goal is to help people avoid surgery and to take an active role in physical therapy.

Pain management specialist Paul Shin, MD, offers insights for patients considering having a nerve block. He says your doctor will help you determine the best procedure for the pain you have, but in general, here are four things to expect if you have a nerve block.

1. Fear of the injection is almost always worse than the injection itself

Patients are often hesitant when it comes to needles. Some procedures for arthritic conditions may involve up to six needles, but most procedures are well tolerated and brief. Generally, they only last five to 15 minutes. A local anesthetic or even IV sedation are sometimes used.

A fluoroscope, or low powered x-ray, allows whoever administers the nerve block  to visualize the bony structures. This enables accurate placement of the needle and reduces complications. You’ll spend most of your time preparing and recovering from the procedure afterwards.

2. Everyone responds differently to a nerve block

For some people, a nerve block gives immediate relief. For others, it takes a series of injections before it helps the pain. It’s very unpredictable. This is because pain is a personal perception and everyone responds differently.

Also, if you have had chronic pain for 10 or more years, it could involve multiple pain generators. There are many anatomic structures and the pain could come from more than one joint or nerve. In the spine, it’s possible that your first injection will take away some of the pain but that other injections will offer more improvement.

This also means that the sooner you can get an injection before your pain becomes chronic, the better your result. In addition, injections are typically combined with other forms of treatment such as physical therapy to increase your chances of getting better.

3. You might have some post-procedure soreness

You can expect some post-procedure discomfort or soreness that will also improve within days of the injection. The local anesthetic doesn’t last long and for some people, it may take a while for the steroid to work and provide a long-term benefit.

The peak effect of the steroid will usually be between three and 10 days. It is slowly released into the body, and for some people, there is an interval before you start to feel the improvement. Your response to the first injection helps guide your doctor about future treatments as he or she works to pinpoint the nerve that is causing your pain.

4. Your injection frequency depends on your medical history

Based on your medical history and physician preferences, you can usually repeat this procedure from three to six times in a 12-month period. Medical conditions, such as diabetes, will mean that your doctor will need make injections less frequent. Your doctor will determine the exact number of injections that you can receive.

Ultimately, the goal of nerve block injections is to decrease pain, increase your function and, for some patients, allow more aggressive physical therapy. They work well for many patients.

How to Treat Back Pain Without Dangerous Drugs


Story at-a-glance

  • Back pain is a prevalent problem in the United States, with at least 31 million Americans experiencing low back pain at any given time.
  • Sports injuries are common causes of back pain. But there are other factors that increase your risk of this condition, such as poorposture, obesity, poor physical conditioning and inactivity, psychological and emotional stress, and silent diseases like osteoporosis.
  • Prolonged sitting and poor posture put you at risk of not only chronic back pain, but other health issues as well, such as weight gain,obesity, joint problems, and other diseases.
  • Prescription drugs for back pain are saddled with severe, even life threatening side effects. NSAIDs, one of the most commonly prescribed painkillers in the market, put you at a two- to four-fold higher risk of heart attack, stroke, as well as a variety of other health problems.
  • There are many safe and effective alternatives to prescription and over-the-counter painkillers, and while they may require some patience for them to work, the improvements they generate are often longer lasting. Some of the effective strategies I recommend include chiropractic care, yoga, massage, exercises for back pain, and Neuro-Structural Integration Technique (NST).

Back pain is a common health issue today that affects at least eight out of 10 people. It is a prevalent problem among Americans. In fact, statistics from the American Chiropractic Association (ACA) reveal that at least 31 million Americans experience lower back pain at any given time.

The ACA report also says that:

  • One-half of all working Americans admit to having back pain symptoms each year.
  • Back pain is one of the most common reasons for missed work. In fact, it is the second most common reason for visits to the doctor’s office (next to upper-respiratory infections).
  • As many as 75 to 85 percent of the population will experience a back problem at some time in their lives. In most cases, this pain is mechanical in nature – it is NOT caused by a serious medical condition, such as inflammatory arthritis or fracture.

Chronic back pain has become such a debilitating problem – and it’s costly, too. According to the ACA, Americans spend at least 50 billion dollars each year on back pain—and that’s just for the more easily identified costs!

I cannot stress enough that preventing or treating disease is possible without the intervention of medications. The same is true for back pain. You only need to address the root cause of the problem by changing your lifestyle and the way you eat and move.

Below is a discussion of the potential causes of back pain, my recommendations for back pain treatment, and how you can alleviate this problem without putting any additional burden on your health.

What Are the Common Causes of Back Pain?

Accidents and sports injuries are the most common causes of chronic back pain. But sometimes, even simple activities or movements – like bending over to pick up an object from the floor – can trigger pain.

There are also a number of other factors that can increase your risk of back pain, such as:

Poor posture Poor physical conditioning facilitated by inactivity Internal disease, such as kidney stones, infections, blood clots
Obesity – According to a study posted in theJournal of American Epidemiology, overweight and obese people had a higher prevalence of low back pain than non-overweight individuals.1 Psychological/emotional stress Osteoporosis or bone loss (as measured by the Z-score and not the young adult-based T-score)

 

Sedentary Lifestyle Puts You at Risk of Back Pain – and Much More

There is one common denominator among most patients who suffer from severe cases of chronic pain: sedentary lifestyle. A majority of back, neck, and other muscle pains are related to imbalanced distribution of force throughout your body, which is created by working or staying in unnatural positions for extended periods. Prolonged sitting and poor posture are major risk factors of not only back pain, but also of weight gain, obesity, joint problems, nerve problems like carpal tunnel syndrome, and other debilitating diseases. In fact, prolonged sitting – along with smoking and obesity – is now an important risk factor for chronic disease!

An analysis of 18 studies showed the value of reduced sitting. It was found that people who sat for the longest periods of time were twice as likely to develop heart disease or diabetes, compared to those who sat the least. This proves that being physically active is great not only for your back, but also for your overall health. In fact, reducing your sitting time may even prolong your life. One study published in the British Medical Journal found that reducing the average time you spend sitting to less than three hours per day may increase your life expectancy by two years (the average American today spends 4.5 to five hours per day on a chair or sofa).2So if you have chronic back pain, it is critical that you evaluate your lifestyle and whether or not you’re getting enough exercise. Failing to exercise, and moving your body enough in general, may be the main reason why you’re suffering from this condition.

The Price You Pay for Poor Emotional Health

There’s increasing evidence that back pain and other types of pain may be exacerbated by psychological or emotional issues. It is my experience that emotional health and your ability to effectively address your stress is an essential component for optimal health, and can have a major influence on whether or not you’re effectively eliminating your pain.

If you have any underlying emotional issues and unresolved trauma, it can profoundly influence your health, particularly in terms of physical pain. A 2004 study on back pain supports this theory. Its researchers followed 100 patients over the course of four years. All of the patients, who were back pain-free at the start of the study underwent psychological tests. Afterwards, the researchers compared which of the participants remained pain-free and which ones developed back pain.

According to the results, the people who scored poorly on the psychological tests were three times more likely to report having experienced back pain by the end of the study.

Many health experts from various fields of medicine agree that emotional and psychological trauma has severe effects on a person’s risk of acquiring chronic pain. One example is Dr. John Sarno, a psychiatrist who uses mind-body techniques to treat patients with severe low back pain. He specializes in helping individuals who already had surgery for low back pain but did not get any relief.

This is one tough group of patients – yet Dr. Sarno has a greater than 80 percent success rate! He uses techniques like the Emotional Freedom Technique (EFT), an acupuncture-like technique that stimulates meridian points throughout your body. Read more about EFT. Sadly, many people dismiss these types of treatment strategies simply because they seem “too simple to be effective.” Unfortunately, they believe that in order to get back pain relief, they need to undergo radical treatment or take medications.

The Dangers of Drugs for Back Pain Treatment

Back Pain MedicationsConventional health care practitioners are quick to prescribe medications like non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and even opioids for chronic pain. But even if these medications can provide immediate back pain relief, their effect is only temporary – the pain will come back sooner or later and in some cases will cause hyperalgesia, or increased sensitivity to pain!

What’s more, medications touted to provide back pain relief are saddled with severe side effects. For example, NSAIDs, one of the most commonly prescribed drugs on the market, not only put you at a two- to four-fold higher risk of heart attack, stroke, and other cardiovascular problems, but may also cause:

  • Severe gastrointestinal problems, like digestive tract bleeding
  • Increased blood pressure
  • Kidney problems

Be mindful that these life-threatening side effects of painkillers are not restricted to prescription NSAIDs like Celebrex, but may also come from over-the-counter drugs like aspirin, Advil, and Motrin.

Opioid painkillers like OxyContin, which are also commonly prescribed for back pain relief, also have a highly addictive nature. In fact, opioids are among the most commonly abused prescription drugs today, and are a leading contributor to the increasing rates of fatal prescription drug overdoses. This is why back pain is now one of the primary reasons why so many American adults get addicted to painkillers.

The bottom line is that painkillers always come with risks. Unfortunately, if you consult your conventional physician about your chronic back pain, he will often prescribe a long-term treatment plan that may include anti-inflammatory drugs, muscle relaxants and possibly other types of pain medication or even anti-seizure drugs – a poisonous chemical cocktail that will put your health at severe risk!

Is Your Physician Prescribing This Expensive But Dangerous Drug for Back Pain?

Big Pharma recently began promoting Humira, an expensive drug with a price tag of nearly 20,000 dollars a year. Humira is touted to help treat ankylosing spondylitis, a chronic inflammatory disease of the axial skeleton, which includes the spine. It is outrageous how drug companies promote this dangerous drug for an exceedingly rare cause of low back pain – one that is only responsible for less than a tenth of a tenth of one percent of low back pain! What’s more, Humira may cause severe side effects, such as:

    • Tuberculosis

Back Pain X-Ray

  • Serious infections
  • Increased risk of lymphoma and other cancers
  • Hepatitis B infection
  • Allergic reactions
  • Liver, nervous system, and blood problems
  • Heart failure
  • Immune reactions, such as lupus-like syndrome
  • Psoriasis

This is just the short list; Humira may have even more damaging effects on your health only to emerge later through post-marketing surveillance in exposed populations who are being forced to act as living guinea pigs.

Cut Your Risk of Back Pain Right from the Start!

As with any health condition or disease, preventing back pain is better than trying to cure it after it has set in, and may be too late. So even if you’re not experiencing back pain symptoms, I would recommend you follow these simple tips:

  1. Always stretch before any strenuous physical activity. In fact, I strongly advise you to engage in a regular stretching program. My favorite is active isolated stretching (AIS), developed by Aaron Mattes. It’s completely different from the traditional type of stretching, and is a great way to get flexibility back into your system.
  2. Do not slouch when standing or sitting.
  3. If you spend most of your time sitting, pay careful attention to consciously sucking in your belly and rotating your pelvis slightly up. At the same time, you should keep your head back, with your ears over your shoulders and your shoulder blades pinched. This posture will keep your spine in proper alignment. Do this every hour you’re sitting, holding the muscles tight for several minutes.
  4. Sit in chairs or car seats with good lumbar support.
  5. Switch your sitting positions often. I would also recommend periodically walking around or gently stretching your muscles to relieve tension.
  6. Avoid bending over without supporting your back.
  7. Wear comfortable, low-heeled shoes. Women should also refrain from wearing heels all the time.
  8. Sleep on your side to reduce any curve in your spine. You should also sleep on a firm surface.
  9. When weight-lifting using your legs, always keep your back straight.
  10. Maintain an optimal weight.
  11. Quit smoking. Smoking reduces blood flow to your lower spine, causing the spinal discs to degenerate.
  12. Get enough vitamin D from sun exposure daily, as vitamin D helps keep your bones, including your spine, strong.
  13. Drink plenty of water to enhance the height of your intervertebral disks. Since your body is composed mostly of water, staying hydrated will keep you fluid and reduce stiffness.

How to Relieve Back Pain Naturally

If you are already suffering from chronic back pain or pain of any kind, you should understand that there are many safe and effective alternatives to prescription and over-the-counter painkillers, though they may require some patience. Here are some strategies I highly recommend:

Chiropractic Care

Chiropractic Care for Back PainOne of the best tactics to help treat back pain is to see a qualified chiropractor. I am an avid supporter of the chiropractic philosophy, which puts great emphasis on your body’s innate healing wisdom and does not rely on “Band-Aids” like drugs and surgery.

The problem is that a lot of people ignore chiropractic care, thinking that it’s just “pushing bones into place.” However, there’s a whole lot more to chiropractic care. In fact, one of the basic foundations of this health system is “vitalism” – recognizing that the human body has an innate healing intelligence or ‘life force’ that guides and directs your body’s healing process.

Qualified chiropractic, osteopathic, and naturopathic physicians are reliable, as they have received extensive training in the management of musculoskeletal disorders during their course of graduate healthcare training, which lasts between four to six years. These health experts have comprehensive training in musculoskeletal management.

Many studies have confirmed that chiropractic management is much safer and less expensive than allopathic medical treatments, especially when used for low-back pain treatment.

What’s more, researchers have also found that chiropractic adjustments may affect the chemistry of biological processes on a cellular level. Chiropractic care can affect the basic physiological processes that profoundly influence oxidative stress, immune function and DNA repair. This means that aside from addressing any immediate spinal misalignment that might cause back pain, chiropractic care can also help address, prevent and treat deeper dysfunctions in your body.

Exercises for Back Pain

Adapting an exercise program can help compensate for long hours of being sedentary, a risk factor of back pain. Exercise and being physically active help strengthen the muscles of your spine. One of the best back pain exercises I recommend isFoundation Training, created by chiropractor Dr. Eric Goodman. He developed it to address his own chronic back pain.

Foundation Training exercises are simple but powerful structural movements that help strengthen and realign your body posture and address the root cause of lower back pain, which is related to weakness and imbalance among your posterior chain of muscles that are caused by a sedentary lifestyle and too much sitting.

Foundation Training focuses on your core – the part of your body connected to your pelvis, whether above or below it. These include your hamstrings, glutes, and adductor muscles. Foundation Training teaches all these muscles to work together through integrated chains of movement, which is how you’re structurally designed to move, as opposed to compartmentalized movements like crunches.

Every exercise included in Foundation Training lengthens the front of your body, which is over-tightened, and strengthens the back of your body, helping you stand tall and move with grace and flexibility.

Anyone who wants to do Foundation Training must learn “The Founder,” the key basic exercise. The Founder disperses your weight through the posterior chains, helping to reinforce proper movement while strengthening the entire back of your body. This excellent exercise can help reverse the effects of frequent and prolonged sitting that may lead to back pain. To learn how to do the Founder,

To help address back pain caused by excessive sitting, I also recommend Egoscue Exercises, a series of stretches and special exercises that help restore your muscular balance and skeletal alignment. I often spend at least one hour or more doing an Egoscue exercise called “The Tower.” It’s simple – you only need to lie on the floor and allow your pelvis and thoracic spine to relax. I found this exercise tremendously helpful for treating my chronic low back pain, which is now gone.

You should also include high-intensity sessions in your exercise routine, although you only need to do these once or twice a week at the most. You should also include exercises that not only challenge your body intensely, but also promote muscle strength, balance, and flexibility. Remember to build up your abdominals to avoid back pain. And, as mentioned above, always do some stretching and warm-ups before engaging in strenuous physical activity.

Remember, though, that just because you exercise regularly doesn’t mean that you can justify your long hours spent sitting. In fact, even if you’re fairly physically active, you may still succumb to back pain and other health problems if you spend most of your day behind a desk or on the couch. This phenomenon is called the “active couch potato effect.” In order to avoid this, you must make it a habit to break the pattern of sitting as frequently as possible. Dr. Goodman says:

“Stand up throughout the day to stretch your body appropriately, the way it is meant to be stretched. The simple act of standing as tall as possible for a minute or two will help break the pattern of sitting, as long as you repeat it frequently. Be sure that while standing you take full deep breaths to expand your torso as well. We often have very shallow breath while we sit, counter that with big deep breaths as often as you can throughout the day.

My opinion is that people should not go longer than 30 minutes in a chair without standing, deep breathing, walking and stretching. If you think I am crazy for asking that much of you, then I suggest you not go longer than 20 minutes.”