Q & A: Pain Management and the Back
When your back is in chronic pain, an approach that heals the mind as well as the body is needed, says Dr. Scott Fishman, an anesthesiologist and chief of University of California, Davis' Division of Pain Medicine. He also talks about the risks of relying too much -- or not enough -- on pain medications.
NPR: Many listeners wrote in saying they wanted a solution for their chronic back pain that didn't involve drugs. They're worried about side effects, and are also concerned that drugs just mask the problem vs. curing it. What's your take on using drugs to treat back pain?
My answer is that anyone should have a fear of taking any drug. All drugs come with risk, even over-the-counter drugs have risk. So if you can help yourself without medications, that's always our first, best option. Pain medication is often for symptom control, and there's a role for it when other, more curative or less risky options have failed and when pain has limited your function to the point where you can't do the things you want to do.
But patients also need to know that it often takes a trial-and-error approach of zeroing in on that medicine that gives the most benefits with the least side effects. There's no way to predict which patient will do best on which specific drug. There's always tinkering involved.
Q: What about prevention? Are there things a person can do to prevent back injuries? -- Cindy Price, Portland, Ore.
Consumers need to understand that everyone gets back pain, and it's largely a function of conditioning within our spine. The spine and the muscles and all of our attachments -- ligaments, joints -- constantly need to be in motion to remain in good condition. When they're put to rest or overused, they tend to get irritated. So often back pain is a function of overusing or underusing, and conditioning will help.
The problem: It's a long-term proposition and the average person wants to exercise aggressively and get rid of the pain, and then likely not exercise for some period of time, and that strategy doesn't work.
What does work is moderate exercise, not too extreme and not too gentle. Frequent exercise will give durable effects, and that's what helps the back stay healthy and in good condition.
Q: My father is 63 years old. He has had three disc operations and his mobility and health seemed to decline after each surgery. It has been at least 15 years since his last surgery and he is now currently being treated for chronic back pain. He takes OxyContin daily. My concern is not only his physical health, but his mental health as well. What are the long-term effects of OxyContin? - Jennifer Piascik, Portland, Conn.
Surgery can correct mechanical defects and effects on nerve roots and the spine, but unfortunately, too often it doesn't take the pain away. One of the most potent medications is morphine-type drugs, also called opioids. OxyContin is one. If taken properly, it can help improve function, but there is a risk with of abuse and addiction with all morphine-type drugs. It comes down to risk and benefit assessment: How much risk is there for your dad to not take it and how much is there to taking it?
If the patient developed addiction, I wouldn't keep him on the drug anymore. But if the pain is so severe that it's preventing dad from moving around and is leading to the continued deconditioning of his body, if he's becoming depressed, if his quality of life is diminishing, that's when it's worth taking the risk of using it. Pain medication, combined with long-term physical therapy, can give you your life back.
Q: My pain management doctor recently recommended a relatively new procedure for my herniated disk. It's called disc nucleoplasty. Can you explain what is and comment on its effectiveness? -- Bruce Kahn, Atlanta, Ga.
These are new procedures where we go into the disc and either melt away the nerves inside the disc or decompress the disc and help resolve a bulge that might be pressing on a nerve. These are very select cases. We used to think that all back pain was due to the disc, then we thought that discs caused none of the pain. Now we're going back to the idea that discs cause some of the pain. These new procedures have only been available for several years, and we don't have a lot of good data to know how well they work and most importantly, what the long-term implications are. With that said, if it's a decision between using this type of procedure or surgery, opting first for the procedure may be in some patients' benefit because if it doesn't work, they can still go on to surgery.
Q: I have a herniated disc. My doctor is treating with naproxen for "pain management," hoping to avoid surgery. What would your concerns be for long-term use of this medication? -- John Garland, Minneapolis, Minn.
Naproxen or any of the anti-inflammatories, such as ibuprofen, are very potent pain relievers. In some cases, more potent than the morphine-type drugs. Many people think that because they're over-the-counter, they must be safe. But when you start taking them for long periods of time or at higher dosages, there is a whole host of side effects, include the potential for stomach ulcers, the potential for thinning of the blood and subsequent bleeding problems anywhere in the body. Long-term use also could lead to kidney damage. Long-term use should be monitored and medicines that protect the stomach should be added. They're called proton-pump inhibitors, and some are even over-the-counter drugs such as Tagamet, Pepcid and Prilosec. The prescription version is Nexium. We would certainly avoid using anti-inflammatories in anyone already on a blood thinner or in patients with any possibility of abnormal kidneys.
Q: I have chronic problems with lower back pain. After I exercise (swimming, yoga) it generally feels better, but after a couple of days the pain comes back. The pain is generally not severe, although if I have to stand for an extended period it can be quite painful and I need to sit down. I am 51 and am otherwise in good health and not overweight. Is there anything else that I can do to help? -- Paul Robbins, Bethesda, Md.
This is a case where I would examine what exercises are being done and ask whether the exercises are appropriate for the kind of pain the person has. Is there anything in the exercise program that is worsening the pain? Is there anything else that isn't being done that might help? I would also then look to see if there are any medications or any injections that might jumpstart the physical reconditioning and help the patient get to a higher level of function.
The issue of back pain is often the secondary reaction of the muscles to degeneration, and exercise can make those muscles feel better. Again, gentle and persistent exercise -- not harsh and all at once.
Exercise does two things: It helps prevent degeneration for those who haven't had it, and it gives the spine and all these spinal tissues nutrition. If the spine isn't moving and working, it's not clearing out the toxins. The bottom line: The back needs to move to remain healthy.
Q: My daughter had surgery in 1994 at age 15 for spondylolisthesis. Rods and fusion were used to prevent further slippage at L5 and S1. At age 18, she had a second surgery to stabilize the vertebrae. She is still in pain and has numbness in her legs and feet. My question: What can she do to relieve the pain, and are there new procedures that might be available to help correct the area of damage? -- Linda Bell, Gettysburg, Pa.
There's a great deal that can be done and the key now is listening to the kind of pain this patient has and essentially dissecting out the mechanical pain (from surgeries and spinal instability) from the nerve-injury pain and treating them as separate entities. For nerve-injury pain, we often use drugs that are used to treat seizures, such as in epilepsy or arrhythmias of the heart, which are basically seizures in the heart. These drugs calm overactive nerves. Pulse radio frequency is a procedure we use, for instance, to calm the nerve; it uses electricity to shock the nerve but not harm it. This is the kind of situation in which it will probably be necessary to see a pain specialist who knows these medicines as well as the different procedures.
Anti-inflammatories and opioids, as well as muscle-relaxing methods are being used to treat mechanical problems. The most controversial new technique we have involves Botox, which is the same medicine used for wrinkles. It temporarily paralyzes muscles and helps calm them.
NPR: How do people find the best care for their back pain?
That's a really good question and a hard question. How do you get people who know enough about pain and how do you get your primary-care doctor to refer you out to the proper folks? There aren't enough specialists, and a lot of insurance companies don't pay for patients to go to outside specialists.
My suggestion is for patients to contact some of the major pain-advocacy organizations, like the American Pain Foundation and the National Pain Foundation, and they can help patients find physicians throughout the country. They even have directories.
Q: My husband has been told that he has DISH disease (Diffuse Idiopathic Skeletal Hyperotosis) and there is no treatment. He is in extreme, constant pain and has very limited flexibility. What is known about this condition? -- Diane Combs, Madison, North Carolina
This condition is a hyper-growth, or over-growth of bone, and there's a great deal that can be done for symptom management, including all of the things we've discussed previously like anti-inflammatories and opioids. There's also an aspect of the reconditioning of the spinal muscles that is important. This is a situation where not only a pain specialist but possibly also an orthopedist or a physical medicine and rehabilitation specialist (PM&R) would help.
Q: I have a severe case of degenerative disc disease and also vertebrae that are disintegrating. I have had three surgeries in eight months, from a microdiscectomy and laminectomy to a lumbar fusion. I am wondering about other options, preferably non-drug. I have been told that the nerve damage may abate -- or not. Additionally, I realize that I was not prepared emotionally for what it is like to be in such constant pain and so unable to do so many things most people take for granted. Any suggestions would be most appreciated. -- Maryjo Juster, Washington, D.C.
The bottom line is that people don't realize the huge collateral impact of pain on the psyche and sense of well-being. When you're in pain all the time, it's hard to do the things that make life worthwhile. Patients get depressed, anxious, there's insomnia, and they even get suicidal. The suicide rate in patients with chronic pain is higher than normal. It takes a physical and emotional toll, and we have just as much responsibility to recondition people psychologically as physically.
I try to emphasize that when someone is in pain, the mind and body are inextricably linked. Understanding that connection, there are many things we can do. When there's depression and other clear psychiatric ailments, we can treat it and treat it effectively. We can offer the same treatment we offer athletes -- sport psychology. The same techniques Lance Armstrong would use to crest the hill in the Tour de France are the same techniques we would use in patients with pain to deal with their own type of marathon. The Buddhists have used these techniques for hundreds of years. When patients learn these techniques, they learn they've always had within them much more control than they ever thought possible to turn their symptoms on and off and to adjust how happy they are in their lives.
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