back pain posts Archives

Why do we over-prescribe strong pain medication?

Tuesday, April 10th, 2012 at 10:01 AM  

The NY Times on 4/9/2012 ran a story about the overuse and unintended negative consequences of strong (opioid) pain medication. They mentioned opposing views concerning the liberal use of opioids. I participated in a debate in 1995 about the inappropriate use of the diagnosis “Chronic Pain Syndrome”(CPS) in patients whose muscles had not been assessed as a cause of their persistent pain, which resulted in the justification to put some of these patients on opioids for the rest of their lives.   

Since then one of the largest growth industries in medicine is the evaluation and treatment of back and neck pain, currently accounting for ~$100 billion in direct medical costs. The pain juggernaut is fueled in part by ignoring muscles which are the most common reason for pain complaints. Addressing the incorrect causes of pain leads to inappropriate, expensive and potentially harmful treatments with poor outcomes, persisitent pain, and overuse of opioids. CPS is a license to prescribe life-long medication. Chronic use of opioids has not been studied for its overall impact on patients with CPS but neither have any of the other medications that we are now using. Does the marginal reduction in pain in many of the patients taking these medications justify their costs and side effects? As the Times reports, for some patients the treatment is actually making them worse.

Imagine if some of these patients had pain that could be eliminated. Many do; it’s from muscles that are not evaluated or treated in a systematic way.  My new book, End Back Pain Forever, to be released by Atria on June 5, 2012 is a wakeup call to change the way we are treating common pain problems.

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Strong pain medication after surgery – is there a downside?

Friday, April 6th, 2012 at 12:46 PM  

A recent article  revealed that 2/3 of patients who received opioids (drugs like morphine) for 90 days following surgery were still taking them one year later. It doesn’t make sense that there still is pain from the surgery one year later. Did these patients become dependent or addicted to the drugs?  Did they really need the medication for pain in the first place?

It was suggested that patients who undergo minimally painful surgeries should perhaps never receive opioids for pain. This thinking is consistent with the current discussion in the USA about the dangers of overuse and abuse of opioids. Annual emergency room visits and unintentional deaths from opioids have dramatically increased in the past five years. Widespread, persistent use of opioids is increasing without a clear understanding of the benefits or of all the associated risks. Making it harder to get the medication and limiting its availability is one way to reduce the unwanted effects.

Many physicians have been alarmed over the misuse of opioids and will not prescribe them at all or will often provide less than adequate doses to effectively treat their patient’s pain. I recently saw a young man who, despite severe back pain that would require surgery, was denied opioid pain medication because he had a high score on a test that measured risk for its misuse. Since I understood the risk, I was able to successfully provide opioids while staying in close contact with the patient and his mother before and after surgery.

Indiscriminate provision of opioids is potentially harmful but so are overly restrictive attitudes and rules governing its availability. Each patient deserves to be evaluated as an individual so that compassionate and rational pain care can be provided.

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How do I know if kinesiophobia is a factor in my pain?

Wednesday, April 4th, 2012 at 11:06 AM  

There may be more to your pain than you think. Pain affects how you feel and how you move your body. More often than not, these changes happen without you even realizing it.  Consider a concept known as kinesiophobia, defined as a fear of movement associated with anxiety related to an injury. Just as stress and anxiety can make pain worse, kinesiophobia can prevent a patient from recovering to their full extent and achieving relief from muscle pain.

 

An example….

Consider the case of a 50-year-old woman who was visiting the Norman Marcus Pain Institute for the treatment of her foot and ankle pain. The pain started two weeks after a fall, and had plagued her for five months. Because she felt that she was unable to walk without support, she used a walker or a cane. She complained of pain in her heel and ankle and in her Achilles tendon.   Her foot was cold and clammy. Attempting to move her foot up and down and applying pressure to the painful areas caused the pain to become much worse. Read the rest of this entry

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Why does back pain appear to move or change intensity?

Tuesday, January 24th, 2012 at 7:52 PM  

There are three different mechanisms that affect your back pain when it is related to muscles- and that means most of the pain you will experience in your life.

1. Referred back pain patterns- Pain may be referred from one muscle to another when the nerves carrying painful sensations in a muscle stimulates the same area in the spinal cord as an adjacent muscle.

2. Central sensitization- When a painful area of the body stimulates the spinal cord and makes the cord more  active, other sensations coming in to the cord that would usually not be experienced as painful are now experienced as pain- like turning up the volume on your stereo and hearing things that you don’t hear when the volume is low. So when the original area of damage causing the pain is properly treated the other scattered areas of pain may disappear.
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Your bulging disc is not what’s hurting

Friday, January 6th, 2012 at 6:24 PM  

Two days ago I reported on a study that showed we are frequently doing a disservice to patients in inappropriately ordering imaging studies such as MRIs. Yesterday I saw a patient who could be the poster person for the study. This patient had a back injury one year ago when a fall onto the buttock produced lasting severe low back pain. The pain doesn’t radiate-it is only in a discrete area on the buttock. She felt a tender sensation when the area was pressed.

Despite the obvious findings suggesting the cause of her pain was muscle and not spine and nerves coming from the spine, an MRI was ordered and it showed a bulging disc and she was told this was the cause of her back pain. She has had a variety of physical therapy interventions and injections without relief.

Her physical examination showed that she could touch her toes and her straight leg raising was 90 degrees, rarely if ever seen with a patient whose pain was the result of a disc. She did have two muscles, the Gluteus Maximus and Piriformis, which were tender when stimulated by the Muscle Pain Detection Device. This showed that these muscles were the probable cause of her pain. A ketamine based cream was applied to the skin over these muscles and her pain was gone, further supporting the connection between the muscles identified and her long-standing back pain.
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Osteoporosis Prevention and Treatment

Saturday, September 17th, 2011 at 6:31 PM  

Osteoporosis in women is a growing public health challenge with an aging population. New approaches are needed to prevent and treat decreases in bone density and strength. Two recent articles present different and potentially complementary approaches.

Diet: Lanou reviews the studies on soy diets for the prevention of osteoporosis and bone fractures. Although the results are not consistent, soy based diets that are part of a diet rich in fruits and vegetables appear to be effective. Other studies have suggested that such a diet has a wide range of health promoting effects. Although there is not yet strong enough evidence to suggest that everyone become a vegetarian, at least for women, increasing the amount of fruits and vegetables and having soy in your diet, is a good idea.
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Above all else, do no harm!

Tuesday, May 24th, 2011 at 6:34 PM  

In our desperate wish for pain relief, we sometimes receive treatment that is harmful. One of those treatments may be botulinum toxin, frequently provided as Botox injections to tender muscles. A recent article showed how Botox could produce permanent damage in muscles with normal muscle fibers being replaced with fat cells.
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Knee pain, back pain, and muscles

Thursday, May 12th, 2011 at 6:36 PM  

A large study of army recruits demonstrated the protective effect of exercise on the development of knee pain. Male and female recruits who performed 4 stretching and 4 strengthening exercises for 7 weeks, were 75% less likely to develop anterior knee pain.
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MRI, CT, and X-rays may mistake the cause of your back pain

Friday, January 28th, 2011 at 6:43 PM  

MRI, CT and X-rays may fool us. A recent article concluded that the amount of constriction of the nerves exiting the lower spine thought to be the reason for back and leg pain was not correlated with the amount of relief a patient experienced with steroid injections around that nerve(s).

Beautiful clear pictures of the spine and nerves seduce us into believing we can see the reason for the pain. Focusing too much on imaging and not enough on the physical examination, results in many patients receiving surgery and nerve blocks that were assumed to be the right treatment but didn’t relieve the pain. Did that happen to you?
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Obesity and Understanding BMI with back pain

Tuesday, December 21st, 2010 at 6:46 PM  

People in all industrialized countries are being harmed by a world-wide obesity epidemic. We generally determine if we are the proper weight by calculating the BMI (Body Mass Index): dividing your weight in pounds x 703 by your height in inches squared. If you weigh 140 pounds and are 5 feet, 8 inches, your BMI would be 21.28-
(140 x 703/68 x 68). Normal is 18.5-24.9, overweight is 25-29.9 and obese is over 30. A study of patients in 30 European countries found that over 70,000 new cancer cases were attributable to excess BMI in 2002. Obesity is also associated with an increased incidence of diabetes, hypertension, arthritis, coronary artery disease and dementia.
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Painless back and muscle injections

Friday, December 10th, 2010 at 6:53 PM  

Pain is a deterrent to many patients when offered a therapeutic injection. There is some encouraging news on ways to make injections more comfortable.

A Cochrane review found that adjusting the pH, with bicarbonate, of a lidocaine injectate for local anesthesia, reduced the discomfort for patients without reducing analgesic effectiveness. The burning sensation produced by the acidic pH of lidocaine injectable is diminished by adjusting the pH upwards from the 3.5 -7.0 usually found in commercial preparations, to approximately 7.4.
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Misinformed medical advice may be harmful

Thursday, December 9th, 2010 at 7:05 PM  

A word in the mouth of a physician is as dangerous as a scalpel in the hand of the surgeon, Eugene Bauer, M.D. 1931

Women who have had breast surgery for cancer do not have more lymphedema with exercise according to a new study published in JAMA. This is an important finding because the myth has been that exercise could cause edema in women who had lymph node excision during surgery. The study showed that not only were the women who exercised stronger, but that they had a lower incidence of edema.
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Spinal Cord Stimulators- How well do they work?

Monday, December 6th, 2010 at 7:06 PM  

Results of a 2 year study on Spinal Cord Stimulation (SCS), sponsored by St Jude’s Medical, Inc., found that 70 % of patients reported 50% or better pain relief at their final two-year visit. In addition 88% of these patients reported that their quality of life was improved or greatly improved. No specifics were reported concerning measures of success aside from reduction of back pain.

These results are much better than the previously reported SCS studies, A systematic review of SCS for failed back surgery syndrome and complex regional pain syndrome showed ~ 50% of patients achieved ~50% pain relief. The devil is in the details and without them, which should include how many patients had to have surgical revision of the SCS because of complications, the number of patients able to return to work, and the reduction in use of pain medications, it is difficult to come to any conclusions about the claims of extraordinary success.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
“Your New York City Pain Relief Doctor”
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Darvon banned by FDA- Methadone spared

Wednesday, November 24th, 2010 at 7:08 PM  

The painkilling drug Darvon (propoxyphene) was banned this week by the FDA because it can cause potentially fatal arrhythmias (abnormal heart rhythms). But other pain medications, like methadone, can also cause dangerous arrhythmias. I have been asked a few times why was Darvon banned, but not methadone?
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Golfers with back pain

Tuesday, September 28th, 2010 at 7:11 PM  

A golfing patient I treated originally came to me with low back pain and later with shoulder pain and neck pain- all preventing his inner champion from blossoming. Like so many golfers he had come to accept the suffering as part of the game. He was amazed to find that he could get rid of the back pain that had plagued him for years. He wrote about it in his blog today bit.ly/9aluAt

Thank you for the mention in your blog.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
Your New York City Pain Relief Doctor”
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Source of your back, shoulder and neck pain

Thursday, August 12th, 2010 at 7:12 PM  

A 35 year old executive complained of neck and shoulder pain radiating into his fingers along with difficulty using his fingers. His MRI showed bone spurs in his neck which were causing compression of the nerves going into his arm. A neurosurgeon had suggested that he have surgery to remove the spurs and to fuse the vertebra in his neck.

He was given cervical spine epidural steroids and after the 2nd injection his pain and difficulties in his hand were eliminated, but the pain in the region of his shoulder blade persisted. He felt that it was time to revisit the neurosurgeon, but I told him that pain only in the shoulder isn’t typical for a problem in the spine.
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Measuring Low Back Pain Treatment Outcomes

Thursday, June 24th, 2010 at 7:14 PM  

The article in the European Spine Journal highlights a major difficulty in assessing the effectiveness of various back pain treatments. No two studies used the same criteria to measure improvement. The lack of uniformity appears to be present in every aspect of the enigma of low back pain. Recent studies demonstrated that the tests a family physician uses to establish probability of a disc herniation may not be valid. There are inconsistent criteria for fusion vs. a simple laminectomy or foraminotomy for back pain. Injection techniques vary widely for back pain thought to be from nerve or muscle.
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Is chronic back pain adequately treated?

Tuesday, May 25th, 2010 at 7:15 PM  

I just read an article on the under treatment of chronic pain with the most common associated disease states listed as osteoarthritis, rheumatoid arthritis, fibromyalgia, and sickle–cell anemia. Since physical deconditioning is fraught with many serious negative consequences, such as obesity, high blood pressure, stroke, heart disease and diabetes in addition to be being a cause of most common pain problems, it should probably rank as a form of disease.
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Activity and quality of life

Tuesday, May 18th, 2010 at 7:18 PM  

A recent article showed that even gentle but regular physical activity in middle aged women reduced the incidence of hip fractures. Lack of exercise contributes to many of the health problems with which we are confronted- obesity, heart disease, diabetes, hypertension, dementia, arthritis, and osteoporosis. At a time when the cost of health care is so important to each of us as Americans, awareness of inexpensive interventions and self responsibility for our well being should be foremost in our minds.

Proper exercise should take into account your level of conditioning before you begin any program. Many new exercisers will strain their weak or stiff muscles causing pain and disillusionment with their new found passion and quit. Remember the most important thing about your exercise plan is that you are able to and actually return for your next scheduled session.
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If I get back pain will it go away?

Tuesday, May 11th, 2010 at 7:22 PM  

Although Low Back Pain (LBP) is thought to affect around 80% of individuals, it is also thought to be self limiting and get better quickly (within weeks). Studies of patient populations however suggest that it is actually a more serious problem. Although most patients who experience back pain do not see a doctor, 60-80% of those that do are still reporting pain one year later and in those whose pain has disappeared, 20% will have a recurrence within months.
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