low back pain…the new way to treat

Friday, February 17, 2017

Emergency doctors get it. The patient arrives in the ER complaining of pain and wants relief. What the patient does not appreciate is that by having a complaint of pain, he has unleashed a battle between the practice and the business of medicine. The practice of medicine would want the doctor to find the reason for the patient’s pain, fix the underlying cause and also help alleviate suffering. The business of medicine would want the customer’s wants and needs addressed and have superior satisfaction scores. But what should happen if the patient and the physician differ as to what should be done regarding the matter of pain control? It’s not like the patient has a choice of who they get to see in ER, and the doctor really doesn’t have a long-term relationship with the patient.

If only patients were as easy as Kansas City Royals’ pitcher Brian Flynn. He fell through his barn roof, fracturing three vertebrae in his back ,along with a rib for good measure. Pain control decisions in trauma are easy. Broken bones hurt and they take time to heal and the odds are that he’ll miss spring training. At least in the short-term for trauma, pain medication is appropriate to be prescribed. But what happens when there is no trauma?

Guidelines from the American College of Physicians published in February 2017 address treatment options for those with acute, subacute and chronic low back pain. They do not apply to trauma patients. They also do not apply to patients with sciatica, inflammation of the sciatic nerve, that causes pain to radiate down the leg. And they do not apply to patients whose spinal cord is potentially at risk and have bowel or bladder symptoms. But for everybody else, and there are a lot of people with low back pain, the message is clear: try heat or exercise or complementary medical care (think yoga, tai chi, massage or manipulation) because medication as a first line treatment is no longer recommended.

What a shock to a patient who wants immediate relief! It is likely not going to happen. Most back pain gets better in 6-12 weeks and the advice from the College of Physicians seems to be “a little pain never hurt anybody”.  Imagine the ER visit for backache:

  • First step and most important, the doctor talks to and examines the patient to make certain a disaster situation does not exist, things like spinal cord compression, aortic aneurysm, kidney stones.
  • If it’s “just “ low back ache, x-rays, CT or MRI are not initially indicated
  • Treatment recommendations will include heat and perhaps referral to physical therapy or a chiropractor
  • Acetaminophen (Tylenol) is no longer recommended
  • Ibuprofen (Advil, Motrin) or Naproxen (Aleve) might work, but patients with kidney disease, gastrointestinal disease (reflux, ulcers, inflammatory bowel disease) or who are on anticoagulation (blood thinning) medications, cannot take these drugs
  • The patient will be discharged home with no prescription for medication and likely in the same amount of discomfort as when they arrived
  • The patient satisfaction survey arrives in the mail and now the business of medicine hinges on whether the doctor was able to educate and persuade the patient about “a little pain…”

If the low back pain persists, there are some medication recommendations to use as second line treatment, including duloxetine (Cymbalta) an antidepressant medication that affects serotonin metabolism or tramadol (Ultram) a narcotic that according to the World Health Organization has a lower potential for misuse, abuse and dependence. Tramadol not only works on the opioid receptors in brain but also on the serotonin receptors as well. Opioids should only be considered after all other options have failed and only “after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence.) 

The practice of medicine and the role of the patient is gradually changing. Patients are becoming active participants in decision making regarding diagnosis and treatment. But as research and guidelines evolve, the delivery of pain free recuperation may no longer be a valid expectation for the patient or a goal for the doctor. The problem is that pain is very subjective and its tolerance varies from patient to patient. Both patient and doctor will have to learn how to balance suffering with acceptable pain and how to minimize the use of pills to fix things. While the guidelines address back pain, they are likely the tip of the iceberg as more research tries to give direction to pain control in general.

The three recommendation are listed below…and by the way, the guidelines appear to classify tramadol differently than a narcotic or opioid but according to the Federal Drug Administration (FDA), it is just that.


Recommendation 1:

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Recommendation 2:

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

Recommendation 3:

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. Grade: weak recommendation, moderate-quality evidence.) 


Image attribution: www.breakingmuscle.com




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how medication works

Sunday, May 3, 2015

Manny Pacquiao lost the fight of the decade but perhaps not the battle of the excuses. ESPN’s quoted the boxer as saying that “he didn’t want to make alibis or complaints or anything…[but] it’s hard to fight one-handed.” The people in his corner asked that he be injected with an anti-inflammatory in the dressing room just before the bell rung, but were denied permission by the Nevada Athletic Commission because the injury was not previously disclosed. Pacquiao’s trainer said that the requested anti-inflammatory had been previously used in training camp and was on the approved list by the US Anti-Doping Agency.

There are two potential injectable anti-inflammatory medications that are used to treat acute or chronic injuries. The first is hydrocortisone or any of the myriads of corticosteroids that are used to decrease inflammation. They are very effective and by decreasing inflammation, the patient’s pain may also be relieved, but it takes 48-72 hours for the medication to have an effect. The second injectable anti-inflammatory is ketorolac (Toradol), which is a nonsteroidal anti-inflammatory, is an effective medication and is often used as a non-narcotic alternative for acute pain management.

For many medications, the presumption is that the injected medication is “better”, working faster and being more potent. Patients are surprised that isn’t necessarily so. If Mr. Pacquiao was interested, almost 20 years of medical research has shown that ibuprofen (Advil, Motrin] taken by mouth works as well as the injectable Toradol. Testing patient pain levels at 0, 15, 30, 60, 90 and 120 minutes found no difference at any time interval. The only benefit to Toradol is that it is injectable, and therefore helpful when people are vomiting or cannot have anything to eat or drink.

Other medications are similar in that their action works quickly when taken by mouth. An allergic reaction may be a true emergency, especially if there is difficulty breathing, shortness of breath, wheezing or difficulty swallowing. These are all potential disasters that can be associated with anaphylactic shock and calling 911 is a reasonable first step. The second step is taking diphenhydramine (Benadryl) by mouth. Surprisingly, its onset of action is relatively quick when taking orally, starting to work within 15-30 minutes. Hopefully, by the time the patient arrives in the ER, the medication is kicking in. For those patients who develop hives as their allergic reaction, the oral Benadryl may be all that they need.

As much as its important to know how quickly a medication work, it’s just as important to know when the effects begin to fade. For pain medication, that allows the prescribing provider to know how often to recommend taking the drug. Take it too quickly and the accumulation of the drug within the blood stream may lead to an overdose; delay too long and there will be gaps in pain control. The same thought process goes into prescribing long term medications for most medical ailments from seizure control, to heart failure to diabetes. Understanding the pharmacokinetics of a drug, how it’s absorbed, how the body metabolizes it and how it’s excreted, is crucial to know when and how much to take.

For Mr. Pacquiao, the shoulder injury may have put him at a disadvantage in the fight. While the Athletic Commission didn’t allow injectable medications, not considering alternatives might have been a difference maker. But when all was said and done, there would be little opportunity to complain when the judges’ scoring was not in his favor.


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