Pain brings more people into contact with medical professionals than any other presenting problem. Based on estimates from the CDC’s National Center for Health Statistics, pain affects more Americans than diabetes, heart disease, and cancer combined, and the percentage of the US population affected by chronic pain is increasing.
Back pain is among the most common pain-related ailments, and Americans are estimated to spend as much as $86 billion a year in search of back pain relief. However, a new study out of Harvard Medical School advises that in terms of treatment, less is often more. Despite well-established guidelines to treat back pain conservatively, the extent to which patients are prescribed opioid painkillers, given advanced imaging procedures such as CT scans and MRIs, and referred for surgery, has increased dramatically during the last decade.
The American College of Physicians and the American Pain Society recommend that people with back pain be treated with nonsteroidal anti-inflammatory medications (NSAIDs) like ibuprophen (Motrin) and naproxen (Aleve), or acetaminophen (Tylenol), in combination with the use of ice packs, heating pads, and exercise. Opioids are only recommended for those with “severe, disabling pain” that doesn’t improve with over-the-counter medications,—and then the risks for abuse and addiction need to be assessed and weighed against the potential benefits.
In the new study, “Worsening Trends in the Management and Treatment of Back Pain,” (JAMA Internal Medicine, 7/29/13 online edition), researchers reviewed nationally representative data on outpatient visits for back and neck pain from 1999 to 2010. They looked at about 24,000 visits, representing a total of 440 million appointments across the US during that period. Their findings indicated that referrals for CT or MRI scans increased by 57 percent, and referrals to another doctor—most often for surgery or other extraordinary treatments—increased by 106 percent. During that eleven year span, prescriptions for acetaminophen and NSAIDs decreased by more than 50 percent while those for opioids increased by 51 percent. Opioids, such as oxycodone (Percocet, Oxycontin), hydrocodone (Vicodin, Lortab), morphine (MScontin), methadone, and fentanyl (Duragesic, Actiq), are the most prevalent treatment for both acute and chronic pain.
Unfortunately, prescribing more powerful narcotic medications and subjecting people to more expensive and invasive interventions has not resulted in better treatment outcomes. There is no data to support that using opioids beyond three months for chronic non-cancer pain is effective, and there are many potential problems with these medications. Side effects include, but are not limited to cognitive diminution, constipation, and opioid-induced hyperalgesia—wherein sensitivity to pain actually gets worse. Over time tolerance and physical dependence develop, and the feelings of euphoria that opioid use can evoke, make these medications highly addictive.
Treating back pain can be especially complicated because there are a variety of potential causes, including disc, joint, and nerve problems. Acute pain typically runs its course and will resolve if given time and appropriate conservative care. When pain is chronic, there are no “magic bullets,” though there are many things that can help people live with their pain and improve the quality of their lives. However, Western medicine focuses on eliminating or killing the pain. Pain sufferers often want a quick fix, and based on the study results, many doctors are apparently inclined to err on the side of overtreatment. This may stem from a genuine belief in the efficacy of that approach, an interest in placating patients’ demands, and/or prevailing reimbursement structures. This often leads to treatments that are unnecessary, expensive, and have not proven to be effective. Invasive interventions have increased risks. Not infrequently, procedures such as steroid injections and surgery leave patients with the same or even greater levels of pain.
Some Assembly Required: A Balanced Approach to Recovery from Addiction and Chronic Pain introduces readers to the concept of pain recovery and how it contrasts with the conventional medical model of pain management. The book describes in great detail how recovery from both addiction and chronic pain is much more than maintaining abstinence from drugs (including legally prescribed opioid painkillers) and being free from pain. Recovery is the ongoing process of learning how to live a whole, healthy, and healed life, which involves the way we think, how we cope with feelings, how our body is functioning, and our spirituality.
Some Assembly Required details how twelve-step recovery can be combined with mindfulness-based practices, and noninvasive physical interventions (most of which are self-administered) like stretching and exercise, as well as Western psychological theory and psychotherapeutic approaches. The integrations of these elements help people build the awareness and skills to learn how to diminish their subjective level of pain and live with the pain they do experience as gracefully as possible, while improving their functioning. In presenting a multidimensional model for successful recovery from the twin challenges of addiction and chronic pain, the book provides information that can change how these disorders are viewed—by the general public, the recovery community, and yes, medical (and behavioral health) professionals.