Opiates no solution to back pain

Steven J. Atlas, MD, MPH

Over the last year, the general public has been inundated with a steady stream of reports about the dangers of opiates — pain medicines like codeine, Percocet, and OxyContin. The harm in terms of ruined lives and death from illicit drugs such as heroin is not news. But what is new, and concerning, are the risks of prescription pain medicines — those doctors prescribe for pain due to a range of causes, including musculoskeletal problems like low back pain.

The history of using opiates for chronic pain

Back pain isn’t a new problem either, but the history of how doctors have treated it is probably new to many. A “cliff notes” version of what changed goes something like this. Studies showed that doctors weren’t adequately treating the pain of people with advanced cancer. Research also showed that pain medicines such as opiates improved quality of life for these terminally ill patients. This realization led to recommendations that doctors monitor pain as they would any other vital sign (like temperature or blood pressure) for all their patients — and that all types of pain receive aggressive treatment, including long-term (chronic) pain, such as low back pain. At the same time, drug companies promoted new formulations of opioid medications with longer duration of activity that made it easier for patients to take on a regular basis.

The problem was that this fundamental change in practice was really devoid of any proof that it would help people better manage pain and minimize its effect on their lives. Prior reviews of the medical literature have documented that there is little evidence supporting the use of opiates for chronic low back pain. The modest benefits seen were with short-term use. The practice of using these medicines for long periods of time has not been carefully evaluated. Few risks were seen in these short-term studies, but tolerance to the effects of the medicine, side effects and dependence/addiction have become clearer with longer use.

A recent study published in JAMA Internal Medicine adds to this knowledge. Dr. Abdel Shaheed and colleagues performed an updated literature review, and their conclusions reinforce that only short-term benefits have been proven and the amount of that benefit is modest. Moreover, they examined the doses of pain medicines used in these studies and found that the pain relief people actually experienced was not that great.

Opiates for chronic low back pain carry big risks with uncertain benefits

This and prior studies clearly show that the leap to widespread use of opiates for non-cancer pain was premature. We didn’t know the long-term benefits and risks. We still don’t know the benefits, but this dramatic increase in use of pain medicines hasn’t helped people return to their previous level of activity, and rates of disability haven’t gone down. What is becoming clear are the risks, specifically rates of addiction, overdoses, and the rise of deaths attributed to prescription opiates. And people who have become addicted to their prescribed pain medicines often switch to heroin, which is cheaper and more readily available.

Now this doesn’t mean that we should stop treating pain. For many, the pain is real, chronic, disabling, and they need help managing it. And it doesn’t mean that everyone prescribed opiates becomes addicted. Nor does it suggest that opiate medicines have no benefits at all. But what it should do is give all of us pause. The bottom line is that simply taking a pill (or a handful of pills) doesn’t fix low back pain — and can lead to a whole lot of trouble.

What you can do for back pain

Fortunately, there is growing evidence for treatments that can help with chronic low-back pain, but they aren’t simple fixes in the form of pills, shots or surgery. Instead, treatments should focus on getting back pain sufferers active again and learning to manage, not cure, the pain. A range of therapies including exercise, education about how to care for your back, yoga, and mind-body techniques have been shown to help control back pain.

So what do I tell my patients? For those with chronic back pain who aren’t on opiates, steer clear. For those who are already take them, you can’t go cold turkey. Your body has adjusted to these medicines and stopping them abruptly is a bad idea. With help, people on opiate pain relievers can try to wean themselves off these medicines gradually and replace them with other treatments. This isn’t easy, but for many people it starts a long process of regaining control over the pain that has taken over their lives and can help them avoid the terrible consequences of opiate addiction.

Comments:

  1. D Burnett

    This article can really help one to understand how opiates do not necessarily benefit someone. The growing issue of people becoming addicted to opiates is very concerning. Many people can easily become addicted to them after they are prescribed by a doctor. Those who do become addicted often aren’t aware that it has become an addiction or are too ashamed to ask for help to combat it. Harbor Village Detox is an addiction treatment facility that can help someone if they do have an addiction. Hopefully, with the correct treatment, someone suffering from an addiction can successfully overcome it.

  2. David Rodgers

    I have suffered from a rare form of back pain which is in my upper thoracic and neck. My brother had surgery for his neck which left him in more pain that he started. I have a familial tendency to herniate discs. When I went to the neurosurgeon to get help with my thoracic disc (which is horribly painful) he wouldn’t take me seriously, refused to order tests and tossed me out the door. My only means of surviving these last 20 years has been via immediate release oxycodone. I have had acclimation issues like anyone else and my dosage is high enough that we are looking for ER meds to help. So far, the hunt for an ER med has meant a long siege of horrible suffering for me. With the pain meds I can work and do work. Now that those meds have been taken away so we can seek out an ER (which don’t seem to have many useful results) I am in too much pain to carry my coffee cup with comfort.

  3. Trinny

    Anyone who thinks replacing opioids with mindfulness, yoga, meditation etc can be done , has no idea how that makes a chronic pain sufferer feel. Don’t you think if it was feasible then nobody would ever start taking the opioids in the first place. Why should we have to live a life with severe pain because a minority of pain sufferers do the wrong thing with these drugs.

    • Todd

      Amen, I love the Dr in gov who haven’t treated patients with severe back pain saying how it doesn’t help. Even with sometimes you still have severe pain. Unfortunately I follow the rules set forth in my drug contracts with the Dr and do everything by the book unlike the ones who do not and make life hell for the rest of us.

  4. Joint Replacement Surgery Hospital India

    Thanks for sharing this valuable information …!!
    It helps a lot …. to know how Opiates are usually reserved for the treatment of severe short-term back or leg pain that has not responded to other medicines as these pills are potentially addictive which causes sever musculoskeletal problems like low back pain. This post become the best resource for patients who are suffering from back pain.

  5. Michael Baca-Atlas

    Really nice article! Will share with patients and other providers. We have begun to work other members of the patient centered medical home to offer holistic approaches to addressing pain, particularly LBP.

  6. Diane

    It’s exceptional, but my mother just began having intractable back pain at 101. It seems to me that an aggressive regimen of opioids might be best for her. Do you agree?

    • Steven Atlas

      Diane,
      Though I can’t comment on the care of an individual patient, side effects of opiate medicines are more common and severe in the elderly. Many doctors avoid using strong opiates in the very elderly. For someone 101 with new and intractable pain, I’d look for a cause such as a compression fracture that may have other treatment options first.

  7. Chris Grammar

    Steven, as a pain management physician, I take exception to your characterization of the introduction of opiates into medicine. The “cliff note” version can be found in the law suit Chicago vs Purdue Pharma et. al.. It can be found in the felony conviction of Purdue in 2007. It can be found in the use of strippers by Insys to market subsys to physicians. JHACO and the “fifth vital sign” all bought and paid for by big Pharma. Using Edward Bernays and his marketing schemes to sell drugs. It goes on and on.

    • Steven Atlas

      Chris,
      Thanks for you comment. There were many motivations that led to this change in practice. The financial one was definitely a factor, though I’d say it wasn’t the only one.

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  10. Haven

    this is very helpful, I have been having back pains

    • Gail

      I don’t want to comment I want ANSWERS -PLEASE?? I’ve lived with severe chronic low back pain for 41 years. At 20 yrs old had my first Spinal Fusion L-5 & S1. Surgeon ( one of the top 10 in Canada) had never seen a20 yr old with bones& osteoarthritis such as mine .Quote ” You have bones of a 70 year old woman,never have I seen or read of such a case!” I was also diagnosed with Sciatica,Spondylithesis & Degenerative Disc Disease. The day I met him back in 1977 I was carried to hospital as suddenly I was paralyzed! He tried manipulation under sedation- made it worse! Followed by 3 months of pelvic traction with no improvement- I could not stand let alone walk. My 4th month in hospital spinal fusion was performed.(using bone from my iliac crest) Two more months in hospital to get me out of wheel chair & hopefully walk again- @ 20 I was given a 50/50 chance of walking again! Finally graduated to a walker & sent home after 6 full months of hospital. I eventually got myself to a cane & finally free of that after a yr long experience. At that point I was on Demerol then switched to Tylenol 3 with Codeine . I lived on theTylenols for 12 years ( yes I have major stomach problems-eventually lead to chronic pancreatitis -have suffered 5 acute attacks that were so horrible I wanted to die & nearly did twice! My Mom was told I’d never make it/ by some miracle I’m still here suffering severe chronic back pain & chronic pancreatitis . I lived a fairly normal life & returned to work @ age 21 till age 32 when I required a 2nd fusion- original came apart it was wires & my bones deterioted! At that point prior to surgery they tried an epidural needle for pain- I’m not lucky……they hit a nerve and paralyzed me. Told I’d spend the rest of my life in wheelchair! I was a newlywed! I also went on a Canadian Disability Pension at that poin.After 2nd fusion in chair 2 years & determined to walk again I eventually did water exercises to strengthen muscles for months daily – I was not staying in that chair! It took several months & pain continued to increase. With increased pain I finally made it to a cane. Some bozo Doctor along the way put me on 40 mg of OxyContin 3X daily. ( in my early 40’s) I couldnt drive I was a mess &!pain never ever really left! Although prior to my 50Th Birthday I made up my mind I was no longer ” the young girl with the cane”!-as many at my church referred to me as. I realized I’d soon be 50 &!Id be the old lady with the cane! No way- not going to happen! Back goths swimming pool daily 3-4 hours of treading water to strengthen muscles! It worked-put cane in closet next to my Walker & wheelchair. Although my pain was worse than ever I proved my MRI wrong that read “‘never able to walk again ” – ha! Showed them, all the time living in pain, tears, sleepless nights. It’s just become a way of life for me . I now have osteoarthritis throughout my body & more degenerating discs up to my neck now. At 52 overcome by pain I rolled in bed crying for over 48 hours- now a widow trying to manage on a Disability Pension. A dear friend of my late husband came to check on me & couldn’t handle the sight of me rolling from hip to hip in tears. After this had gone on a little over 48 hours he picked me up in my nightie & carried me to his car- rushed me to hospital.!I’ll make this as brief as possible . A Xray was done however they could not see my spine. So a CAT Scan ASAP- meanwhile I’m on an IV drip- finally able to sleep. Our trend woke me as Dr returned to ER – I was obviously in la-la land as the Dr.!looked concerned&!said “we found large grey mass covering spine must do a MRI ASAP. I couldn’t understand why my friend had tears running down his face& fell back to sleep! I don’t even remember having MRI I was fast asleep! My friend once again woke me when this time 2 doctors returned this time. First words were ” Good news it’s NOT the “C” word-my friend was suddenly crying happy tears. The doctor continued ” although the reason we could not see the spine is because your right kidney is dead & we’ve just drained 6 litres of urine from you & can now see the problem. Your L-4 disc is missing there is no disc or cushioning no wonder your pain is so excruciating . I am putting you at the top of the Emergency Surgery List as of this point no food or liquid as we never know when we will have all the staff needed n your situation (#1 was my chronic pancreatitis ) operating room & time available . I was put not my room to wait & wait as the is the hospital for All Acute a Emergencies – helcopters &!ambulances were arriving constantly wth accident vctims that of course took priority. On my 3rd day of waitng I asked the surgeon ” can you please take me off this awful OxyContin? I e been stuck on it for 9’years & I want my life back!” The dr. Couldn’t believe his ears! He looked odd & stared at me saying “Did you say 9 years? ” I replied “Yes” she was mortified! He said ” I’m embarrassed to belong to a medical profession that would stick a person on this poison & leave them on it for 9’years! However you just can’t come off it cold turkey- your heart will stop as your body is dependent on it. It will be gradual & must be replaced with a narcotic for the amount of pain you live with day to day with your several diseasees.”! He put me on 3 mg of Hydromrphone & 10 mg of Diazepam both 3 X daily/ it has remained that way for 7!years now with 2mg hydromrphone for break through pain however that doesn’t help so I don’t bother with the 2 mg break thru. I suffered whiplash & concussion November 2015 that has added to my neck pain & left me with daily migraines . Some days unbearable to get out of bed or have any lights around me as I vomit from ntense pain & dizziness. My lower back pain is out of control, my hips thighs & knees ache constantly the Meds Ive been on past 7 years do nothing, I cry & hate myself as I’m now a procrastinator – I can’t seem to accomplish anything. Pain has taken over my life. My new husband can’t understand how I can’t sort all the papers, health receipts etc to file our 2015 Income tax that should have been filed by April. I know we don’t owe as my new husband was diagnosed with cancer in 2014- thatwAs our 2nd anniversary gift! He was operated on & luckly had 4 lymph nodes removed – the Oncologist said ” if I were you Dennis Id quit my job & enjoy life to the fullest while I could!” She scared us to death when his horrible infection healed we began Travelling & did so for 13 months till we realized we were broke! ( my late husband died insolvent leaving me with $400,000 debt- his best friend arranged an attorney for me & paid for the attorney to make settlemrnts as I Refused to claim bankruptsy even though the attorney advised me it was my only option especially as I Was/Am on Canadian Disability Pension Plan ( CDPP) I refused! I almost killed me however After too many law suits to mention ( my late husband was self employed so As he lay bedridden win CODP , CHF & kidney failure we had no income but my $840.00 month pension. The bills piled, customers did not pay him and as dick as I am I tried to care for him. I was his caregiver for 8 months with no outside help- I found I’m dead one afternoon just 20 minutes after talking to him in bedroom. When I went back to check on him he seemed to be asleep- wrong! I was in shock ! By the way this best friend of his that helped me thru his death , the almost bancruptsy & the one that rushed me to hospital is the man I married. Our fiend ship grew through my surgery &!months of bedrest unable to walk, on a Catheter as well As a terrible fall where I shattered my hummeris in 3 places- ambulance took me to the closest & worse hospital! They X-Rayed & said ” wow you are lucky so close to needing surgery “. Idiots- it’s been 7!yrs I still cannot even wash or Blowdry my own hair because of their incompentance ! I was never able o be given physio it never healed properly . Now I must pay a hairdresser weekly to wash & Blowdry my hair – certainly not in budget however no choice. Now at 59 my pain in worse each day’s my legs & right arm both go numb frequently . What could that be? When this happens Im stuck- must remain in position till feeling returns so I don’t fall on my face – they are numb & rubber like. Even sitting on a toilet for 15 mins will cause legs to go numb & I’m stuck. The reason I’m sitting is because I’m always constipated- also more pain. Please? This is not a comment. I need help! I beg you, can you tell me what type of Dr I need PLEASE answer me. I just spent 3 hours writing you as I don’t know what to do 😰😰It takes over 2 years to see a Specialist here in Ontario, I live just 30 miles west of Toronto. I don’t even have an appetite anymore due to the amount of uncontrollable pain. Oh yes I’m also waiting on bunion & toe fusion -it has gotten so bad I can’t find a shoe that is comfortable nor can I afford he $500 orthotetics they want to sell me ( Dr) to put into a comfortableb shoe- the shoe the Dr recommends is over $400! We’ve already had to mtg our home that was paid for from Mtg insurance when my late husband died. I’m in so much pain & depression I don’t know where to turn . I beg you please can you give me sme answers? My fingers are now once again icy , blue & numb from typing the past 3 hours. This is not a joke. Every word I’ve shared with you is true- Id swear on my first born if I’d been able to have children. You are supposed to be the Best in North America – surely you can tell me what might be wrong with me? No Dr has ever even run any tests to see if I have Lupus , MS, or some other diseases . They just list all that is wrong with me. Oh I’ve also been so sick for most of he past 7 months. I finally did go to Emergency to find out later that I have been suffering from “‘aSuper Bug” of my bladder the reason I can’t pee- I just dribble. My Mother died young @ 71 from an autoimune disease ” Primary Billary Chirosis” they found it when she was just 61 & said ” you have a rAre disease in10 years you will need a liver transplant or you will die” This is Canada not the USA-we have a small population, they should have put her On the organ waiting list when they found the disease. NO! They let her my Mom , my best friend my only family slowly die. I had her live with me the last 2 years of her life as she was so frail weak & unAble to care for herself. I wanted to donate a portion of my liver however they said I wasn’t healthy enough to do so.. I now fear I will die even younger than her as nobody cares . PleAse respond to my email . I’m willing to be a Guinea pig- anything -I cannot go on like this. I’ve even shrunk 2.5″ in the past 2 years.! Seems my last fusion with titanium L/3-L-4,L-5 & S1 must not be holding . I recently saw an -Xray & my spinal column seems to be growing out into a S. Thus making me shrink & I suppose the reason for the extra 24/7 pain that I have now lived with daily for 41 years.! However never this bad on a daily basis . I don’t want OxyContin anymore ! I would appreciate some help. Please, please give me some direction I’m lost & I can’t seem to function daily anymore. Dressing, showering & getting on a bus is exhausting for me . Some encouragement / direction/PLEASE!
      Eagerly await your response . I don’t drink, don’t smoke & NEVER hAve done recreational drugs. I’m a practising Christian who prays daily & never a misses Mass on Sunday. Honestly I’m a good person who helps others in any way si can. Now I am the one that despertly needs help & no where to turn. All family has passed away same with my husbands. Just lost my wonderful Mother In Lawi January- she actually live to almost see her 90 th Birthday. My husband was blessed to have his Dad who love him very much live to be 85 & Mom to 89. My Mom loved me as much I love her yet she died 15 years ago at 71- my Dad never wanted me I loved him even though he didn’t love me. I lived in the hospital next to him for 5 months taking care of his every need, I sort of slept in a lazy boy chair till he died at 78 that was 6 years ago, right after I started to walk again after my last fusion & finally got rid of catheter -I wasn’t well myself. I found out he really did hate me as he didn’t want children however when I was 7 he had a daughter with hid girl friend who is as evil & mean as herMother.He left her everything he owned . It hurt but money won’t buy me good health . I’m praying for an Angel to help me have some sort of life that doesn’t contain pain daily for whatever days I have left.
      Thank you for listening to my story & pray you can give me some answers.
      God bless you,
      Gail M.
      .