Opioids don’t work. Surgery and injections rarely do, and scans are unnecessary. Better to get moving
Businessman sitting on leather chair with hand on back
“I’m sorry you’re in pain.”
“You have no idea,” she growls. She is a middle-aged, obese woman with chronic back pain admitted to hospital for the third time in a year.
“Will you at least talk to the physio?”
She has stayed put in bed, refusing to move, and the nurses are tired.
“No, he can take you for a walk.”
This isn’t going well, I rue.
“And you won’t increase my morphine!” she harrumphs.
“I’d like to manage your pain in other ways. Opioids don’t help in this situation and there can be serious side effects.”
“My doctor always gives me a script.”
Now, I am treading the fine line between being paternalistic and honouring a duty of care.
“I am afraid I’d be doing you a disservice by giving you more.”
“I want my MRI now,” she says querulously.
“You don’t need it,” I reply gently. “Your back pain will get better, like before.”
“You don’t know what you’re talking about and I don’t like you.”
The resident squirms. Having already been yelled at, he’d thought to spare me the humiliation.
Stepping outside, I teach my interns that chronic back pain is one of the commonest causes of pain, disability and lost productivity, with a total cost estimated to be almost $140bn a year.
Caused by wear and tear and experienced with variable severity, it almost never requires bloods or tests to diagnose. The best management is early mobilisation. Importantly, we should avoid prescribing opioids and discourage false expectations of complete and lifelong resolution, instead promoting gradual adjustment.
“Then why doesn’t anyone believe us?,” protests the medical student. “Why do we spend all our time convincing patients only to have them think that we are unkind, uncaring and plainly wrong?”
Chronic back pain might possibly be one of the most pedestrian and yet most challenging conditions for doctors to treat. Many situations in medicine prompt debate and disagreement but few get more heated than the treatment of back pain, which has a lot to do with the fact that the vast majority of patients should not be managed in hospital but in the community setting and the most valuable interventions aren’t medical but rather primary prevention, lifestyle and exercise.
An excellent report in the Economist delves into the subject and makes for instructive reading. Back pain costs US$88bn annually, nearly as much as cancer treatment ($115bn) and, while not a fatal illness, can easily provoke a lifetime of misery.
The arguments between doctors and patients centre on two issues – how to diagnose and how to treat back pain.
First, to pain management. Researchers are discovering that the mechanism via which patients experience pain may be related to damaged pain pathways remaining “switched on”, in which case taking more pills doesn’t help. Simple analgesia such as paracetamol and ibuprofen are often useless but opioids such as codeine, morphine and fentanyl have been shown to be no more effective. They do not improve function, do not expedite return to work, can lead to addiction and, worse, fatality.
Opioid-related harm has become an Australian and international public health crisis. In Australia, there has been a 25% increase in hospitalisation related to opioid poisoning and three people die of opioid overdose every day. In the United States, that number is a staggering 130 deaths a day. Most of these deaths occur due to prescribed pharmaceutical opioids, not illicit drug use. Evidence suggests that the earlier a patient is prescribed opioids, the higher the risk of chronic abuse.
What about surgery? Less than 5% of patients have a surgically remediable problem; despite their abundance, procedures on vertebrae and discs have not been shown to improve longterm outcomes. The Economist cites one American study which found that two years after spinal fusion, 87% of patients described pain severe enough to require medication. Bolts, braces and other foreign surfaces risk causing more discomfort and hard-to-treat infection. Surgery for back pain, and its frequent precursor, steroid injections, are now deemed low-value interventions.
Second only to the annoyance of having drugs withheld, patients hate being told that they don’t need a test to elucidate the cause of non-specific back pain, which accounts for nearly 95% of presentations. (Back pain due to tumour, infection or nerve root compression is usually accompanied by “red flags”). Experts advise that as many as 80% of scans are unnecessary, creating enormous cost as well as the anxiety of incidental findings that trigger more tests. But patients primed to expect tests in hospital feel they are being fobbed off when presented with the evidence.
The bottom line for chronic back pain is that opioids don’t work and should not be initiated. Surgery and injections rarely work, and scans are unnecessary. Each of these interventions carries a risk of harm and, in the case of opioids, the treatment, rather than the disease, may be fatal. The problem is that patients feel cheated when “everyone” including the neighbour, colleague and spouse seems to obtain an immediate MRI, a script for morphine and a neurosurgery referral. And yet, as any honest clinician would attest, this hapless situation has only resulted through deficient medical education, aggressive opioid marketing, perverse insurance incentives, and the pressure on doctors to do something. It takes 30 seconds to order morphine and an MRI but 30 minutes to (often unsuccessfully) explain why to avoid both. Finally, in an era of defensive medicine, it’s much easier for doctors to over-treat than follow principle and find themselves alone.
So how do we move forward? The Economist briefing should be essential reading for all doctors, especially GPs who act as gatekeepers, and patients with chronic back pain. Those sceptical of professional guidelines may find independent writing more convincing. Health administrators could take note of educational campaigns to keep moving, including one in Australia that partnered with employers, unions and clinicians to reduce doctor visits and the cost of care. Another Australian initiative to provide emergency patients early access to physiotherapy reduced hospitalisation.
There is an unmistakeable need for doctors to do better but, ultimately, doctors cannot help patients who won’t believe them. It might seem like anathema in this transactional world of modern medicine, but patients must recognise that the most effective long-term management of their back pain rarely belongs in the hands of doctors and that their suffering is far more likely to respond to graduated exercise, weight loss and a realignment of expectations. Admittedly, doctors don’t excel at giving such advice; patients don’t excel at taking it, but in view of the enormous individual and societal cost of back pain, sitting still, figuratively and literally, is not an option.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
Bron: The Guardian / 3 februari 2020