Problems with a sore back or neck? You’re not alone. It’s estimated that over 80% of people experience this pain some time in their lives. But how these problems are treated and what medications are used is changing…
Why?
First, many treatments in the past have resulted in high failure rates. Complete bed rest, disk replacements, steroid injections and spinal fusions have not delivered the success rates that were claimed and sometimes had nasty side effects. Some patients actually became worse instead of better…
Secondly, too many people are dying from overdoses of narcotics prescribed for pain – nearly 4,000 in Canada last year – and it’s not just drug-abusers living in the streets. In spite of having told us years ago that these drugs were safe when used for pain with less than 1% becoming addicted, 4 out of 5 heroin users in one government study reported having started opioid use with a prescription. And many of these started with pain relief for muscle or joint pain that just didn’t get better. Canadians are the highest users of opioids in the world.
The Centers for Disease Control (CDC) in US stated that overall one out of every 550 patients started on opioid therapy died of opioid-related causes, an average of 2.6 years after their first prescription. This statistic increased to 1 in 32 patients who were taking the equivalent of 200mg a day of morphine or more. These same statistics were observed in Ontario residents on Social Assistance. The CDC stated “We know of no other medication routinely used for a non-fatal condition that kills patients so frequently.
So, how did all this happen?
One defining characteristic of opioids is “tolerance”, where your body adapts to the effects of narcotics. This means you require increasing doses over time to achieve the same pain relief. However, these drugs have another property that was not widely recognized initially and is rarely discussed with patients, called “central sensitization”. This is a condition where the brain becomes sensitized to pain and eventually even non-pain messages coming in. Levels of pain messaging chemicals (like NMDA) increase, sending even more pain messages whirling around the brain’s central nervous system (CNS). This results in the perception of pain from sensations that would normally not be painful, and the person is on his way to long-term chronic pain with seemingly no real cause.
Essentially, the brain, when exposed to opioid drugs, “learns” to experience chronic pain in response to sensations that are not normally painful. Unfortunately, with long-term use of opioids, these changes can be very difficult to reverse when the drug is stopped.
Treatment for muscle and joint pain is changing…
Governments are responding to these alarming statistics. In Canada a new guideline was created: The 2017 Guideline for Opioids for Chronic Non-Cancer Pain. In it, they strongly recommend optimizing treatment with non-opioid drugs (anti-inflammatory medications like naproxen and ibuprofen, and in some cases muscle relaxants) and non-drug therapies (like heat and exercise), rather than giving a trial of opioid drugs.
The American College of Physicians (ACP) responded by creating similar pain medication guidelines in 2018. Both guidelines recommend using opioids as a last resort and then only in people with no history of drug abuse or mental health problems. The Canadian guideline strongly recommends that not more than the equivalent of 90mg of morphine be given daily and that current patients taking more than this for chronic non-cancer pain should be gradually reduced to 90mg daily for safety reasons.
A new study this year, the SPACE study, found that the ability to function and relief from chronic pain was not significantly different in patients who took only anti-inflammatories compared to those who took opioids for their pain. And those who took the narcotics had more side effects.
So, even if you had success taking Tylenol #3 or Dilaudid the last time your back “went out”, don’t be surprised if your doctor gives you Naproxen 500mg instead if it happens again. He’ll be following pain management guidelines that have your best interests in mind!
Next week I’ll talk about non-drug strategies for back and neck pain…
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