By Sandro LaRocca, M.D.
People need to be told the truth about their pain relief options and encouraged to seek a surgical consultation and evaluation for lower back pain far earlier than is the norm by their physician. What we surgeons have known intuitively and anecdotally for years, published research now confirms. While waiting for the medical community to stop arguing amongst themselves there are certain things you can do and ways you can empower yourself or a loved one in the grip of chronic lower back pain.
A new study recently published in the journal Spine showed a correlation between chronic lower back pain (cLBP) and illicit drug use. The study, by Anna Shmagel of University of Minnesota, Minneapolis and several other brilliant researchers will be very affirming for anyone who has seen someone battling chronic pain and developing a secondary problem of addiction to prescription opioids. This is a scenario so prevalent that a massive surge in opioid addiction in the last 20 years has created an addiction crisis unlike anything our country has seen and overdose has surpassed car accidents as the leading cause of death in people under the age of 30. There is no new news here, only the reinforced message that pain management is fraught with risk and the once standard of care in prescriptions as pain management must be re-thought.
What was fascinating to me about the study however, was that the correlation in illicit drug use was not limited to prescription or illicit opioids - it held true for marijuana, cocaine and methamphetamine. The study was confirmed this in all directions - those with pain reported more drug use, those with addiction history reported pain, those with opioid prescriptions were more likely to abuse other drugs, and vice versa. This research was basically confirming what most physicians and surgeons are learning about the pathology of addiction and how it intersects with overall health as well how we conduct our healing. But I want to point out another conclusion I believe we can draw:
This recent study about cLBP and illicit drug abuse is one more reason that we need to change our national conversation on back surgery and how we see surgery as a solution for chronic pain. I’ve been an orthopaedic surgeon for over 20 years and performed thousands of neck and spinal operations, including reconstruction after trauma in the emergency room, scoliosis and degenerative conditions of the aging spine. When I entered surgical residency, back surgery for chronic low back pain was a risky proposition with a mediocre prognosis. Surgery was reserved for injuries and only the most severe cases of chronic pain. But in the decades that I have been practicing the techniques, technologies, recovery time and most importantly the positive outcomes have made several types of surgeries early options that were last resorts only a few years ago.
I would argue that in fact we have come so far in achieving positive outcomes with surgery that a pain management plan should be developed only AFTER surgery is ruled out. The pain management practitioner should encourage a thorough imaging review by a surgeon, ideally more than one opinion should be obtained. With the ease of emailing MRI’s and CT Scans to a physician this can be done remotely, and additional opinions obtained without any geographic or travel challenges.
Decisions can be made on simple data - when I review an MRI I can inform the patient what the outcomes are for patients with similar diagnoses and their prognosis - in full transparency. The trouble used to be with cases where a patient had a 50 or 60% chance of relief - that gave everyone pause and usually the smallest hesitation would dissuade a patient from surgery. Even with a great pain management plan, a majority of these patients need surgery after a few years when their condition deteriorates with aging or other spinal degenerations. With this new revelation about the risks of drug use those patients now have additional factors that weigh their decisions towards surgery. Addiction is as lethal as cancer - and we must eliminate its risks in the exact same way. There is a new urgency to back surgery.
My experience is that there is an enormous amount of people who are candidates for surgery with excellent chances of relief and are stuck on the treadmill of pain management limbo because of this overarching myth that surgery should only be a last resort. Instead of navigating the treachery of opioid prescriptions or, god forbid, the self-medicating that the other illicit drug use revealed in the study indicate, a surgical option must be evaluated promptly. That “no man’s land” of chronic lower back pain is a very dangerous place with potentially deadly side effects.