Millions of Americans suffer from Chronic Spinal Pain. Many choose to accept the debilitating function that comes with this type of long lasting and consistent pain, often times interfering with daily functional activity and/or routine activity with family and friends.
The real question becomes what is spinal pain, and what is the accepted course to deal with it.
Our late, and beloved President John F. Kennedy is an example of an elite figure in our history who had to deal with chronic, debilitating spinal pain, choosing medication to do so, in order to carry out daily activity.
Spinal Pain, commonly known as chronic back and/or neck pain, is often caused by a degenerative process of the vertebral (spinal) bone. The vertebral column, or spine, is comprised of thirty (30) bones located along the central, posterior portion of the neck, back, and tail. Often times due to trauma, as it relates to motor vehicle accident, traumatic fall, and/or injury on job, or simply due to the aging process due to shear weight-bearing stress on the spine, the bones of the spine or vertebrae become brittle and began to break down. During the life-long, on-going repair of the degenerative bone, extra bone, known as osteophyte, as well as fibrous and obstructive connective tissue may replace the original boney matrix with entrapped nerves along the cortex of the bone causing intense and severe debilitating pain. Imaging studies, such as CT-scan and MRI, are used to define the anatomy of the abnormal boney structures of the spine. This allows the patient’s health care provider to define the patient’s illness as it relates to the cause of the chronic pain syndrome, as well as to make recommendation for therapy and/or management. Although, many of the painful symptoms are caused by irritation of nerves along the cortex of the vertebral bone, as well as nerves encased in reparative connective tissues within the medullary matrix of the bone, there is also bone on bone articulation where the intervening cartilage becomes less functional or absent all-together, as in degenerative knee/hip pain (osteoarthritis).
Three options for medical care currently exist for patients who suffer from chronic debilitating pain syndrome. Those options are surgery, nerve block (with injecting anesthetic agents), and oral medication. Often times, patients find themselves limited to medication to treat ongoing chronic pain syndrome due to the expense or inconvenience and other limitations that come with surgery and/or nerve block. Certain types of oral medications used to treat pain are similar in action as to endorphins.
“Endorphins are among the brain chemicals known as neurotransmitters, which function to transmit electrical signals within the nervous system. At least 20 types of endorphins have been demonstrated in humans. Endorphins can be found in the pituitary gland, in other parts of the brain, or distributed throughout the nervous system.Stress and pain are the two most common factors leading to the release of endorphins. Endorphins interact with the opiate receptors in the brain to reduce our perception of pain and act similarly to drugs such as morphine and codeine. “
Most, responsible patients who partner with their physicians to do the right thing in managing their chronic pain syndrome do quite well on oral medication, which tends to be effective in allowing the patient to carry on daily functional activity. Surely oral medication tends to be more readily affordable for most patients as compared to the other two options.
Responsible management becomes the most prominent position to address. Nationally respected panels of pain medicine experts have created guidelines and recommendations for patients and physicians to follow, given the fact, that more than 80% of physicians who manage patients for chronic pain are general practitioners and family medicine practitioners. And, studies have shown this to be safe and effective when done under appropriate guidelines and recommendations.
(The Journal of Pain Volume 10, Issue 2 , Pages 113-130.e22, February 2009)
It becomes the patient’s responsibility to partner with a physician in choosing which course of management will be most effective for the patient.
Every patient May NOT be a candidate for out-patient based pain management, and licensed physicians who treat patients with certain medications for chronic pain syndrome should be held responsible in making this life-altering decision for patients (in keeping with FIRST DO NO HARM). Certain high-risk patients for outpatient pain management include those who: 1) require more than 200 mg of morphine-equivalent opiates per day; 2) have been previously discharged from pain management clinics due to overdose, diversion, abuse, and/or addictive behavior; 3) patients who do not have evidential, imaging support of disease indicative of pain management. The idea is to treat debilitating pain, and NOT pleasurable behavior. Thus, my recommendation to patients who suffer from chronic debilitating pain syndrome, is to choose your physician and/or health care provider wisely by doing due diligence in reading, asking questions, and making sure the patient understands risk versus benefit in long-term, oral medicinal/therapeutic management for pain. Moreover, patients who chose to “doctor shop,” visiting multiple doctors simultaneously for certain medications, or “pharmacy shop,” visiting multiple pharmacies simultaneously for medication fillings, place their own lives at risk for serious complications related to certain type of medications. Physicians or other health care providers who treat patients for chronic pain syndrome with certain medications have ethical and legal obligations to discontinue care of such patients in keeping with the platform, “first do no harm.” Furthermore, combination therapy, such as xanax, Klonopin, somas, should not be used while taking certain oral medications because of the risk of seizure, coma, and/or death. In our practice, our strategy regarding managing patients with certain types of medication is to follow National Guidelines and Recommendations (refer to above reference article in The Journal of Pain) with respect to: a) retard the development of rapid, high-dose medication tolerance through appropriate dosing of medication; b) monitor for side effects with oral medication(s);c) monitor behavior for abuse, diversion, and/or addiction; and d) appropriately make recommendation for detoxification with withdrawal protocols, and referral to board-certified MD-psychiatrist and/or addictionologist as clinically indicated. HIGH RISK PAIN MANAGEMENT-A DIRECTION FOR PATIENTS
We, at MDC-Atlanta, have found that the best course of therapy for our patients is to base treatment strategy on the degree of MRI or other imaging findings, i.e. severe degenerative changes with canal and/or foraminal stenosis, nerve/spinal cord impingement, with or without osteophyte formation and/or bone on bone articulation. The level of pain also helps decide treatment strategy. Thus, the idea is to “start low and go slow” with chronic opiate therapy for NON-cancer related pain (COT), to maintain low risk potential for addiction, diversion, and abuse. With this, we suggest oral treatment should only be taken when pain level exceeds level 8 out of 10, and to resist the notion of around the clock COT usage. Typically, there is a relief of debilitating pain during tolerable therapy for 5-6 hours or more. By the patient supplementing pain therapy with anti-inflammatory or topical analgesic type medication in between high level pain, this may also delay rapid development of high risk potential. For example, during tolerable oral medication therapy, if a patient takes a pain (analgesic) medication, a tolerable pain level should be achieved for 5-6 hours or longer. As patient begins to experience an incline in intensity of pain, then the patient should take an anti-inflammatory-type medication (i.e. ibuprofen, motrin, advil, aleve, etc) to retard the need for another stronger analgesic medication. Thus, the time for next dosage could be around 8-10 hours or longer. Therefore, typically 2-3 tablets of select analgesics (pain medication) (less than 100 mg dosage equivalence/day), each tablet separated in time by at least 6-8 hours, over an 18 hour day, per day, may be all that is needed. Keep in mind, the chronic pain patient should also get appropriate sleep for at least 5-7 hours per day, given a therapeutic cycle of 12-18 hours over a 24 hour period, under appropriate prudence of oral analgesic (pain) medication usage.
REMEMBER: ONCE YOU HAVE BEEN DISCHARGED FROM MY CLINIC OR ANY OTHER PAIN CLINIC DUE TO CONCERNS ABOUT ADDICTION, IT IS NOW RECOMMENDED FOR THOSE PATIENTS TO GO THROUGH WITHDRAWAL PROTOCOL AND DETOX UNDER PSYCHIATRIC CARE, AS WELL AS CONSIDER METHADONE OR SUBOXONE (THE PREFERED ROUTE BY THIS PRACTITIONER) FOR ONE YEAR, WHILE YOU CONSIDER A LIFETIME OF ABSTENENCE FROM NARCOTIC DUE TO INHERENT NATURE OF ABUSE AND ADDICTION. YOUR PAIN AT THAT POINT CAN ONLY BE TREATED SAFELY THROUGH OTHER NON-NARCOTIC ALTERNATIVES.
It requires law-enforcement, pharmacist, and health-care practitioner communicating with one the other to keep patients safe. One missing link in this communication effort may bring harm to patient.
MDC-Atlanta remains committed to keeping patients informed for better quality and safe health care!