The latest copy of the Journal of the American Medical Association has a lead article on the use of opioids in the long-term management of low back pain. The article is a study of some 200 people who were managed either with opioid-type medications or without them. The conclusion was that there was no difference in level of function with the use of opioid medication.
There is a large problem with this study, since it does not distinguish between the wide variety of patients who have back pain. Back pain can be due to everything from spine problems to nerve damage and residual surgical issues. As it has been preached multiple times, opioids are only one tool in the treatment of back issues and there are often many different strategies to control pain.
Opioids and Back Pain
The reality of life is that many different things can cause pain, and treatment should be aimed at the cause of pain. Depending on what is causing the sensory complaints, management will vary based on the individual’s needs. A combination of strategies is often necessary to treat every different component contributing to a problem. Treatments may be simple, such as ongoing exercise, to complex, including injections and surgery. Sometimes simple strategies fail and the only medication that does help are opioids. Since these drugs have tremendous problems, they often are not a good solution especially for long-term use. Pain specialists often know a wide realm of treatment options and can help lead one to better choice or a combination of choices.
The biggest problem with the use of opioids is that they are cheap and they have been pushed in the United States as a great, inexpensive tool to manage any type of pain. It takes a lot of work to manage pain, and in this country many have opted out of the challenges. On top of the drug companies pushing these medications, often the insurance companies are equally complicit by not allowing treatments that may be more expensive. Everything from physical therapy, massage, chiropractors, acupuncture and even fitness centers with athletic trainers are often more beneficial than many medications and may well be cheaper. However, most insurance companies turn a blind eye towards alternative treatment strategies. Now that opioids are a problem, insurance companies still want to say no to alternatives to drugs, but are not willing to pay for the better alternatives.
Alternative Treatment Options
The important message from the study of opioids is that for most people there are better treatment strategies than these drugs for the management of pain in the long term. For short-term, these medications may be okay. For surgery and several days immediately afterward it may be reasonable to use them. After that time period, medications that are not addictive may be used with the strategy to return the body to normal functional patterns. The body needs to move and relearn normal movement and function. As the body moves and functions as it was originally designed, the body acts appropriately and does not generate pain sensory signals.
If you have a body that cannot move and function normally due to permanent changes, these may constantly send sensory signals that are interpreted as pain. Designing treatments that bring the body as close to normal motion and function as possible can reduce pain. This is difficult and requires significant effort; rarely is there a magic pill that performs this function. If one gets past the thought that life is pain free and then focuses on making life as close to ideal motion and function, then one can improve their quality of life.
The last take home message is that medicine needs to understand that some people honestly have tried everything available to treat their problems and nothing has worked. If they have worked with a legitimate pain expert, sometimes it is found that opioid medications are appropriate in the management of a problem long term. This should be considered a last option in most cases. Hopefully our culture will get a more realistic understanding of opioids in the management of pain and all those involved in treatment will support the use of reasonable alternative strategies. Initially it may not be cheaper, but a healthier society is likely the final outcome.