Is Low Back Pain Inherited?

March 5, 2018 / Thomas Cohn, MD

A frequent question I receive from patients is whether low back pain is just your fate and if it’s inherited. This is an especially hard question to answer, but genetics may influence the fact that you develop problems with your back. There are many conditions that may cause low back pain, and some of them are linked to your genes and thus could be inherited.

Back pain that may have genetic causes include scoliosis, inflammatory arthritis, osteoporosis, spondylolisthesis, obesity and possibly even lumbar degenerative disc disease. Back pain in younger people tends to be more related to traumatic causes such as force exhibited on discs, joints and muscle sprains. In older adults, the lists of causes of back pain are often associated with lifestyle issues as well as genetic causes.

Inheriting Back Pain

There are certain causes we know that have definite genetic causes and have direct links to back problems. One of the most common is scoliosis. About 3 percent of the population has scoliosis, and in most cases it is usually a minimal curvature without any significant impact on the back mechanics, and therefore it does not cause pain. Most scoliosis is considered idiopathic, and that implies that we have no idea why it is present, but there is a family association of roughly 30 percent and thus there is likely some sort of genetic component. Another five percent of scoliosis is associated with a variety of neurologic and musculoskeletal disorders, like Marfan’s syndrome or muscular dystrophy, and these diseases are definitely related to genetic causes. A lot of these latter diseases are associated with significant curvatures of the spine and the structural abnormalities are painful.

Another category of genetic causes of back pain are related to certain inflammatory disease that are linked to arthritis. These are disease like rheumatoid arthritis, lupus, psoriasis, and ankylosing spondyloarthritis. All of those problems can cause a variety of structural changes to the spine, especially to the joints as well as to the discs and bones. These conditions can lead to structural and motion changes, whic could cause spinal narrowing and nerve irritation. The combination of physical changes in the spine often results in pain.

Degenerative Disc Disease and Osteoporosis

Research out of Kings College in London in 2012 identified a gene known as PARK2 that occurred in some 65-80% of those people whom have lumbar degenerative disc disease. As everyone ages, the discs do degenerate by losing hydration and shrinking in height. This may lead to some changes in movement patterns in the spine, and also lead to bony changes in joints and discs. Sometimes these changes can cause narrowing where the spinal cord is and where the nerves exit the spine. In some people these changes are painful, and in many they are not since the body can adapt to many things, especially if the change is very slow.

One common but often not recognized disorder that more commonly affects women is osteoporosis, which is commonly inherited. Thinning of the bones oftentimes occurs in the spine, which may cause the vertebral bodies to fracture and collapse downward. Sometimes these fractures are painful, and many times they are not, but the overall changes to the spine may lead to motion changes, muscle changes, and spinal narrowing, which may cause pain.

The overall answer to the question of whether your low back pain is due to genetics and is inherited is maybe. There are many things that can contribute to back pain and some of the most common issues are lifestyle related. A lack of exercise and obesity may be one of the most serious problems in our modern society. Many of us sit at desks all day long, eat too much food, and spend the evening in front of the television. Changing factors that one can control like the amount and type of exercise is often one of the most important strategies to treat back problems. One can not often change the inherited factors, but one often can change their impact by controlling your environment and lifestyle.

FDA Declares Kratom An Opioid

February 13, 2018 / Thomas Cohn, MD

We’ve blogged about Kratom in the past, but now the FDA is chiming in on the subject. According to the FDA, Kratom is more than a plant, it is an opioid.

“As the scientific data and adverse event reports have clearly revealed, compounds in kratom make it so it isn’t just a plant — it’s an opioid,” said FDA commissioner Scott Gottlieb. “And it’s an opioid that’s associated with novel risks.”

Kratom, which has been credited with giving users feelings of euphoria, strength and pain relief, has now been linked with 44 deaths. Aside from its obvious dangers, the FDA decided to classify the plant as an opioid because the drug taps into some of the same brain receptors as opioids.

The Dangers of Kratom

Like a number of drugs in their infancy, the dangers of kratom stem from the fact that we haven’t had much time to scientifically study the substance. Despite never gaining approval from the FDA, kratom was advertised as a concentration booster and workout enhancer in largely unregulated supplements. Because of its properties, it also made its way into the pain management community as a potential option for individuals with chronic pain. And ironically, it’s also been touted as a treatment option for opioid addiction.

“Patients addicted to opioids are using kratom without dependable instructions for use and more importantly, without consultation with a licensed health care provider about the product’s dangers, potential side effects or interactions with other drugs,” Gottlieb said in a previous statement.

Now that we’ve had more time to study the substance, researchers are realizing just how dangerous unregulated kratom use can be. After studying the chemical structures of the 25 most prevalent compounds in kratom, researchers discovered that they all shared similarities with opioids like derivatives of morphine. Moreover, two of the five most prevalent compounds in kratom latch onto the brain’s opioid receptors, just like other opioid painkillers do.

“The new data provides even stronger evidence of kratom compounds’ opioid properties,” Gottlieb said.

Some states have already taken steps to ban the substance, and it wouldn’t be surprising if Minnesota followed suit in short order. Kratom is already banned in Alabama, Arkansas, Indiana, Tennessee and Wisconsin.

At the end of the day, we have to remember that there is no miracle pill that can cure us of our pain or treat our opioid addiction. Trust that doctors have your best interests at heart, and that clinically tested and proven methods are best.

Independent Medical Examinations After An Injury

January 29, 2018 / Thomas Cohn, MD

One of my least favorite tasks is seeing what an Independent Medical Exam (IME) has said about any of my patients. IMEs are evaluations performed on a patient usually at the request of an insurance company or sometimes an attorney. Theoretically, these are to be used to determine the true nature of the medical problems and to provide recommendations for ongoing management of a patient. Usually they are performed in cases where there may be legal issues involved; mostly commonly the insurer is either workman’s compensation or auto insurer. These exams are performed by physicians who are often not actively in practice, and may not even have expertise in the area of treatment. Therefore the quality and purpose of such an exam is often questionable.

The Inherent Problems With Some IMEs

In my distant past, I also performed independent medical exams, most commonly for insurance carriers in workman’s compensation cases. The most common reason why insurers sent patients to my office is that they wanted to know what was really wrong with their clients and what may be the anticipated cost for future treatment. A good evaluation by a Physical Medicine and pain expert can at least tell them what is actually wrong with their client, and what are likely going to be necessary future treatments.

Instead of denying any injury ever occurred, several of the insurers took the proactive step to determine what was going to be the best way forward. Since they knew that I was going to tell the truth about the patient’s medical condition, it was valuable and a positive experience for both the patient and the insurance company. The last one I performed was a year ago and I had to ask if they knew the results may not be in the insurance company’s favor and if they would be okay with whatever I determined. Surprisingly, they really just wanted to know what was wrong with their client.

Most independent medical examinations I see are ordered by an insurance carrier and they only will hire physicians that they know will find any way deny that a medical problem exists. Often the physician will minimize an injury, and then report it as not feasible that the patient’s complaint can be present. The history taken is usually very short, and a physical exam is limited. The physician then develops “alternative facts” and delivers the “fake news” back to the insurer. Honesty and an understanding of pain, as well as most conditions that cause pain, is absent. The overall purpose is to minimize liability by the insurance carrier in a future legal setting. These exams are used to limit any ongoing medical care for a patient. The frustrating factor for the patient is that if these were done in a true independent manor and actually were done by professionals with real skill and understanding of the medical problems, then they could actually be useful.

Preparing For Your IME

The take home message for a patient who needs to undergo such an exam is that they need to be knowledgeable about the process. The patient should consider recording the exam for their own record, whether it is having a witness, taking notes or actually filming or recording the event such that one can counter incorrect information in any report. It is important for the patient to be fully cooperative and not combative and really participate in any exam such that any abnormalities will be evident. Lastly, insist that the report be made available to you or your legal representative so inaccuracies can be addressed later.

Rarely are independent medical examinations done to develop a full understanding by all parties involved in settling medical-legal issues. For a patient, the results of these exams should be taken with skepticism at best. For lawyers and insurance companies, honest and good exams would likely be more helpful. To develop future plans for a patient, currently the best source of information is usually the treating physicians. If the insurance company really wants to know what is wrong with a patient with a musculoskeletal problem, recruit the use of an experienced, board certified Physical Medicine physician. A good expert who can explain a range of management options is the needed expert to help settle questions in patient management.

Balancing Best Practices and Patient Satisfaction

January 24, 2018 / Thomas Cohn, MD

You would think that in all cases, giving the patient the optimal treatment plan will result in a satisfied patient. Surprisingly, this is not always the case. In an ideal world, a doctor would have a healthy and satisfied patient, but if they have to sacrifice one for the other, your doctor is going to put your health over your satisfaction.

Balancing the best treatment plan and patient satisfaction is especially tough in the world of chronic pain care. For example, in a recent study of nearly 20,000 people with musculoskeletal pain conditions, individuals who were prescribed opioids to manage their pain were much more satisfied with their care. Individuals who used opioids moderately were 55 percent more likely than non-users to report high levels of care satisfaction, and heavy opioid use was associated with a 43 percent higher likelihood of reporting high satisfaction. The more doctors prescribe, the better the chance patients are satisfied with their care.

The problem with prescribing opioids because it will satisfy patients is that overdose and abuse can set in at any time. Taking opioids for chronic pain is a primary risk factor for dying of an opioid overdose, and an overdose leaves many unsatisfied people in its wake.

Prioritizing Health

As we’ve said on the blog many times in the past and will continue to preach on here, we’re not anti-opioid. Pain medications can play a pivotal role in a pain management plan when closely monitored and administered. Instead, we’re anti doctors who prioritize gaining favor or satisfying patients by prescribing pills when it is not in the patient’s best interest or it is not coupled with active treatment modalities, like exercise, physical therapy or diet changes.

The study that analyzed patient satisfaction also pointed out a major flaw in the healthcare system – doctors are often compensated based on patient satisfaction, either directly on the paycheck, or indirectly in terms of online reviews and word of mouth. So we have a system that rewards doctors for doing what the patient wants, instead of what’s best for the patient. Providing the best care and satisfying the patient don’t always go hand-in-hand in pain management, and when doctors see more benefits in appeasing the patient than doing what’s best for them, it’s the patient who suffers.

Doctors are a lot like personal trainers at the gym. You aren’t going to grow muscles by wearing an ab band and sitting on your couch, you have to pick up some weights and put in the work. The same goes for treating your chronic pain condition. There is no magic pill that will allow you to heal without putting in the work on your end. You might not like your doctor at the end of the day, but if you find a good doctor, you’ll know that they truly do have your best interests in mind. Down the road, you’ll thank them.

Concerning Behaviors Associated With Pain Pill Abuse

December 14, 2017 / Thomas Cohn, MD

Opioid management is probably the most charged topic that we talk about frequently on our blog. Many of our patients and readers take some type of opioid medication to help manage their pain, and they get nervous or angry when they hear big government talk about restricting opioid access due to an increase in overdoses. The majority of people take their pain pills responsibly, and they are concerned that the minority who are abusing pills will make it impossible for them to get the opioids they depend on.

Opioids certainly have value in a pain management program, but we also don’t believe they should be the only treatment option that is being tried. And if you are going to take opioids, you need to be sure you use them responsibly and they aren’t abused by others in your home. One way in which doctors and family members can help stop painkiller abuse is by looking for certain concerning behaviors that are often associated with opioid abuse. We take a closer look at some of those behaviors in today’s blog.

Behaviors Associated With Pain Pill Abuse

Here are some of the behaviors that doctors and family members can look for that may suggest a person is dealing with a substance abuse or pain management problem:

Missing appointments.
Taking their pills for something other than pain.
Using more medication than prescribed, or asking for a refill before the prescription end date.
Repeated inquiries to get an increased pill dosage.
Being aggressive or hostile to healthcare staff or family members.
Taking medication in combination with alcohol or other drugs.
Lack of participation in other treatment modalities.
Bouncing around from doctor to doctor or clinic to clinic.

If someone you now is demonstrating a few or all of these behaviors, reach out for support. Contact Dr. Cohn or reach out to your specialist to learn ways to talk to your loved one about painkiller abuse and how to get them the help and support they need. It’s never an easy conversation, but it’s one that needs to happen.

The consequences of painkiller abuse can be deadly, so don’t sit back and do nothing. Contact a healthcare provider or addiction services center to ask about the next steps in the process. We’ve also compiled a few links that you can check out if you suspect that a friend or family member is abusing pain pills. Please don’t hesitate to reach out if you have any questions.