Spine Surgery Often Unnecessary in Treating Back Pain

October 16, 2013June 24, 2014 / Thomas Cohn, MD

A recent presentation at the North American Spine Society (NASS) meeting, points to the fact that a third of spine surgery patients are still using narcotic/opioid medications one year after surgery.

Further, the study indicates that of those patients using opioids before surgery, 51% continued a to use them a year later. The article goes on to discuss the concern that too much opioid prescribing is occurring. This is the wrong concern. The real concern should be whether spine surgery should have been done in the first place.

Reasons for Spine Surgery

The United States has one of the highest rates of spine surgery. Compared to most other countries, the spine surgery being done is mostly unnecessary. There are appropriate reasons for spine surgery, such as:

Trauma
Scoliosis
Changes in the spine causing nerve damage with loss of muscle or organ function

Pain alone is a poor reason for spine surgery. Most spine pain is caused by degenerative discs and joints. Treating this surgically most often only changes the location of pain, and does not resolve pain. Nonsurgical management of most spine conditions has been shown to be much more successful in numerous studies. Ask a group of surgeons, the answer of course is that the surgery works.

Pain management experts will usually have a more conservative view with regards to surgery. Spinal fusion surgery has at most a 30% success rate for helping with pain. Spinal surgery in general also has a 20% rate of significant surgical complication. The above statistics highlight the real issues with spine surgery – that it often causes more problems than solutions.

Alternative Treatment Options

Treatment for spine pain involves many different options, including a variety of medications and possibly opioids. Every person has different needs, and a Pain Medicine physician can evaluate you and help determine an appropriate treatment program. Surgery should only be considered if neurologic compromise is occurring and without intervention, loss of motor control or organ function may result.

Opioid medication use in the United States may be out of control, but so is spine surgery. Surgery and opioid use are truly independent problems. Pain and opioid use after surgery is not a surprising issue. The problem is too much surgery and not enough good pain management of spine problems by qualified experts.

Signs of a Pain Medicine Overdose

October 9, 2013November 17, 2015 / Thomas Cohn, MD

All medications can cause problems when not taken correctly. Pain medications, even those sold over-the-counter, can have deadly consequences when overdosed. Having the right balance of medications for pain and not having significant side effects is the trick that a good pain physician will try to develop for a patient. It is always necessary to keep track of the patient’s medications, even nonprescription to monitor for adverse reactions. This article will discuss the signs of overdose for opioids, over-the-counter meds, and neuropathic medication.

Opioid Overdose

Narcotic/opioid medications have had the most publicity concerning overdose. These are the drugs like Percocet, Vicodin, Oxycodone, and Morphine. These drugs are powerful analgesics and are commonly given for severe pain. Side effects are common and include:

Upset stomach
Constipation
Nausea
A tired or “drugged” feeling

Signs of an overdose of opioid medications include:

Excessive tiredness & sleeping
Low pulse and blood pressure
Decreased breathing

Significant overdose may be treated with a medication called Narcan to reverse these effects. There is a push for all emergency responders to carry Narcan since overdose of these medications is becoming common due to drug abuse.

Neuropathic Medication Overdose

Neuropathic medications include many antidepressants (like amitriptyline, and Cymbalta), and seizure medications (such as gabapentin, Topamax, and Lyrica). These medications often have annoying side effects such as:

Dry mouth
Short term tiredness

If they cause significant changes like memory problems or worsening depression, talk to the physician about problems. Overdose with antidepressants such as amitriptyline can cause severe respiratory problems and needs to be treated with acute hospitalization.

Over the Counter Medication Overdose

Over-the-counter medications like acetaminophen and ibuprofen also have problems if overdosed. Anti-inflammatories like ibuprofen can cause ulcers and stomach bleeds in some people, even at normal doses, but these affects can be treated. Acetaminophen however is very dangerous if taken in to high of a dose. Taking 1.5 times the recommended amount can lead to liver failure and even death. If you have been taking too much acetaminophen the eyes and skin can turn yellow indicating liver damage, and must be treated promptly by a physician.

Pain medicines can be very helpful in managing symptoms. Like all drugs, they need to be taken only as directed. Make sure your physician knows all the medications that you are taking. Additionally, be sure to talk to your doctor about whether you can eat certain foods, or drink alcohol with your medication. If side effects of a medication are a problem, talk to the doctor before stopping the medication, sometimes these drugs need to be tapered off or just changed slightly to be helpful.

FDA Increases Rules for Opioid Prescribing to Cut Down on Abuse

September 16, 2013September 27, 2016 / Thomas Cohn, MD

The FDA recently decided to tighten the labeling requirements for opioid medications. Over the past decade, opioid medications have become increasingly prescribed for pain conditions. Unfortunately, these medications have also become highly abused in the US. From multiple fronts, there has been a push to control the use of opioids and improve their safety.

A Brief History of Opioids

Opioids are strong analgesic medications used for a variety of pain control situations. Initially, they were used to treat short-term, acute pain related to surgery, injury, and illness. Eventually, opioids also became a pain relief option for terminal illnesses such as cancer. As pain became a concern in quality of life, and considered a “fifth” vital sign, opioid medication prescriptions blossomed. As opioid popularity increased, opioid prescription abuse also swelled. Now both the FDA and DEA are working to stem abuse and improve the appropriateness of prescribing by physicians.

Opioid Abuse and Pain Management

Pain is extremely challenging to manage and treat. The complexity of pain has spawned it’s own medical specialty – Pain Management. Twenty years ago, finding a physician who knew anything about pain management was a rarity. Currently, there are some pain specialists, but still very few board certified specialists in the US. Medical school training programs still do not have formal pain education, and most medical residencies have no pain medicine training or experience at all. Pain fellowships train only a small number of physicians yearly.

Pain management is complex, requiring specialized knowledge, and the ability to find a variety of solutions for difficult problems. Opioid medications have been easy to prescribe and often a simple solution to a variety of pain problems. The FDA is trying to change the wave of opioid use through changing the labeling of medications, warning physicians and patients that these drugs may be dangerous. Unfortunately, this is likely to be an overly simplistic solution to a complex problem.

A Better Solution to Opioid Abuse

Improving opioid prescribing is important, but the better starting point may be improving the understanding of pain by doctors as well as patients. Doctors need more training, starting in medical school and progressing throughout residency and practice. Patients would also benefit from the help of physicians trained and specializing in pain medicine. Pain is complex and opioids are only a small part of a solution. It will take multiple efforts to decrease opioid abuse, and improve appropriate prescribing. The FDA is starting the effort, but it will require concerted effort by doctors and the medical community to increase knowledge of opioid use and its potential dangers.

Opioid Use can Lead to Low Testosterone

July 24, 2013September 27, 2016 / Thomas Cohn, MD

Opioids are medications that include many of the common pain drugs that are prescribed for acute and chronic conditions. A few common examples of these drugs include:

Morphine
MS Contin
Oxycontin
Percocet
Oxycodone
Vicodin
Hydrocodone
Methadone
Dilaudid
and many are trade name medications

How Opioids Impact Testosterone

They are effective medications for management of pain at times, and block transmission and perception of sensory signals related to pain. However, in recent studies long-term use has been shown to cause significant hormone problems, especially androgen deficiency and low testosterone.

Androgen deficiency affects both males and females and may have a significant impact on quality of life. Common symptoms and complaints include loss of libido, fatigue, erectile dysfunction, hot flashes and depression. Physical findings may be:

Loss of muscle mass
Body hair loss
Anemia
Osteoporosis
Hypogonadism

Diagnosis & Treatment

Diagnosis is made by history of symptoms, exam, and laboratory analysis of blood for hormone levels. Treatment can be two-fold:

Reduce opioids
Hormone replacement

Opioids can affect the brain and the regions that control hormone production. Specifically, they affect the hypothalamus region and inhibit the gonad releasing hormone. This causes a decrease in critical hormones for both males and females including FSH, LH, and testosterone. Opioids also are thought to increase enzymes that metabolize and breakdown the above hormones in the body. Thus, these medications decrease these critical hormones in several ways causing significant side affects.

Long-term opioids are not a benign treatment for pain. If the pain is better, why would a person want to have depression, loss of hair and muscles? The problems associated with opioids are significant, and treatment with hormone replacement is often helpful, but may not reverse the damage these medications can cause.

No silver bullet exists for treating pain. Every treatment has risks and benefits. A good pain physician looks at problems in a comprehensive manner to reduce all risks and maximize benefits.