By Charles L. Rosen, MD, PhD, Central Illinois Neuro Health Science
One of the most frequent complaints a patient can have in their life is back pain. Back pain can be horrendous. It can literally bring a patient to their knees. Patients with severe back pain often can not work, exercise, play, or even sleep. It truly can be life altering. I have previously discussed the importance of avoiding surgery, and trying nonoperative therapies to improve back health. Surgery to relieve back pain due to mechanical problems, i.e. degenerative disc disease and arthritis should be a last resort.
So when patients come to me with “bad backs,” and horrible pain, why don’t I just give them some “pain pills,” usually meaning a narcotic based medicine? The brief answer is that the short-term solution greatly affects the long-term outcome.
Let me use an example to help explain. If you stand under a shower with running water, the way that water feels will depend in part on how warm or cold you are. If it is cold outside, and you feel water that is 85°F, that water will feel warm. Conversely, if it is really hot out, the same water will feel cool. Our brain is not good at being an accurate measurer, but it is excellent at perceiving differences. When something doesn’t change, we start to become unaware of it.
Let’s assume that when we first stand under the shower again, the water temperature feels hot. If we stand there long enough, the water will start to feel warm, rather than hot. At that point, you could turn up the temperature of the water, and once again you can get used to it. You can repeat this process until the water gets quite hot. If someone else were to stand in the same shower, that you now find refreshing, the other person might feel that the water was scalding hot. The issue is this: no matter how much you get used to the temperature of the water, the temperature at which you can be burnt does not change. Thus, the window of safety narrows.
The brain responds to narcotics in a similar fashion. If you are in pain, and you are given narcotics, the pain will likely go away, or at least feel much better. Assuming the source of the pain does not go away, after a few days or weeks, you become used to the narcotics, and the pain relief will diminish. You will then start to experience more pain. At that point, if you stop the narcotics, the pain will feel WORSE than before you started treating it. If you maintain the same dose, you will ultimately feel like you are in as much pain as before treatment began, and the only way to help is to increase the dose. Increasing the dose will help treat the pain, but only for a few days or weeks, at which point you will once again get used to the medication.
This cycle will continue until dosing gets high, at which point you are stuck. The options are to go higher, which is potentially dangerous, to keep the same high dose which only serves to keep you at the original level of pain, or to decrease the dose, which will make you feel worse. In addition to being dangerous, as dosing goes up, side effects like constipation and breathing problems, will also get worse.
This is not a pretty picture. So in order for narcotics to be useful, there must be a plan to decrease the source of pain in a short enough period of time, so that narcotic dosing can be decreased before the patient “gets used to” the narcotics. Patients who present with severe arthritis, and other types of degenerative disease, that have been building up over years with more and more pain, often can not be cured in days or weeks. It can take months of therapy to address these long-term changes. If a process of improvement can take months, utilizing narcotics in these circumstances can not only be futile, but counter productive.
This is just a brief explanation of a very complicated situation. At one point, there was a misconception that “real” pain, prevented addiction. However, in recent years there has been an increased understanding that even patients with real pain, can and do get addicted to narcotics.
Treating chronic back pain is a challenging problem. There still does remain a critical role for the use of narcotics in the treatment of chronic back pain, but it can’t just be “Doc, please just give me some pain pills.” The reason I don’t give that script, is not because I don’t care, but because I do.
Dr. Charles L. Rosen is a neurosurgeon at Central Illinois Neuro Health Science (CINHS) specializing in cranial base and neurovascular surgery. For more information, you may contact CINHS at 309-662-7500 or visit them online at www.cinhs.com. Their office is located at 1015 S. Mercer Ave. in Bloomington.