Scott Glaser, MD, DABIPP, president of Pain Specialists of Greater Chicago and a board member of American Society of Interventional Pain Physicians, and Steven P. Cohen, MD, director of medical education for the pain management division at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center, discuss eight myths surrounding pain management.
Here are a few important myths to note:
Narcotics are inherently bad. This myth has been supported by recent headlines after the release of the Center for Disease Control report that found almost 15,000 Americans died from prescription opioid overdose in 2008. The issue is not that cut-and-dried, Dr. Glaser says.
“Narcotics aren’t good or bad; they’re a treatment option with risks that need to be appreciated, communicated, and dealt with,” he says. “They’re not inherently evil, and doctors who prescribe them aren’t evil. For some folks, they’re life savers. It enhances their quality of life without adverse side effects. It’s easy to lose sight of that fact in the pandemonium surrounding the epidemic of prescription drug abuse.”
Dr. Cohen says the important thing is to prescribe drugs based on individual patients. For example, an older patient with cancer pain might respond well to opioids, but a young patient with back pain is at a higher risk for developing tolerance or even hyperalgesia, a condition that makes the body more sensitive to pain.
“It’s like everything else; these things have to be determined on a case-by-case basis,” he says.
All back pain is the same. This myth is found among patients, some primary care physicians, and multiple specialists, Dr. Glaser says. Primary care physicians and specialists such as neurologists don’t have the knowledge of the causes or the tools to treat back pain which leads them to lump lower back pain in to one broad category rather than attempt to understand the unique causes. Dr. Cohen calls this a naïve statement and says distinguishing different types of back pain is essential to determining treatment.
“Perhaps the broadest and most critical categorization is to differentiate between mechanical pain and nerve pain,” he says. “This is a really important categorization because it affects treatment at all levels.”
Dr. Glaser says there are many different structures that can cause back pain such as the intervertebral joints, the sacroiliac joints and effects on the nerves traversing these joints. Other causes include failed back surgery syndrome and the sequelae including adjacent level disc disease, destabilization and nerve damage. The prescribed treatment for each cause of back pain is different.
MRI always results in a back pain diagnosis. While MRIs can provide objective information about back disorders, such as degenerative disc disease and bulging discs, they rarely point to the cause of the pain because of the incidence of these findings in the normal population increases with age. Dr. Glaser says many issues that show up in an MRI might have been present before the patient experienced any pain.
“MRIs actually have very low sensitivity for diagnosing pain,” he says. “Degenerative disc disease is so common in human beings that if you do MRIs on asymptomatic 50-year-olds, 90 percent will have some findings consistent with a degenerative disc disorder.”
Dr. Cohen, who will be releasing a large, randomized trial on MRI use next month, says MRIs don’t improve outcomes and don’t affect decisions. They have very low specificity and are poorly correlated with pain and treatment outcomes.
Pain management is only epidurals. Dr. Glaser says interventional pain management specialists have developed different treatments — including injections, nerve blocks and neurolytic procedures — for different sources of pain.
“Pain management has evolved as a subspecialty because of the advancement and knowledge of the causes of pain through advances in our knowledge in anatomy and the sensory innervation of the joints in the lumbar spine,” Dr. Glaser says.
Surgery is an easy fix for back pain. This myth comes from a hope that surgery can cure back pain, but often there is no cure for back pain, Dr. Glaser says.
“It can be made asymptomatic, but you can’t stop degenerative disc disease,” he says. “You can only minimize the symptoms.”
Dr. Cohen says most studies show that in patients with back pain extending to legs or neck pain extending into the arms, surgery works temporarily. For the first six months, patients are better off than they would have been without surgery, but that benefit wears off after two years.
“First of all, it doesn’t work in everyone,” he says. “Even if it works, it may not improve long-term outcomes.”
Like all surgery, back surgery has its share of risks, Dr. Glaser says. Oftentimes, the risk is not worth the benefit for this elective procedure, he says.
“Back surgery is associated with a high risk of failure,” he says. “Even a microdiscectomy can be associated with rapid onset of epidural fibrosis or scarring. Surgery for back pain is always an elective procedure unless there’s compression of the spinal cord or nerve roots, which is actually extremely rare.”
** Please note that this article is based in an American perspective, written by doctors in that medical environment. Not everything that they comment on as a Myth would be considered the same in Canada or other parts of the world.