Narcotic pain medication — too much of a good thing?

Many patient who see me in consultation have been prescribed narcotic pain medications for their back pain.  In my experience, this is often the beginning of a slowly developing disaster.  Typically, the patient is initially offered a prescription of anti-inflammatory medications by their primary MD which has a modest effect.  However, if the patient still perceives that pain is present, if they have taken a painkiller for some other problem in the past, or if they simply ask for something stronger, they are often offered a prescription for a narcotic.  Examples of narcotic pain medication include Norco, Vicodin, Oxycodone, and Lortab.  These are opiate medications that are in the same class of molecules as Heroin and Morphine and their effect upon the brain is still incompletely understood.  Recent research suggests that one of the effects of taking these drugs is an increase in levels of neurotransmitters — tiny little molecules that buzz around our brains and effect how we feel — such as Dopamine that are associated with generalized feelings of satisfaction, accomplishment, and meaning.  After taking these medications for a short period of time, the patient experiences the opposite emotions if the drug is not taken regularly.  This typically results in an increase in feelings of anxiety, depression, lack of purpose, and more PAIN.  For a fascinating discussion of this area of research, click here for a recent interview with Nora D. Volkow, the scientist who is in charge of the National Institute of Drug Abuse. (

Nora Volkow a general in the drug war

The first image in the next sequence of pictures is from the marketing campaign for a new narcotic pain medication.  In my mind, there is not much difference between the first image and the second.  Both are using advertising to deceptively suggest that a substance has less risk than it really does.  One thing is certain, the rate of narcotic pain medication consumption is skyrocketing.  The Drug Control and Access to Medicine Consortium, which is based at the University of Wisconsin, tracks world wide per capita opiate use.  The consortium publishes a fascinating interactive map and chart of world wide per capita opiate consumption online.  Click here for the DCAM web site.

nucynta opiate poster  marlboro man annual opioid consumption oxycodone use in 1995  oxycodone use in 2007  opiate consumption as a function of GDP


These charts speak for themselves.  The United States has the highest rates of per capita opiate consumption and the largest year upon year increases.  For example, in 1995, each citizen in the United States on average consumed about 10mg per year of Oxycodone, but by 2007, this rate increased to 140 mg of Oxycodone use per year per person.  This represents a staggering increase.  Some of the factors contributing to this increase include aggressive marketing by pharmaceutical companies, increased expectations on behalf of the patient, and increased permissiveness on behalf of physicians.  Narcotic pain medications are important tools and they are indispensable in the management of fractures, post-operative pain, pain caused by cancer, and other ailments.  IN MY OPINION, the use of narcotics for the management of back and neck pain without nerve root impingement is inappropriate.  Back pain is typically an open ended experience — meaning that there is rarely a defined point in the future when we know the pain will diminish.  This is unlike the situation faced by a patient who has a fracture or post-operative pain, for example.  If someone has a fractured bone, with reasonable certainty we know that the fracture will heal within 6 to 8 weeks and the pain will typically subside.  I have no problem giving someone with a fracture a prescription for narcotics because it is likely that the pain will subside within a reasonably short period of time and the patient will stop using the narcotics before they become “habit-forming”.  However, if someone starts taking narcotics for back pain, I frequently them, “When will you know that its time to stop?”  If they answer is, “When all of my pain is gone”, then this is a very unrealistic expectation and is likely to result in a long period of narcotic use which in turn leads to narcotic addiction.  While there are many doctors and patients who believe that narcotics are a reasonable drug to use for the management of neck and back pain, I do not.  I respectfully acknowledge that there are many medical experts and patients in this country who believe that pain is still being under-treated in the US but I do not provide the service of ongoing narcotic based management of pain.


Take home message #2: if you are not a candidate for surgical treatment, you will not be offered narcotic pain medication.

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Leave a comment

Alain Claudel, PT, DPT, ECS

11 years ago

Michael LJ Whyte-Feehan

10 years ago

I could not agree more. Prescription drug abuse amongst young people in the US, and, to some extent, the UK, is costing more lives per annum than illegal drug abuse. The reason for this is that they are much easier to obtain, especially if somebody in the home is suffering from a chronic pain problem but is not monitoring their drug use rigorously enough to notice if a few pills go missing. Young teenagers only have to obtain an enjoyable experience after taking a couple of oxy’s as a dare to become addicted in very short order. I have a disease of the spinal cord that ties me into consuming opiates and psychoactives. I am deliberately closely monitoring my own consumption to ensure firstly, that none of my meds go missing and secondly, to ensure that I keep my dosage down. The last thing I would need is to develop hyperalgesia and have to go running to my pain consultant for stronger drugs, if that means I have to manage more pain than the next guy, it’s OK. This policy saves me and my loved ones the temptations offered by such strong meds so it is well worth putting up with a wee bitty suffering. If you have low back pain, and 20% of the working population of the western world reports to the Dr’s office every year with it, explore every other choice available on the menu of treatments before asking for meds. I managed to keep going for over 30 years with regular visits to my osteopath who stayed away from the ARC but made sure the back muscles and structures above and below it stayed in good order. I would only advise against epidural injection procedures which my in depth research has shown me is ineffective and possibly dangerous. If you should have to resort to meds and have kids at home ensure that they are kept under lock and key at all times. When studying the abuse problem I came across a news report of an eight year old who found Mom’s meds, tried a few because of peer encouragement and died in his sleep!


Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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