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. (http://www.nytimes.com/2011/06/14/science/14volkow.html)
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.
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.