Several events last week related to opioid treatment for lower back pain mean it could be on its soon become a thing of the past. And thank Heaven — we need to be paving the way for a future in using alternative treatments for back pain. Last week, the American College of Physicians shined the spotlight on the opioid addiction crisis, deeming the historically effective but notoriously abused drugs unnecessary for treating lower back pain, especially as a first method. New Jersey Governor Chris Christie signed a bill that limits the first prescription for opioids to only five days, calling the typical 30-day prescriptions dangerous and unnecessary. A physician can issue a second prescription of course if its needed but requires a pain management contract between doctor and patient after subsequent prescriptions. This not only invests the patient in their outcome to wellness but also acts as a de-facto risk education tool highlighting the risks that go along with these powerful medications.
A recent New York Times article regarding new guidelines by the American College of Physicians affirms how I have run my clinical practice and likely how most of my colleagues have as well. As surgeons, we’ve learned a great deal about acute pain management. But these new guidelines are still necessary because we are at a unique intersection of under education in the primary care physicians’ office and a severe and deadly opioid crisis that effects one in three households. The ACP guidelines suggest doctors no longer rely on medication, including over-the-counter analgesics, as their go-to remedy for the most common type of back pain: axial pain. When we say “axial back pain” we are referring to non-surgical pain confined to the lower back without radiculopathy due to a disc herniation that gets worse with particular activities or positions, and typically resolves itself naturally over time. This type of acute pain generally persists for four weeks or less, and the guidelines suggest looking to other remedies such as massage therapy and exercise (like yoga) while “waiting it out.” Even those with chronic back pain, or pain that lasts at least 12 weeks, are advised to take medication such as ibuprofen, naproxen, or acetaminophen as an alternative to opioids. But whether I or my colleagues agree with these new guidelines is a moot point since I practice in the state of New Jersey — and last week that decision was made for us.
The NJ legislature made an unprecedented move last week, passing a bill limiting doctor’s prescribing powers for opioids which the Governor signed into law. Every day 78 people die of accidental opioid overdose, according to last November’s Surgeon General’s Report on Alcohol, Drugs and Health. Because of the addiction crisis that is sweeping the nation New Jersey Governor Chris Christie signed a bill limiting painkiller prescriptions to five days only. My surgery patients vary with pain severity during recovery, but it’s rare that a patient requires opioid medication after five days. The difficulty in legal regulation is a “one size fits all” approach. But pain is subjective so there’s no way to define what the scale of 1–10 is — what constitutes a “4” for one patient may be a “9” for another. Normally, legally limiting prescribing powers is heresy to most doctors, especially when my pain management colleagues have spent a lifetime refining and perfecting clinical diagnostics of pain levels and deploying appropriate treatment plans. And make no mistake- I will defend physician discretion and the judgment of my colleagues to the bitter end on just about every area in medicine in addition to pain — but it is impossible to overstate or quantify the suffering and social consequences of our current opioid crisis. Desperate times call for desperate measures.
There is a moral obligation to avoid over-prescribing strong pain medication to a patient who does not exhibit pain that requires it, but there is also an obligation to treat a patient who is in pain and suffering. So where does all this leave us? Putting new guidelines and laws into place normally would be a risky proposition but both the new NJ law and the ACP guidelines are well thought out and carefully written. They happened after years of warnings culminating in last March’s letter to every physician in the country from CDC Commissioner Tom Frieden with new prescribing guidelines for opioids. They represent a good start and will hopefully be a step towards changing our collective understanding about opioid prescriptions and how we as physicians manage pain — ideally cultivating the conservative approach that a surgeon knows from handling powerful medications in an acute pain cycle. The problem that these regulations are responding to is over-management of both acute and chronic conditions with tools that are simply too powerful. If you are experiencing axial back pain, have a conversation with your doctor. If your doctor feels that either the guidelines and recent law are unnecessary or that axial back pain cannot be managed without the deadly risk of opioid prescriptions, it may be time to find a new doctor. In the meantime, rest, ice and ibuprofen will not only alleviate your pain but may save a life…
Originally published at medium.com