The ancient Chinese and Indian healthcare providers who were masters of acupuncture, yoga and Tai chai must surely be smiling in their afterlife. In a report released during the second week of February 2017, the American College of Physicians released new guidelines for dealing with the most common maladies affecting modern mankind – lower back pain – with these ancient health techniques before prescription drugs and surgery are employed.
Many medical experts called these guidelines “historical” in their implication for treating back pain. According to national media reports, such as this one from the Wall Street Journal, the primary reason for the issuance of these new guidelines lies in the epidemic of opioid addiction. “Opioids, one of the most commonly prescribed medications for pain relief and the source of the increasing addiction and death, should only be considered for chronic back pain when other alternatives – natural and prescription – don’t work”, say the guidelines, which were published in the Annals of Internal Medicine.
Even over-the-counter medicines such as acetaminophen, which is the primary ingredient in the popular pain medicine Tylenol, is no longer recommended for acute back pain. These new guidelines will most likely influence how doctors such as those at Texas Back Institute treat patients with back pain. However, one of these highly-respected and world-class spinal surgeons, Dr. Michael Hisey, feels most back surgeons and spine experts have been following these guidelines for many years.
These Guidelines Have Been Evolving for Several Year
“There’s not much new in these guidelines,” he noted in a recent interview. “We’ve always known that 9 out of 10 patients would improve without surgery, which should be the last option. I agree with these guidelines about not treating someone with a mild onset of back pain with opioids. If surgery is the last option, prescription drugs have become the next-to-the-last option for treatment.
“Narcotic drugs can be useful for short-term pain management treatment after surgery or a fracture, but they are not ideal for long-term treatment at all.”
Opioids: The Primary Focus of the Guidelines
Dr. Hisey explains how opioids “work” in the treatment of back pain and why they are also dangerous.
“Opioids are analogs of heroin and morphine,” he noted. “They target the pain receptors in the body, which helps give a patient relief but, unfortunately, they are also dysphoric, which means they can cause an intoxicated condition.
“They are also very constipating and they suppress the body’s ability to produce endorphins. When the endorphins are repressed and the pain receptors inhibited, the patient’s brain receives signals to ignore whatever pain is occurring,” he said. “Pain is there for a reason. It is ‘telling’ the brain that something is hurting the body and action should be taken immediately. This final point can lead to a dependence on the drug to manage any type of pain. This can cause both psychological and physical addiction to these medications.”
Acute, Subacute and Chronic Back Pain
These new guidelines are an update from 2007 and include a review of more than 150 studies. They are broken down between “acute,” “subacute” and “chronic” lower back pain. Dr. Hisey explained the difference.
“The difference in these terms relates to the amount of time a patient has had the pain,” he said. “Acute means one has had the pain for two weeks or less. Subacute pain is defined as two to six weeks, and chronic pain is longer than six weeks.
“For example, if you bend over and lift something that might be too heavy, you have a sudden ‘pulling’ in your back and then the next morning you wake up with your back stiff and sore, that would be an acute back pain. This type of pain can be effectively managed with treatment by a physical therapist by a chiropractor. They can also be treated with acupuncture.
“Even though these guidelines are ‘new,’ we have been treating acute, subacute and chronic pain in a manner consistent with them for many years. I am a spine surgeon, but short of a fracture or severe nerve compression, I would never consider recommending surgery for a patient with acute back pain. There is a similar protocol for prescribing narcotic drugs. They are not a first-line treatment for acute back pain.”
Sciatica is Not Included in these Guidelines
The condition of radicular lower back pain, which is often referred to as sciatica, is not included in these new guidelines. Dr. Hisey explained why.
“The symptom of sciatica is pain in the leg or legs,” he said. “It is associated with nerve compression and that pain is managed differently from lower back pain. It can involve the loss of neurologic function such as numbness or weakness. This condition must be addressed quickly, at the risk of long-term disability. While not everyone who experiences leg pain is a candidate for surgery, these patients are in a different category from the more common lower back pain.
“Interestingly, the patients with leg pain tend to respond better to surgery. We are always concerned about the unintended consequences of back surgery – more wear and tear in other, non-affected areas. However, with leg pain caused by nerve compression, the results of surgery tend to be more predictive and positive to the patient,” he concluded.
Check out the full interview with Dr. Hisey below!