If disability is the ultimate benchmark, we are losing ground — not gaining.
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Unfortunately, there are no magic bullets, but I will give some pearls not always mentioned in the watered-down and overly politically correct pain monographs. I hope you will find that while patients with chronic pain do require more than quick 15-minute visits, once you have your system down and values in place, it does get easier — and sometimes even rewarding! First, let’s try to figure out how we got here. While one could argue that the increase in opioid prescriptions reflects better screening and detection of pain, let’s consider a recent article analyzing Medicare disability data.4 These data from millions of Medicare patients show that disability from pulmonary and cardiovascular disease has declined over the past decade — no doubt thanks to antitobacco programs and lifesaving cardiac interventions. However, disability from musculoskeletal injuries, namely back pain, continued to rise (from 20 percent to now 25 percent of permanently disabled workers drawing Social Security benefits). This is despite huge increases in imaging of the spine, epidurals, and back surgeries.4 If disability is the ultimate benchmark, we are losing ground — not gaining. If anything, we are pathologizing what previously may have been considered normal aging. Human beings were quadrupeds not long ago on the evolutionary timeline, and, as a trade off for bigger brains and freed-up hands, yes, we get bad backs at some point in our lives. Yet somehow, generations have managed to live with it, thrive, and reproduce. Now, back pain is considered a disease and is treated as such. Patients, in turn, are quick to assume this “sick role.” In 1997, with the robust L5-S1 of a 22 year old, I climbed the volcano Mt. Merapi in Indonesia with a tour group. Upon my descent, I collapsed on the side of the trail to catch my breath. While pondering why I paid for this experience, I was amazed to see what looked like an 80-year-old native lady lithely trotting down the slope with an ungodly stack of kindling on her back. Her muscles were impressive cords dancing under her tan skin, but her joints looked horribly knobby and arthritic. She
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smiled a toothless grin and left me in the dust. Since then, I have come to appreciate that if you don’t use it, you lose it. I sometimes reflect on this woman and imagine her transplanted into our American culture. Here she would probably be depressed, not know her neighbors, live in fear of crime, hoard lots of unnecessary goods made in China, have chronic pain, be on several pain killers, and have gone through a barrage of marginally useful imaging and treatment procedures. So how do we get out of this mess? Any pain expert will tell you that the goal of pain management is to maximize function, not eliminate pain. That is the one point of this article you should take to heart: FUNCTION. Forget the 0–10 pain scale; it is a carryover of an inpatient tool and has little utility in the clinic setting. Rather, a local pain management friend of mine asks every patient, “What are you able to do with this pain medication that you could not do before?” If there is no discernable increase in function like playing with the kids, tending to the garden, or riding the bike again, then the medication is not working and not worth the side effects or abuse potential. Here are the arguments I use to dissuade patients from opioids and to dissuade myself and the residents I teach from prescribing them. s Hydrocodone has become the #1 prescribed medication in our country and yet more people are becoming disabled (less functional) despite its use.2,4 s According to the CDC, deaths from prescription painkillers have doubled over the past decade. (Prescriptions for them have quadrupled.)5 s Visits to emergency departments for misuse of controlled substances doubled during 2004–2008. Over a half million people go to the ED yearly for misuse of controlled substances.1 s Methadone, oxycodone, and hydrocodone are statistically most likely to result in overdose and death.5 This doesn’t mean they are not effective and useful in many patients. But they come with real risks and require