Sometimes, you're just a pain in my coccyx.

No, not you, I like you if you're actually reading this, low back pain (LBP) is the object of my ire. My old friend LBP, we meet again. As a former early 20 something male and Marine, I was obviously strong enough that I didn't need to take care of my body. My ego was about 7.64 times bigger back then too, which puts a lot of strain on the low back as well. After all, I was going to be the strongest and most hardcore (if you missed the sarcasm I have pity for you). All that and suddenly, like divine intervention, I have a constant companion. No, not Abby, though she is too. Back pain. 

Back pain is one helluva problem for a lot of people. Ranging from slight annoyance to shooting, debilitating pain. I will now quote myself because retyping is for suckers:

    

    "Back pain, specifically low back pain (LBP) is pretty common with worldwide estimates of 7-8% of people suffering from some level of LBP. Likely an understatement, especially because some people (maybe me) refuse to admit it until it becomes a really big problem. Either way, at least 577 million people as of 2017 have some LBP, likely even higher given that most of us can sit on our butts to work from home now and we all have terrible posture. Doesn't help that we have an obesity epidemic but that is for another time."

Call me the Poe of modern literature, I put Walt Whitman to shame with my prose. See? My ego is still pretty big. Putting that aside, back pain is a problem as I have covered before. One of the contentious points about back pain is what role drugs play. I'm sure everyone of the 3 people who read this have taken acetaminophen, ibuprofen, naproxen, etc.. many times for back pain (or any pain really). And anyone who has had a more serious injury has probably had some form of opioid pain killer for something "more powerful." For me, I have no experience taking anything more than dangerous levels of acetaminophen maybe so I cannot speak to their effect directly. However, opioids are very commonly prescribed for back pain.  I will do a post later about opioids and the many types of them, differences, and all that. But for now, let's talk about opioids and back pain. 

Sources differ in their estimates, but all point to the widespread use of opioids for chronic pain. One study showed in 2019, 22.1% of adults in the U.S. with chronic pain used prescription opioids. The CDC reports that chronic pain, pain lasting 3 months or longer, was present in an estimated 20.9% of U.S. adults while in those with "poor general health" (whatever that means), 67.6% had chronic pain. In those with musculoskeletal conditions (such as low back pain, osteoarthritis, etc..) the rate of opioid use between 2009 and 2016 was 20.5% and 24.5% in those with fibromyalgia in the same period. These rates can be higher in some countries with 30% of those who reported pain used opioids as reported from a study in Brazil in 2019-2020. 

I am not saying anything about if this is too much or if providers are too afraid of misuse and are not prescribing enough, merely pointing out their ubiquity. I am however talking about a recent study in the Lancet I read about on MedScape. 

A small group of participants (347) with at least "moderate" back or neck pain, were split into two groups, one that received the current Aussie guidelines (activity and reassurance) and an opioid (oxycodone up to 20mg/day) and one with only the guidelines. Checking pain scores on a 10-point scale, the opioid and placebo were almost identical, 2.78 vs 2.25 pain scores respectively. I would have liked to see more but I am not paying for this and I can't find it on my school library yet. Either way, the authors make the definitive statement that opioids should not be used for acute non-specific back or neck pain. What about chronic pain? Thats my question. Talking about combination therapy before, I would like to harp on it some more. 

These combinations do not have to be pharmacologic, in a poll of 2000 U.S. adults 42% utilized rest (never heard of that word), 34% used OTC pain medication, 32% had physical therapy,  34% used stretching, 36% got acupuncture or massage, 33% used hot or cold therapy, and 73% spent time with loved ones. That is a big range of things to do, and I will say again, this is not the right thing for everyone and I am not talking down about prescription pain meds either. This just highlights how expansive our repertoire is, and that wasn't even everything. I could go on, antidepressants (which may not be effective in themselves), anti-seizure meds, celecoxib, topical diclofenac, "Tiger Balm", and other stuff can all play a role. 

I would like to say something about antidepressants though, I talked about how they may not be effective in relieving back pain previously. But an elevated mood would seem to reduce the focus on pain. I can only speak anecdotally but depression can cause everything to hurt worse. All this to say, we need to look at the whole individual and the factors associated with their pain. Maybe their back hurts, they are depressed, and sedentary, treatment and education for this person will/may be different than someone with back pain, a history of opioid abuse, and osteoporosis (just making things up). What can we address without drugs? What are the priorities to treat? Does that mean we can use one medication to get the source controlled instead of three others for the symptoms? All of this is part of treating a whole person in my mind. 

Thanks for reading! If you enjoyed this, please share it. If you hated it, share it out of spite to your enemies. Check out the podcast if you'd rather hear my dulcet tones in your ears. Love y'all, be safe. 

References 

Americans Try Many Things to Ease Chronic Back Pain by Yasgur on MedScape from May 23, 2022

Chronic Pain Among Adults — United States, 2019–2021 from the CDC by Rikard et al., April 14, 2023

Image of osteoarthritic hip on x-ray from Radiology at St. Vincent's University Hospital websit

'Landmark' Trial Shows Opioids for Back, Neck Pain No Better Than Placebo by Brooks from MedScape on June 29, 2023

Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial by Jones et al., in the Lancet June 2023

Prevalence of pain and use of prescription opioids among older adults: results from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) by Mullachery et al., from The Lancet Regional Health in April 2023

Prevalence of Therapeutic use of Opioids in Chronic non-Cancer Pain Patients and Associated Factors: A Systematic Review and Meta-Analysis by De Sola et al., in Frontiers in Pharmacology November 2020

The National Health Statistics Number 162 from August 5th 2021: Prescription Opioid Use Among Adults With Chronic Pain: United States, 2019 by Dahlhamer et al., and the CDC

Pain Management Medications from the NIH StatPearls by Queremel Milani & Davis from February 2023