The scandal of cortisone injection material tainted with fungi has created a large burden of illness and death among a small proportion of individuals who received epidural injections for back pain. Calls for better regulation and oversight of compounding pharmacies are being made of the FDA and other governmental agencies. However, another story that may ultimately be more important needs to be highlighted. How many of these injections were indicated and how many were likely to be helpful to those receiving them? Unfortunately, studies demonstrate that the majority of these injections are not indicated and not effective.
In all medical decisions, it is incumbent upon the physician to calculate an analysis of the likely benefit of a given treatment versus the potential risk. This calculation is at the heart of all good medical practice. When a treatment is effective, doctors and patients are often willing to choose treatments that have a significant risk, such as is common in people with cancer. Another reason to tolerate treatment with significant risk is for conditions that are severely disabling, again as with cancer.
Medical decision-making for people with back pain has been very similar to that of cancer. Back pain is viewed by both doctors and patients as a severely disabling process that is likely to be chronic and unresponsive to simple interventions. Therefore, invasive treatments such as epidural and other injections, back surgery, and the use of opioid narcotic medications are commonly prescribed. The potential risk of these treatments is great as demonstrated by the fungal meningitis outbreak. In addition to this potential complication, the risks of surgery are well known, such as paralysis, infection, increased pain, and the need for re-operation. Opioids have been shown to have tremendous risk, having the potential for addiction, overdose and death, and the development of hyperalgesia, i.e., sensitizing the brain to actually experience more rather than less pain. Of course, the costs for back pain treatment are astounding, amounting to at least $100 billion per year in the U.S.
Speaking of the costs of treating back pain, the number of MRIs, injections, opiate prescriptions, and back surgeries has risen by 200-300% in the last decade or so, yet the rates of those with disabling back pain has also risen (by about 25%). What we are doing is clearly not working.
From my point if view, the problem is this: We are using the wrong approach for the majority of people with back pain. Only a small, proportion of back pain is caused by a clear pathological entity, such as a tumor, fracture, infection or obvious nerve root damage. These causes are estimated to comprise about 10-15% of those with back pain. The rest are likely caused by psycho-physiologic processes. This concept is so foreign to most people (and to most doctors) that it likely to be rejected out of hand. Yet, it is true. Minor “abnormalities” on MRIs are typically presumed to cause pain when there is no evidence that is the case. Abnormal MRIs occur in the majority of adults who have no back pain. Cutting edge neuroscience demonstrates that pain can be caused by the brain and that emotions lower the pain threshold. It is well known that the brain can create symptoms as severe as paralysis; this is called a conversion disorder.
What is not appreciated is that stress is the most common cause for chronic back pain (and other conditions such as chronic headaches, irritable bowel syndrome, and fibromyalgia). All pain is real — very real! Pain not caused by structural problems (e.g., fractures, tumors, infections) is caused by neural pathways that have been “learned” by the brain and create real physical pain. Careful histories of people with severe chronic pain uniformly uncover the underlying causes of the pain. Briefly, the situations that cause psycho-physiologic pain are those where an individual has been sensitized by stressful life events earlier in life (e.g., a controlling or abusive relative) and later a triggering event occurs such as a physical or emotional trauma that creates fear, anger, or guilt along with a sense of being trapped or feeling helpless. Severe pain develops as a reaction to these scenarios. The reason doctors never notice these connections is that they never take the time to look for them.
There is now an emerging body of literature showing that treatment of chronic back pain is effective when one uses a psycho-physiologic approach. We are in the process of publishing data showing that the majority of patients with severe chronic back pain can recover. This treatment approach is very cost-effective. In fact, it often only requires a change in how one views the cause of the pain and simple behavioral steps to change the nerve pathways causing pain. Dr. John Sarno has sold approximately a million books describing this model. From anecdotal reports, about 10% of those who have read one of these books have had rapid recoveries from chronic back pain. Can we learn something from 100,000 people? Most back pain (and other chronic painful conditions) can be cured. The current bio-technological approach of opiates, injections, and surgery is making us worse, rather than better. Millions of back pain sufferers need help and this help is closer than we think.
To your health,
Howard Schubiner, MD