In Part 1 of this series on back pain, we learned about Lamont, a man who had dealt with crippling back pain for most of his life, and the problems with understanding and “fixing” chronic back pain.
The irony of pain meds
As mentioned in Part 1, the human body has the incredible ability to adapt to opiates (pain medications), causing one to take higher and higher dosages over time.
Unfortunately, it now seems that high-dose opiates are now associated with interruptions in deep-sleep cycles. It’s counter-intuitive—even the name “narcotics” is derived from the Greek word for “sleep”. Poor sleep is associated with more pain, and consequently, depression.
There is a clear association with high-dose opiates and endocrine dysfunction. This causes dysfunction in the hormones for men and women, which in turn causes libido loss, decreased energy, a decreased feeling of well-being, and osteoporosis (brittle bones).
On top of it all, there’s emerging evidence that high-dose opiates are associated with increased pain! It’s so ironic: pain isn’t lessened, but probably intensified by the hundreds of milligrams of morphine people consume each day! This phenomenon has been proven true in rats, rabbits, dogs, sheep, and monkeys. And, with humans sharing about 98% of the same DNA as monkeys, it’s assumed that pain med-induced hyperalgesia (heightened sensitivity to pain) probably happens in people as well.
What did Lamont do?
If you remember from Part 1, Lamont’s body had adapted to higher and higher doses of morphine over time. When I met him, he had been taking 800mg of morphine per day. So, my first order for Lamont was weaning him down to a more acceptable level of pain meds. This wouldn’t be easy.
To reduce opiate intake requires a disciplined approach to dropping dosage slowly over a period of weeks or months. Too rapid of a drop, or a complete halt, would result in severe and painful withdrawals. (A detox clinic could be enlisted to get patients off a high dose in a more rapid, controlled manner, but insurance sometimes doesn’t cover that kind of service).
If Lamont could lower his dosage—and that was a big “if”—I wanted to work on getting him back in shape. He was very weak by the time we met—just getting on the exam table was difficult for him. He told me he got winded just by walking out to get the mail. This wasn’t necessarily because he was lazy; again, the pain Lamont felt dominated his life, making him feel that he couldn’t be active.
I told Lamont the possibility that his back pain had gotten worse because he’d stopped being active. The human spine is amazing—it can tolerate literal tons of pressure each and every day, and still give us years of excellent service. An interesting feature of our spine is that there is no direct blood supply to the spinal discs. The discs rely on getting their nutrition and fluids—and then dumping the cellular waste in an osmosis-like reaction—from nearby blood vessels. This exchange of nutrient-rich blood to nutrient-poor discs is maximized by physical activity. Being active—bending, twisting, increasing heart rate, increasing oxygen uptake—it all helps in directing nutrients to the discs.
Imagine it like this: Our spinal discs are sort of like a little pond next to a stream. The faster and stronger a stream flows, the easier it is to keep the little pond filled and clean. On the other hand, if the stream was just a slow trickle, the pond would soon become grimy and parched. Essentially, by being active, we can keep our “streams” of blood flowing easily and providing nutrients to our “little ponds,” or spinal discs.
Lamont also smoked two packs of cigarettes every day, which also contributed to his pain (and led to other diseases such as heart disease, stroke, and cancer). Many studies of patients with back pain show that those who smoke have worse, more tenacious pain. It may be due to the toxins in the smoke itself, or the carbon monoxide that prevents the blood cells from being able to carry oxygen—but what’s clear is that smokers experience more overall pain. Lamont had to stop smoking.
Understandably, Lamont was quite bitter about what had happened to him, and he was quick to blame his insurance company, doctors, surgeons, physical therapist, pharmacists, and everyone else who had been involved in his pain. Even as he described his fall from the ladder many years ago, he became angry. His face got red, his speech grew louder, and he spoke faster. To me, it seemed like he had been reliving the day of his fall over and over again for the past few decades. And, from the way his mother rolled her eyes when Lamont launched his tirade, she had heard this rant many times. So, I encouraged Lamont to also see a pain psychologist to work on relaxation techniques and a better mental response to his situation.
So, this was the broad plan we came up with: take less meds, do more exercise, stop smoking, and let go of anger. Lamont was very skeptical. At times, he got angry, and at one point, he walked out of the exam room. But his mother, who shared my point of view, helped bring him back and listen. It took two weeks for Lamont to agree to start working on a few things.
This is how Lamont started his journey to recovery:
- He chipped away at his morphine dose, dropping it by 10% every two weeks or so.
- He made it his goal to walk around the yard once, every other day.
- He agreed to see the pain psychologist, which was a big step. I’ll be the first to admit that the psychologist has been just as helpful, if not more helpful, than any of the other things we’ve done with Lamont.
That was two years ago. This is where Lamont is now.
- He’s down to 150mg of morphine every day. That’s an incredible 650mg decrease.
- He lost 35 pounds, and goes on a 30-minute walk or bike ride just about every day.
- He’s smoking only about ½ a pack of cigarettes a day, as opposed to 2 packs per day.
- He’s far less angry now, and his mother reports that he’s even been helping her around the house.
And, when it comes to his back pain, Lamont says the pain is “much better,” even though he’s only taking one-fifth of the amount of medications he was on before.
After so many years of trying to be free of an intense pain that controlled his life, feeling “much better” is the best thing that could have ever happened to Lamont. And for the rest of us, we can take heart in knowing that it’s possible.
- Back pain is common but for most people, it’s transient.
- If back pain becomes chronic, there are multiple ways to address it: physical therapy, cognitive-behavioral therapy, injections, medications, and surgery.
- Keeping active, within reason, is good for your back. This is true even if, or especially if you have chronic back pain.
- Work with your physician in establishing a “rational” poly-pharmacy approach to chronic pain medications.
- Stop smoking.