Back pain in this country is big business. Interesting thing happened recently when the hospital was remodelling offices in the building housing cardiologists, along with spine specialists. Guess who got the biggest offices and most space? That's right the back pain docs. This is at a major heart center in the region. It's obvious that back pain and its related aspects are profitable.
One article I read said that back pain is the number one reason people visit their doctor. It ranks number two in why people miss work. It is responsible for 30% of workmans comp claims. It is a billion dollar industry that employs doctors, physical therapists, attorneys, drug manufacturers and many more. It seems like a lot of the surgery that is done on the back doesn't really help.
I am interested in this because we see so much of it in the emergency room. Everyday I would say that we see 10-20 people with chronic back pain. They are out of meds, they have an appt down the road, etc etc etc. They are often given vicodin or percocet. You might not like this, but I think the main reason they get the narcs is because it is easier for the docs, who don't want to deal with them. I have seen a couple of people get out of control when they didn't get their narcs.
I read an article in emergency medicine magazine that takes about a doctors role in treated chronic pain in the emergency setting. What's fascinating about it is that the author says that 50% of chronic pain sufferers have personality disorders or affective disorders. I can vouch for that. They wear you out, the people who come in for chronic pain because they are people who are neurotic and difficult to work with. Antidepressants have been found to be very helpful in these people, along with psychological help. They seldom get it.
What the author recommends is that acetaminophen be the first line choice for back pain, along with NSAIDS. He thinks that doctors should avoid using terms like, "pinched nerve", "ruptured disc", or "inflammation". Realistic expectations should be set for pain control. Long term management should be reinforced with physical therapy, exercise, etc.
I guess my thought is that in the emergency department we reinforce short term solutions. Why would you commit yourself to changing your lifestyle with exercise, relaxation, etc. when you can go to the ER and get a quick fix? Pretty soon you are dependent on narcs and will do anything to get them, including hospital hopping, making up stories. Why won't doctors commit to not prescribing narcotics for chronic pain patients and refer them back to their own doctors? Is it because all those back pain sufferers provide income for the ER or the doctor? Somebody tell me. Then we wonder why we are a nation of addicts.
17 comments:
There's a (rather large, IMHO) segment of the population that believes that any amount of pain, no matter how slight, is unacceptable. Period. They want their drugs. And they're damn vocal about it. The squeakier the wheel, and all that,
The rest of us in the minority accept that there is some discomfort associated with the real world, and move on with life. Without too much complaint.
what is really interesting is that one day I went into my brother's workplace to wait for him to go for lunch. It deals with auto repair and parts. There was a long line of impatient rude people waiting to get their car serviced, etc. What I noticed is that they were the same people I had seen standing at the desk in ER for years and they were the same about their tires as they were about their drugs...demanding and abusive to the person at the desk. I think it is just the way some people are. They like to complain in long lines!
When I go to Aldi's, a discount grocery store chain that offers generic and fresh foods at deep discounts, there are always some of the locals in there (it's in a bad neighborhood) literally screaming and hollering about the long line at the cashier's.
I was standing perfectly still and quietly waiting my turn and the guy in front of me was complaining to me about the line incessantly. I said, "We are saving like 50% on our food today, and so a 13 minute line doesn't bother me one bit. We've only been waiting 8 minutes so far, I've been watching. If it bothers you enough to complain, you should go pay 50% more for the same stuff and go to a different store---there are 2 more grocery stores within 2 blocks of here."
That shut him up and he actually started telling the other people in line the same thing---hey, we're saving a lot of money, what's an extra 5 or 10 minutes in line? Quit complaining, let the cashier work! I felt like I'd won a battle against loud, obnoxious people that day.
Once we're relatively certain the patient doesn't have an aneurysm, paraspinal abscess, cauda equina syndrome, or anything else that might be dangerous, we don't really have to give them anything except a reassuring pat on the back and a fare-thee-well until their next appointment.
But most of us are compassionate types who don't like to see our patients suffer, and all we really have to offer the chronic back painers are medications. A handful of vicodin, maybe a muscle relaxer and the NSAID of choice.
Who cares, really? If it gets them out the door even one minute sooner and with less drama than the hard-ass approach, then it's win-win.
Kudos! Very informative article, keep up the good works! More power
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Polarising an issue such as chronic pain seems rather arrogant and futile. Nothing is gained except more aggravation and perhaps some form of pleasure by the antagonists.
If it is so, that CP patients are largely overreacting to some minor pain event as implied here, can the good Dr explain why, when said patient is denied pain relief long enough to go into withdrawal, that they experience acute pain at the site? (e.g. back, neck,etc) Surely if he was just a malingerer, he would suffer the standard withdrawal symptoms which are not site specific.
Jason
I have chronic pain issues, and I have found some relief in replacing my computer chair with an exercise ball. I've had several friends do the same, with good results. It's a decent suggestion for people with back pain who have jobs where they sit down a lot.
Of course, I keep the chair nearby for days when I'm too exhausted to concentrate on sitting on the ball, but overall, it's been a good thing.
As a person with Ankylosing Spondylitis, (and yes, that is mostly back pain), I have been prescribed Kadian and Oxy IR for my pain.
On occasion, for one reason or another, I have had to venture into the emergency room. I really don't like it, but it has happened, and when it has happened a flare of my chronic condition, Spondylitis, has been the cause. My doctor tells me to go, so I go.
Perhaps, I am one of a few people with chronic pain that most see in the ER that doesn't ask for narcotics. I don't know. I only know that my pain is out of control and I need some help. As I related to one emergency room doctor, "If you were to tell me that standing on my head for an hour in that very spot over there would help my pain be even a little less so I am then able to function, I'd do it.".
I do not expect to receive narcotics whenever I visit an ER. I don't like taking them to begin with and wouldn't if I could do things any other way. What I do expect is a small bit of relief so that I can get myself back to functioning semi-normally, and make it to my regular physician.
I *do not* expect to be pain free all the time. I do expect to be able to live with dignity, and part of living with dignity means being able to function by myself, for myself. If my pain is so bad that I am unable to do that, is anyone winning?
Narcotics aren't the only answer. I believe that the narcotics help me to be able to do other things that help my pain. Without them, I couldn't exercise. With them, I can exercise, and as I became stronger, I was able to cut down the dose of my narcotics.
I suppose it will always be a double-edged sword.
I was hit by a car when i was a kid and have alot of back ache and back pain but i dont see why i should claim benefits or not work! There are plenty of ways to reduce back pain so you dont have to miss work, i have a special mattress for my bed that lets me sleep and i can wake up without pain! That greatly reduces any pain i suffer so why cant others do the same?
Back Pain is a pain in my… well… back!
I was hit by a car a few years ago and since then I have suffered a lot of lower back pain and back ache! I was on strong painkillers for awhile but then I was getting addicted to them so had to drop them before it got too bad. That was about a year ago now and since then I have been looking for alternate ways of relieving the pain and aching until a month ago I was struggling to find anything that helped but I managed to get hold of some Cheap Slumberland Beds and I finally got a good nights sleep! It was great!
However!
Upon waking from my beautiful bed the relief only lasted until I got to work then the suffering began once more!
Can anyone give me any advice to ease my pain?
My mother has suffered from chronic back pain for about 15 years now and reading the main blog and then other peoples comments to it I see why it really has been a struggle for her. The doctors, the nurses, the pharmacist, and random people who harrass us when she puts up her disability placard. I definetly understand that our nation is dependent on drugs and most people do not need them and are addicts and that is what is sad because the people, like my mother, who do have legitimate pain get treated so poorly. To give a brief background on my mothers pain she has been diagnosed (by several top doctors, not SELF diagnosis): Chronic back pain (due to 3 ruptured disks from a work accident and 3 failed major back surgeries , Reflex Sympathetic Dystrophy (RSD), ( I cant remember the term) no blood flowing to the hips to where she will need total hip replacement, fractured neck bones, degenerative disk disease, osteopeana, and currently a broken foot because the bones are so fragile. So im sure many of you are saying this is ridiculous and it is, but its true! And on top of it the medicine she takes is so vile it rotted out the whole top row of her teeth to where she has to have a denture! And you talk of just getting a new bed, exercising and get a medicine ball to sit on...well thats crap. Some people do not have the money to buy a tempur pedic bed, exercising would break more bones and the one saying they sit on a ball while at your computer, YOU DONT HAVE " CHRONIC BACK PAIN" so you shouldnt even comment on it. My mother has been through so much dealing with the negative attitude of this nation on people who really have pain, she cries day to night, but she wants to live and hates everyday she cant work, she loved her job. My final word is, if you dont really have chronic back pain or live with someone who does you know NOTHING about it, nothing. You the nurse and you the doctor, imagine someone stopping your life and taking everything you enjoyed in it and leaving you with the worst pain you have ever felt in your life and its not getting better it will only get worse! So think about that when someone comes in to the ER for back pain and you and your colleagues go laugh at them in the break room and call them a quack and say they need mental help, your part of why America is full of heartless, cold people especially in the medical field. (And also I am not just some child "sticking up for my mother", I am a graduate student from a top college who is done with people suffering with chronic back pain being treated poorly by everyone!)
So why is it that so many people with this "chronic" (which means "continuing a long time or recurring frequently" as defined by Webster's dictionary) pain find themselves in the emergency (which means "a sudden, urgent, usually unexpected occurrence or occasion requiring immediate action" as defined by Webster's dictionary again) room? If it is chronic pain, don't they then have a primary care physician that takes care of them on a regular basis, especially with such long-winded health conditions as you listed above? I would think that chronic health conditions would be better managed by a health professional who has a relationship with the patient and knows all of the facets of the chronic disease processes, not some poor ER physician or nurse who is forced to muddle through and decipher the myriad of health conditions listed on the "medical history" portion of the triage form; at which point the ER doc ends up contacting the primary physician anyhow (usually in the middle of the night), to get a reccommendation as to what the proper medication/treatment/test would be for this individual. But hey, that's just my side of the pancake. Maybe you wouldn't get such vile looks from the ER staff if you used the ER as it was intended.
FOR INDEPENDANT SLAVE
I have Chronic back pain, I had a doctor I went to when the sciatica flaired up, I was treated with steroids, anti-inflamitories, and darvocet. I went through this for 3 years and I told my doctor I felt I was getting worse and she told me it was JUST sciatica and I'd be fine. When I couldn't even sit in my chair at work properly, had to sit on my right hip and stretch out my leg to be able to do any work, had numbness going down my left leg and weakness, which my doctor dismissed until I showed up at her office w/o and appointment because they were booked and told her I needed to be see, that is when she finally sent me to a specialist who took x-rays and mri's and I was diagnosed with severe degenerative disc disease throughout my entire spine and stenosis throughout my entire spine and bleeds and told they'd try physical therapy which was scheduled a week out. I followed what my doctors said, my general practicioner who let my condition worsen w/o sending me to a specialist when I first spoke to her of my fears, and listened to the specialist that physical therapy was the way to go. I had severe pain over the weekend and went to the hospial ER, they did the mri and x-rays and the ER doctor was very nice but he said he had the same thing as me and he was able to live with it and he sent me home, 2 days later I woke up and lost all bladder control and could barely walk, lost most of the feeling in my left leg, I went to the ER and I had emergency surgery that day. 3 1/2 weeks later it happened again, so I was back in the ER, this surgery found tumors, in the exact same place the first surgery was done 3 1/2 weeks earlier. A year later I told my specialist of arm numbness and weakness in my hands and arms and I was told that I didn't look like I had any problems, that most of his TRULY IN NEED patients needed assistance to get back to the exam rooms so I felt offended but I also was intimidated but I insisted he treat me as if he believed me so he did make an appointment for an MRI which was set for 2 months later, he said he couldn't get it earlier even though I told him I really thought it couldn't wait but he said he knew better than me. I waited about a month and a half but my symptoms were getting worse and when I'd call the dr he had his nurse tell me my MRI was soon and he'd see me after he got the results but I couldn't wait I went to the ER and I was diagnosed with cervical stenosis which was damaging my spinal cord and had emergency surgery, had 4 cervical discs removed, bone from my hip put into my vertebrae for fusion where the discs were removed and a plate and screws. I now have a lovely huge scar in the front of my neck, vertically, not horizontally because my doctor didn't take me seriously and put off the MRI for a two months. THIS COULD BE WHY PEOPLE WITH CHRONIC BACK PAIN GO TO THE EMERGENCY ROOM.
When you have insurance and your doctor refuses to give you a referral for a specialist or your specialist says there is no reason for emergent service by him then insurance will not pay for me to dr hop so the emergency room was the only option, and the right one.
I could have been paralyzed from the waist down the first couple of times and the last time my arms suffered permenant nerve damage. I avoided going to the ER because of people with the same attitude as you have of people going to the ER, even family members saying trust your doctor. I say, trust your instincts if your doctor will not do all he/she can for you.
It's not all black and white. People shouldn't have to suffer, there are those who abuse it, but I'm not one of them and I was made to feel like I was by all the doctors and the emergency room nurses and doctors until PROOF came back I was not drug seeking, do you know I almost didn't go to the ER the first time even after losing bladder control because of the way I was treated by nurses the first time I went, the only person who treated me like I wasn't a drug seeker was the dr who said he had the same thing as me, but still, he didn't help me so I was very wary of going back.
All I can say is "What comes around goes around." God is not looking at you all too kindly . YOU may be the next victim of chronic pain. God wants you to learn. And if you don't change, He'll keep giving you harsher and harsher lessons. God please take care of all those people that end up in YOUR ER that are being unjustly judged and critisized. God may NOT have mercy on YOU when YOUR time comes. We have posted all of YOUR comments on the National Chronic Pain Suffer Association. You should see what is being said about all of YOU crazy character defected so-called "professioanls"
How dare you self-righteous people condemn those of us who can barely walk and suffer all day with substantial pain. Believe me, those who need to go to the ER don't go through the ordeal of getting there unless they are in extraordinary distress. To the person who sits on a ball--I only wish I could sit on anything and work. Not working because of pain occupying all my thoughts all day and night is pure hell.
All I can say is I hope that one day all of you people who belittle, label and generally dismiss chronic pain get to experience the hell it truly is someday. Not only do we have to deal with excruciating pain, but we have to deal with bigotry on top of it.
To those of you who wonder why people with chronic pain who have regular physicians may need to go to the ER, I have two words for you PAIN FLARE. Pain is not typically static; it fluctuates. One minute you can deal with it, and the next you are curled up in your bed, unable to straigten out in order to walk to the bathroom. There is no one to call, because your pain doctor doesn't take call from patients atfer hours. So, you wait. And wait. Until you can't stand it anymore and are willing to put up with the *looks* you get from the ER personnel.
Have some compassion, people. One day it could be you in the flimsy gown on the gurney hoping that you get an understanding physician.
This article is depressing. I got here because of a google search. I am miserable. I am in pain and can't hardly fuction here at work. After 10 years happily here, my work is going to sh1t because I can't concentrate due to pain. Nobody cares to help me. My doctor give me inneffective medicine. This article makes it clear going to the ER is pointless. I want help, not drugs. I have been to my primary care doc, a spinal doc and even a psychologist out of desparation. At this point, jumping off a bridge is looking good.
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