How pain changes us

When I was eleven years old, my family adopted a dog from the San Francisco animal shelter. She was a special dog-- a regal mutt with the posture and coat of a Doberman, softened by an unidentifiable 'other'. We didn't meet her at the shelter. In fact, my mom found her one early morning stepping off the commuter bus in San Francisco. The dog was running up and down Parnassus Avenue with no supervision-- a recipe for disaster. Mom coaxed her into her capture and kept her on campus for several hours until animal control was able to retrieve her. When the dog-catcher finally picked her up, he mentioned casually to my mother that she had first rights if no one claimed her.

A week later, we took her home.

We named her Skippy, after our favorite peanut butter.  Skippy spent the entire 40 minute drive home jubilantly licking my little sister's face in the back seat.  She was elated!

Two weeks later, Skippy broke her leg running in the hills by our house, and over the next several days she morphed from a vivacious lovable licker into a seriously mixed blessing. She became cranky and frustrated. She was easily upset and downright mean. Perhaps worst of all, she was unpredictable.


We often have wondered how much that broken leg shaped Skippy's personality and her world-view-- after all, the story only begins with the broken leg. The aftermath was months and months of casts, pain, repeated trips to the vet, restricted mobility, and a serious lack of exercise. During her darkest moments, Skippy would literally lay down in the middle of the road and refuse to walk a single step further. If we tried to coax her, she would bare her teeth and growl. There were multiple instances when 12-year-old me would sit in the middle of the street for thirty minutes or more waiting for her to be ready to move on. She also began to snap at us if we tried to keep her from chewing at her cast and soon became tremendously possessive about her food.

She was angry.  We were scared.

Eventually Skippy recovered physically, and though she did not seem to suffer permanent disability from her broken leg, the effects of those few months on her personality never retreated completely. For much of the next twelve years, she was a loyal, playful and loving dog, but she was forever unpredictable. When upset or unhappy, she would bare her teeth and growl. She bit all of us at one time or another (plus my favorite cousin, at least one neighbor, a passing cyclist, and the mailman). She misbehaved frequently and did not respond well to correction. She often acted wounded, not in a pathetic beaten-down sort of way, but in a overcompensating self-righteous way. She remained a behavioral challenge her whole life, and we adjusted many of our own family patterns around her capriciousness. And yet, we loved her.

We loved Skippy so much-- so much so, in fact, that almost ten years after her death, we still reminisce regularly about how smart she was and how special she was, despite her very obvious shortcomings

Even so, I will always wonder what pain did to her psyche.

As a physician, I see lot of pain during my work days: headaches, ear pain, neck spasms, low back pain, chest pressure, stomach pain, pelvic pain, hip pain, knee pain, finger pain, and even isolated large toe pain (gosh darn gout!). Heck, much of my day is filled attending to patients in pain.

And this little list doesn't include all the examples of what I like to refer to as life pain: pain caused by separation and divorce, abandonment, addiction, poverty, unstable housing, violence, depression, poor self esteem, physical disability, learning challenges, generational oppression, sexual assault, sexism, racism, and more.

The list of things that cause pain is endless. And pain changes us, just like it changed Skippy.

Pain makes some of us edgy and anxious. It makes others impatient and frustrated. And still others tired and listless. It colors the world in a yucky grey-brown color that kind of looks like a mix of vomit and poop and makes us not want to eat, ever again. It shortens our fuses, lengthens our nights. It turns some from half-full leaders into half-empty followers. It disrupts sleep and one's sense of smell. It influences appetite, making some eat more, others less. It's depressing and anxiety-producing. It's scary.

Those of us who have been lucky to live much of our lives without pain should consider how crappy we feel when our throat hurts for a day or our wrist aches after writing a long letter. Many of us crumble completely under just a few hours of discomfort. Others tolerate quite a bit, until we can tolerate not one moment more. Pain is life altering in ways that we might never predict, until we experience it.

Like Skippy, I believe we are all lovable lickers in our essence. Most of us want nothing more than to gallop through the hills at full speed, be caressed by those who love us, get scratched in that spot that itches the most, be commended for our beauty, and be given special treats for good deeds. But, just like Skippy, we are also all mixed-blessings, victims of our life circumstances and undeniably changed by the myriad pains that we experience. After all, we cannot completely avoid pain.

And so, this is what I wish for all of us:

May  our pain be limited.
May our pain be tolerable.
May we acknowledge the power of pain over our very essence.
May we believe in the power of recovery.
May we be patient.
And may we not bite one another at any point in the process.

Why does back pain hurt so much?

I know you well. I see you a couple of times per week. Sometimes I see you a couple of times per day.

Your back hurts.

http://www.sweetsharings.com/2013/04

You are the young dad who threw your back out this weekend wrestling with your kiddo right after helping your buddy move a piano up to his second-floor apartment.

Or perhaps you're the very pregnant lady who cannot find a comfortable place to stand or sit or lay down or basically exist in the world because your back is killlllling you.

Or you're the vineyard worker, hauling huge crates during crush without a proper moment to adjust your body mechanics.

Or you're the mom of a twenty-five-pound toddler who insists on being carried most hours of the day.

Or maybe you are the middle aged dude who commutes two hours five days a week and whose back will not forgive you this month, even on days you avoid the car entirely.

Or perhaps you are an amateur athlete training for a big event next week with a little zinger that moves from your mid-back down your leg.

Or you're a waitress. . .or a student. . .or a nurse. . .or a programmer or a writer or a baker.

Whoever you are, your back hurts, and you join lots and lots of fellow humans, who at some point in our lives, will suffer from back pain.

Back pain is common
In fact, 25% of adults report having had back pain for at least one whole day in the last three months. Back pain can be miserable (serious misery), and though many people with back pain do not seek medical attention, studies show that 1in 10 primary care visits is for  back pain

As a family doctor, I see about 18 patients per day. That means I see 1.8 patients per day with back pain. And most people with back pain are unhappy-- they are so unhappy that they have taken time off work, ridden their horse three hours bareback, and hired some scary babysitter to watch their kids to come and see me.

Little me.

That's a lot of pressure (on me).

And a lot of pain (for you).

And to be perfectly honest, I hate your back pain almost as much you hate your back pain. Give me an ear ache or strep throat or a funny looking mole or even a broken arm any day. I can fix those (or at least make you feel better) even before you leave my office. The problem with back pain is that there is no quick fix, and, quite honestly, that sucks (sorry, Mom-- she hates that word).

I know very well that when people come to the doctor for back pain they are always 1) in a lot of pain and 2) scared.
 

Just before I knock on the exam room door for a "back pain" visit, I often find myself wishing for a magic rock, fairy godmother, any god, even a mind-altering substance-- knowing any of these modalities will make the pain and the fear go away quicker than I will be able to. Unfortunately, my wish is never fulfilled. Instead, I summon up my own empathy, compassion, and good listening ears. These are my  most effective doctoring tools-- especially when it comes to back pain.


Here's the scoop on most back pain
1) Back pain, particularly low back pain, is super duper common. As I alluded to above, between 70-80% of adults will experience back pain at some point in their lives. Each year, between 6% and 15% of people will experience back pain for the first time. I'm sorry. I feel you. I've been there.

2) Most people don't go get seen by a doctor when their back hurts. 

3) Back pain usually rears its evil head in people between the ages 20 and 50, with the highest rates in people in their forties.

4)  Most often back pain fits into 1 of 4 general categories: non-specific low back pain (that's most people), pain with radiculopathy (radiculopathy is doctor-speak for pain that radiates somewhere, most often down into the back of the leg, often referred to as sciatica), spinal stenosis (pain caused by the spinal cord getting scrunched inside the vertebrae, most common in older people), and back pain as a result of another "spinal" cause (this is a catch-all category including most of the very scary things that people worry about when their back hurts, e.g. the big "C" metastatic cancer, spinal infection, fractures, etc)

5) Back pain usually goes away (check this out: 54-90% of the time it resolves with absolutely no intervention)

6) But then it often comes back (recurrence rate ranges between 24-80%). Sorry.

7) Doctors often don't know how to make patients feel better

(I know, this is exactly what you didn't want to hear. In a recent study of almost 24,000 patients with back pain (1999-2010), doctors were found to be prescribing less anti-inflammatories and acetaminophen and increasing opiate medications (e.g. vicodin, oxycontin-- 19-29% of the time), even though the studies consistently show opiates don't do a better job for pain. The same study also showed an increase from 7% to 11% of patients getting an MRI or CT scan to evaluate their back pain, even though there is really good data discouraging providers from doing so.

8) First line medications for back pain are acetaminophen (aka generic Tylenol) or non-steroidal anti-inflammatory medications (in doctor-speak NSAIDS, including ibuprofen, naproxen, motrin, etc).

9) X-rays, MRI, and CT scans are not actually therapeutic. They do nothing (I repeat "nothing") to make you feel better. However, requests for these imaging studies are an important reason people make doctor's appointments. There is something about the human psyche that makes people believe that getting that MRI will make them feel better. I have no idea what that is.

10) You should probably only get an MRI/CT scan if you are considering surgery (or epidural injection). If you are one of those "No way in hell, doc, is anyone operating on this virgin spine" people, then trust your doctor NOT to order you an MRI. Why?

When even the doctor is scared
Of course, there are (rare) cases when back pain can actually be scary. Here are a few examples of what health care providers call "red flags"-- things that make us worry your back pain could be something worse than run-of-the-mill-every-day-back-pain. Please do note that these red flags are NOT perfect. In fact, more than 80% of people will have at least one of these red flags with their back pain and still have run-of-the-mill pain, but if someone has more than two, a provider will likely be more thoughtful about the evaluation.

• A personal history of cancer
• Recent unintentional weight loss (over 20 pounds in the last 6 months)
• Age over 50 or under 17
• Not getting better, especially after 4-6 weeks
• Persistent unexplainable fever (>100.4)
• You inject drugs
• You have new problems controlling your bowels and/or bladder

There are many more in the list of red flags, but you get the gist. A good health care provider will probe a bit to be sure he/she isn't missing a more serious diagnosis. This is just one more reason to have a personal relationship with your primary care provider--it's double advantageous for your provider to know you and to ask the right questions.

For all of those patients who DON'T have red flags, here's my doctor shpiel for routine I think I might die back pain.

I'm sorry, back pain is evil.
I'm sorry, I am so glad I am not you right now.
I am sorry, I know it feels like you are going to die.
But this IS going to get better.
It really is.

And in the meantime, after you are done cursing your body and your provider, please consider:

1) Anti-inflammatory (NSAID) or acetaminophen for pain, whichever you find helps most.  (I hate to tell you, but Vicodin and all its bed brothers (e.g norco, percocet, oxy etc) do nothing for back pain. They just numb you against the evil unfairness of being in pain. Such numbness might seem helpful, but can also be risky). 

2) Rest (though rest just for a little bit-- in the good ol' days, people with back pain used to be sent to bed for days-- research has found that prolonged immobility makes back pain worse). You shouldn't be lifting those giant bags of rocks or cleaning your bathtub tonight, but hopefully you can get back to those activities in a short amount of time. Gentle walks are a good idea.

3) Ice/heat (whichever your prefer, don't believe anyone who tells you there is actual evidence that one or the other is better). The choice is yours.

4) Time (and time's best buddies: patience and trust)

5) In very certain circumstances of acute spasm (e.g. your boy friend lying frozen on the ground saying, "I cannot move, I cannot move, do something"), just a few short days of muscle relaxant might be indicated (like cyclobenzaprine or baclofen or diazepam). My patients know I am stingy with these guys-- just a few days worth can sometimes do the trick. Talk to your provider.

6) Core strengthening is always a good idea. It probably does nothing to help your acute back pain but may prevent recurrences by taking some of the stress off your overloaded back.

7) Restructure your work station (too much sitting is FAMOUS for causing low back pain, often screens are not appropriately set, etc) or your work environment. Often it's something you are doing 6 or 9 or 11 hours a day that's really driving your back mad. Change that!

8) Consider physical therapy and integrative modalities if you cannot seem to kick the pain-- my personal preference is osteopathic manipulation (OMT), an amazing medical modality that is gentle and actually works for many people. Look for doctors who have a D.O. after their name, instead of an M.D. and be sure to ask them if they practice osteopathy.

9) Stay in shape. Seriously.

So, at the end of the day, do I actually have any idea why back pain hurts so badly? Sorry to tease you with the catchy title, but I don't. I have to admit I just don't. But it does.  The good news is, for most of us, it will go away with a little time, some attention to behavior change, and good self-care. And if it comes back, start at the beginning and do it all over again.

It will work!

To end, an attempt at back pain haiku, because, well, why not?

Back aches, gnaws, screams, squeals
Lies down in deep dark silence
Where pain has no voice

 **

Stand up for patience
Time and change, may you be well
The pain will pass soon


______________________________________________________________
Additional References:
http://www.ncbi.nlm.nih.gov/pubmed/21665125
http://www.ncbi.nlm.nih.gov/pubmed/1477891
http://annals.org/article.aspx?articleid=736814
http://www.aafp.org/afp/2012/0215/p343.html#afp20120215p343-b2
http://www.fpnotebook.com/ortho/sx/LwBckPnRdFlg.htm
www.npr.org/blogs/health/2014/01/13/255457090/pain-in-the-back-exercise-may-help-you-learn-not-to-feel-it

Prescription painkillers (I)

Gina was one of my most challenging patients. She had overwhelming anxiety, and with just a phone call, she could make our clinic spin like a top. I knew pretty early on that she had a tendency to overtake medicines-- and not just the addictive ones. She even overtook non-prescription medicines like acetaminophen (aka Tylenol), diphenhydramine (generic for Benadryl, an anti-itch and allergy medication) and omeprazole (generic for Prilosec, an acid reflux medication).

She was a beautiful woman, and though her mental health issues were intense, she was really quite endearing. Each time I saw her, she gave me a big hug; she also often brought me thoughtful little gifts. At one visit, she brought a beautiful silk flower clip for my hair. (I sometimes wear it on tough days in clinic). A few months later, she gifted me a picture of her swimming with the dolphins in Hawaii. That picture hangs above my desk; she is smiling broadly in it, and I love to think of her without pain and without anxiety.

I last saw Gina one Wednesday morning more than a year ago. She had just had a successful hysterectomy and was particularly anxious. She had a history of chronic back and hip pain and was on small doses of methadone for this pain. Two days later she was found dead in her own bed.

I was not surprised to learn that, on autopsy, unsafe levels of methadone were found in her blood. She clearly overdosed on her prescription painkillers and never woke up. I will never know the whole story, but I doubt she did so intentionally.

Prescription pain medication overdoses are on the rise-- over 14,800 deaths in the US in 2008 (that's more than cocaine and heroin combined, and more than motor vehicle accidents too). When you see the term "prescription painkillers",  this usually refers to the opiate or narcotic pain medicines: vicodin, (hydrocodone), oxycontin (oxycodone), morphine, and methadone. Unfortunately, these are medications often prescribed for surgical procedures like wisdom teeth extractions or appendectomy, or even during simple ER visits for minor trauma. These drugs aren't inherently evil-- they work quite nicely for people with acute pain that is self-limited. I personally prescribe them for every one of my post-cesarean section patients and often for patients with fractures (e.g. broken legs).

Check out this image from the Center for Disease Control (CDC):





According to the CDC, most prescription pain medications are prescribed by primary care doctors (yup, that's me). And, perhaps even more alarming as someone who prides herself on her care of women, recent data released shows that prescription painkiller overdoses in women have increased 400% since 1999 (they have also increased dramatically in men by 265%). More than 5 times as many women died as a result of pain medication overdose in 2010 than in 1999. And opiates are involved in 1 out of 10 suicides. Ay!

We need to do better.

Clinicians (ahem. . .myself included) need to be more careful about how we approach pain, what medications we offer our patients, what are our expectations. We need to use the statewide databases and really encourage our patients to get rid of leftover medications (rather than share them with family members). We also need to screen women (and men) for risk of abuse/misuse and be clear about our plan from the get-go with ourselves and our patients.

Patients (that's all of us) need to be aware that these painkillers are a group of potentially addictive medications. There is an appropriate time and place for their use, but pain meds should be used wisely for limited periods of time. They may or may not actually help people feel better but definitely can kill (or make you impotent, depressed, constipated, and dysfunctional).

Do me a favor, go to your medicine cabinet right now and throw out that leftover Vicodin you have sitting there from your last encounter with the healthcare system. I know you've been keeping it around 'just in case', but it just ain't worth it. Don't share it with your neighbor or your partner or your kid. Pitch it. Or, even better, throw it down your toilet (though please don't do that with the rest of your prescription meds- click here for more info,).

Other things to read:
1) http://www.drugabuse.gov/publications/research-reports/prescription-drugs/trends-in-prescription-drug-abuse/how-many-people-abuse-prescription-drugs
2) http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html