I had not visited this site for some time and I see that there are over 2400 comments to approve. The majority of the comments are in Russian?!

Then there are the usual spam comments trying to sell everything from xanax to toner refills. I did not have time to go through all of them to check which ones were genuine, so I deleted them all.

An excellent review conducted  by  David Fishbain et al. (Department of Psychiatry at the University of Miami) published in Pain Medicine (Volume 9, Number 4, 2008) calculated that among patients without a past or current history of drug abuse the chance of aberrant drug-related behaviors was about 0.2%. In other words: only 1 out of 500 patients without a past or current history of drug abuse will develop addictive behavior. The risk in patients with a past or current history of drug abuse was three times higher at 0.6%. In this group you would expect about 1 out of 170 patients on chronic opioids to develop an addiction.

Some may think that even a low risk is not acceptable. As a general rule physicians make treatment decisions based on the overall perceived risk and benefit of any therapy, be it medication, procedures or even doing nothing. All of these options have their complications and risks such as medication-related complications (allergic reactions, side effects, drug-drug-interactions, addiction risk), procedure -related complications and what is often forgotten: the risk and side effects of not doing anything.

Many patients will describe years of spending all day in bed, in miserable pain, unable to do anything. After some time patients get dysfunctional, deconditioned, alienated from family and friends, depressed and suicidal. Many are in tears about the years they wasted not being able to enjoy life.

When patients ask me about their risk of addiction to opioids I tell them that it is very low if they do not have an addictive personality and past addiction issues with drugs. Patients with current and a strong history of past addiction issues  are very difficult to treat and will benefit from the involvement of a psychiatrist-addiction specialist.

The conclusion is that even one drink a day will increase the risk for breast cancer, oral cancer, larynx (voice box) cancer, esophageal cancer, rectal cancer, liver cancer and overall cancer.

There was no safe limit of alcohol use regarding the development of future cancers.

Some will wonder “Well, isn’t alcohol/red wine supposed to be good for your heart?”

The editorial in the same issue of JNCI written by Michael Lauer and Paul Sorlie sums up the research regarding the protective cardiovascular effects of red wine that is always mentioned in the mainstream media. They conclude that even if there is (questionable) minimal or modest cardioprotective effects of red wine, the increased risk for cancer clearly outweighs that modest benefit.

It describes in detail the new NIH (National Institutes of Health) Undiagnosed Diseases Program. The focus is Summer Stiers, a young (although much older looking) female patient from Oregon with a multitude of symptoms and medical conditions. It follows her evaluation at the NIH and explains that sometimes there is no clear diagnosis.

This reporting is different from the usual sensationalistic reporting of “miracle cures and wonder drugs” we see in the mainstream media. It shows the process of coming up with a right diagnosis or multiple diagnoses.

It is 8 pages long but definitely worth the time!

There are many factors that have to be considered to give an informed answer.
In some situations undergoing an operation is the best way and sometimes the only way to treat the pain and loss of function.

I recommend my patients see a spine surgeon in the following scenarios:
1. significant and worsening neurological impairment like inability to control bowel or bladder function and significant weakness in legs (or in arms if the problems are in the neck).
2. severe unrelenting pain despite aggressive treatment by a pain specialist.

The decision to undergo an operation is relatively easy to make in case of significant neurological impairment. If you cannot stand up or walk or lift your arm, you have to be emergently evaluated. Often these situations are surgical or medical emergencies and I instruct patients to call 911 or get to the nearest emergency room as soon as possible to be evaluated if they need surgery right away. Sudden weakness, numbness or incontinence can not only be caused by a massive disc herniation pressing on the spinal cord but can also be caused by a stroke and other disease processes. In all of these circumstances immediate evaluation and treatment is in order.

The situation gets more complicated in the vast majority of cases when there is no or only minimal numbness and weakness and no incontinence. One of the rules of surgery is “If you operate for pain, you will get more pain”. This means that if you operate when there is no clear neurological damage due to operable structures (like herniated disc) you may end up with more pain. One of the most commonly made statements I hear in my practice are patients who underwent multiple operations with worsening outcomes: “If I had known that I would end up like this, I would have never had the first operation!” Of course my patient population is skewed as the ones who do great after neck or back surgery do not seek a pain specialist.

Another way to look at this question is to compare the incidence of back operations in the United States with the statistics in other countries and even in different regions within the US. In the UK you usually have to wait to undergo a back operation unless you have a severe neurological impairment. As luck would have it, some of the patients on the waiting list get slowly better and then end up canceling the surgery as they slowly recover on their own. As nobody waits in the US, those patients that would have recovered on their own, will end up undergoing an operation. Most patients do well for at least some time after a back or neck operation. The statistics for neck operations are more encouraging than for low back surgery. The problem is that often patients who initially do well after surgery start to develop scar tissue and a recurrence or even worsening of the symptoms they had before the first operation. This often leads to repeat operations and many patients end up with fusion of parts of the spine. It is also very interesting that the incidence of lumbar fusions (number of fusions per 1000 population) varies greatly depending on where you live within the United States. The incidence in Medicare patients ranged from a low of 0.2/1000 in Bangor, Maine to a 23-fold higher rate of 4.6/1000 in Idaho Falls, Idaho. Read: United States’ Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003 (pdf).

Read also these articles: Variation in Surgical Decision Making for Degenerative Spinal Disorders. Part I: Lumbar Spine, Evidence-based Guidelines in Lumbar Spine Surgery – Free Preview (pdf), Evidence-Based Guidelines for the Performance of Lumbar Fusion (pdf). Here are some abstracts regarding reoperation rates and outcomes of low back operations: Outcome of lumbar fusion in Washington State workers’ compensation, Lumbar fusion outcomes in Washington State workers’ compensation, 5-year reoperation rates after different types of lumbar surgery, Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures, Outcomes of posterolateral lumbar fusion in Utah patients receiving workers’ compensation: a retrospective cohort study and Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology?

In the past many patients were quick to undergo a back or neck operation. Nowadays, everybody has a friend/relative/neighbor who had back or neck surgery, underwent multiple re-operations and then finally was disabled and is now dependent on a scooter to get around. Therefore, the public has an appreciation that success with spine operations is not “guaranteed” as it is with appendix or gallbladder operations which have a much higher success rate.

The bottom line is that patients should discuss their concerns frankly with their physicians. The decision when to obtain a surgical consultation and when to proceed with the operation should be made after detailed discussions between the patient and the physicians (primary care physicians/family doctors, pain specialists and spine surgeons). Going into surgery with unrealistic expectations will just produce frustration, regret and anger after the procedure.

• on average the patients had a 2.9 point mean reduction of pain (on a 0-10 pain scale)
• a 7.0 mean decrease in disability level as measured by the Oswestry Disability Index (Fairbank JC, Couper J, Davies JB, OBrien JP (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 1980 Aug;66(8), 271-273)
• an 18 point mean improvement in bodily pain as measured with the SF-36
• a 7.0 point mean decrease in disability level as measured by the Oswestry Disability Index.

This meta-analysis clearly shows that some patients do benefit from the procedure which saves them from undergoing an open back operation.

At this point most insurance companies do not cover IDET (and the related Biacuplasty) and only patients with the means can afford this procedure.

A search at dictionary.com shows 7 different definitions from various references.

The definition from the Random House Unabridged Dictionary (c) 2006 states: “the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma”.

The American Heritage Dictionary (c) 2006 defines it as: “Compulsive physiological and psychological need for a habit-forming substance. The condition of being habitually or compulsively occupied with or involved in something.”

WordNet 3.0 (c) 2006 states: “1. being abnormally tolerant to and dependent on something that is psychologically or physically habit-forming (especially alcohol or narcotic drugs). 2. an abnormally strong craving. 3. (Roman law) a formal award by a magistrate of a thing or person to another person (as the award of a debtor to his creditor); a surrender to a master; “under Roman law addiction was the justification for slavery” “.

The American Heritage Science Dictionary (c) 2002 defines it as: “1. A physical or psychological need for a habit-forming substance such as a drug or alcohol. In physical addiction, the body adapts to the substance being used and gradually requires increased amounts to reproduce the effects originally produced by smaller doses. See more at withdrawal. 2. A habitual or compulsive involvement in an activity, such as gambling.”

The American Heritage Stedman’s Medical Dictionary (c) 2002 has addiction defined as: “Habitual psychological and physiological dependence on a substance or practice beyond one’s voluntary control.”

Merriam-Webster’s Medical Dictionary (c) 2002 states: “compulsive physiological need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly: persistent compulsive use of a substance known by the user to be physically, psychologically, or socially harmful- compare Habituation, Substance Abuse”.

Merriam-Webster’s Dictionary of Law (c) 1996 defines it as: “compulsive physiological need for a habit-forming drug (as heroin)”.

Wikipedia states: “the term addiction is used to describe a recurring compulsion by an individual to engage in some specific activity, despite harmful consequences to the individual’s health, mental state or social life”.

Of all these definitions I prefer the wikipedia one as it does not confuse tolerance and withdrawal with addiction.

This is one of the most common misconceptions: “I stopped my pain medication and went into withdrawal. I think I am addicted to these pills”. We have to step back and tease “tolerance” and the associated “withdrawal” from the addiction.

Tolerance simply means that if the body gets a substance for some time (from days to weeks to months) it gets used to it and its effects diminish. Most patients can easily comprehend this concept as it is common that a specific medication dosage worked in the past and now “it does not work (as well) any more”. This is a physiological adaptation of the body to almost any substance.
Just take caffeine as an example: if you have somebody who was never exposed to caffeine drink a cup of strong coffee, they will experience the usual “side effects” of caffeine from increased alertness to fast heart beat, increased blood pressure and perspiration. Now, if that person continues to drink the same amount every day these effects will slowly diminish. To get close to the effect as with the first cup that person would have to drink more. This is nothing more than tolerance and identical to what patients experience commonly with pain medication.

The other physiological effect that often gets mixed up with addiction is withdrawal. Withdrawal is the body’s normal reaction to have a substance, that it was used to, either completely taken away or markedly diminished. Many people have experienced withdrawal, be it from caffeine or from nicotine or other substances. The withdrawal reaction is usually a reversal of the usual effect. In caffeine withdrawal people will feel drowsy and lethargic, have excessive yawning and may get a caffeine-withdrawal headache. Other well-known cases of withdrawal reaction (sometimes called rebound) is the extreme high blood pressure and heart rate in patients who are suddenly taken off blood pressure medication like beta-blockers or clonidine. Even withdrawing insulin from a diabetic person will lead the blood sugar to skyrocket. Nobody would say that the patient was “addicted” to insulin or blood pressure medication.

Now about real addiction: the hallmark of true addiction is the continued compulsory behavior that leads to harm in the individual’s health, mental state or social life. One aspect is the compulsory behavior (psychological need and craving), the other aspect is the harm. The harm could be loss of health, money, job, family, driving privileges, freedom and ultimately death. Addiction will lead people to lose control with the drug running their life and everything they do revolving around getting more drugs (doctor shopping, early refills, “dog ate the medication”, fell into the sink/toilet…). It is interesting that under Roman Law addiction was the surrender to a master. It is indeed the case that these patients are “slaves” to their addiction and the drug becomes their “master”.

Scientific American had an excellent article about the biochemical and genetic changes in the brain in addicted persons in their March 2004 edition. The main author was Dr. Eric Nestler (Chairman of Psychiatry at UTSW) who is one of the pioneering researchers in the field of addiction medicine.

To make a long story short:
Addiction is always a concern with habit-forming drugs including benzodiazepines (e.g. valium, xanax, ativan), opioids (e.g. hydrocodone [vicodin, lortab, norco...], oxycodone [percocet, percodan, tylox, endocet, oxycontin], fentanyl [patch, Actiq, Fentora] or methadone), barbiturates and other substances (carisoprodol [Soma]).
The question that patients are asking is: “What are my chances of getting addicted to these pills?”. The answer is very complex as there are many factors that determine the likelihood of addiction. As addiction has genetic and environmental components it is very important to look at the whole clinical picture.
Risk of addiction is clearly increased in patients with a family history or past history of addiction (be it to legal or illegal drugs). One important psychological maxim is “past behavior predicts future behavior”. If somebody was coping in the past in response to a stressor (relationship, financial, health problems) by using drugs (mal-adaptive behavior), they are prone to repeat that behavior in the future. There seems to be some indication that patients who have to have their first cigarette right after they wake up, may be more likely to get addicted to pain medication. Some patients who have experienced the horrors of addiction, hit “rock bottom” and became clean with a 12-step type program may not have a higher risk of addiction. Most of these patients will specifically request to be treated without the use of addictive medication as they are very afraid of relapsing.

The overall risk for a chronic pain patient to actually get addicted to habit-forming drugs is probably in the 5-10% range. Some studies had lower numbers while others found a higher incidence of aberrant drug use. This depends on the patient population and the treatment approach and philosophy. Almost exclusively, patients who worry about addiction and voice their concerns are in the very low risk category (elderly patients without any previous addictive behavior). The risk of addiction has to be weighed in the overall concept of risk versus benefit. Every therapeutic intervention from prescribing a medication to interventional procedures to not doing anything carries a potential for benefit but also specific risks.

The risk of addiction has to be weighed against the risk of inadequate pain relief. Looking at the big picture, there is a known risk of under-treatment of pain. Patient who do not get sufficient pain relief will get less functional and less active. With time, due to their inability to exercise they may gain weight and end up in poorer cardiac and pulmonary health (deconditioning). The quality of life of the patient and of their family and friends will be adversely impacted. And ultimately, patients with intractable pain are at higher risk for suicide.

The bottom line is that in general the risk of addiction to pain medication is relatively low in the general population. Addiction is mainly a concern in patients with past addictive behavior. Addiction to habit-forming medication is a devastating psychiatric condition and should be treated ideally by an addiction specialist. The treatment is very challenging as can be seen from all the relapsing substance abusers. Some opioid abusers do well with long-term treatment with methadone (as part of a methadone maintenance program) or with the newly available suboxone which is the first office based FDA-approved treatment for opioid dependence.

What does that mean: physicians will be even more hesitant writing for any medication that could impair a patient. This includes all controlled pain medication. This decision will keep more physicians from prescribing pain medication to patients who need them due to their increased medico-legal exposure.

I could not agree more with the dissenting Chief Justice Margaret H. Marshall who emphasized the “sweeping” change it would usher in, citing its chilling effect on medical practice: “The physician would be forever looking over his shoulder.”

Patients will be forced to sign more complicated legal waivers and consent forms just to be considered for pain medication.

Luckily, this court decision is not directly applicable for Texas but who knows how the Texas Supreme Court would decide in a similar case.

Click here for the article in the American Medical News.

Click here for the article in the Worcester Telegram and Gazette Opinion section.

Click here for the article in the Boston Globe.

Everybody in pain management from the physicians to the patients and their families have to be very vigilant about these issues as legal decisions of this kind will make it harder for physicians to prescribe pain medications and for patients to obtain pain medication to improve or at least maintain their quality of life.

Now this entry is about structures in the spine (from the neck [cervical spine] to the low back [lumbar spine]) that most patients have never heard of before. We are talking about the facet joints (anatomically known as the zygopophysial or z-joints) – the unknown cause of chronic back pain.

Multiple studies have shown that between 25-50% of chronic low back and neck pain is caused by these small paired joints that connect vertebral bodies with each other.  For pictures about the facet joints go to the office website here.

Facet joints can cause pain depending on their level.
In the neck area the highest levels have shown to cause pain in the upper neck and head while the lower neck facet joints can cause pain all the way down to the shoulder blades. The facet trainer shows which facet joint level correlates with pain in specific areas of the neck and upper back. In the low back the pain is usually described as a band going from the middle to the side with sometimes radiation into the hips.  Rarely (about 5% of cases) will patients with lumbar facet arthritis have pain going past the knee. The more common culprit for pain that shoots past the knee is a disc herniation causing irritation of a nerve root (“sciatica”). Facet joint pain is usually aggravated by certain positions. Quite often the patient will complain of pain leaning forward (doing dishes, cooking), vacuuming or trying to get up from a sitting position. This is not very specific as a disc herniation will also cause increased pain with leaning forward.

Why do patients get facet joint arthritis? The simple answer is that facet joint are not any different than other major joints in the body from the hips to the knees and shoulders and they are subject to the same kind of trauma and degeneration (wear and tear) like all the other joints. There is also a relationship between degenerated discs accelerating facet joint arthritis as the facet joint have to bear more weight at a level with a degenerated disc. It is also well known that patients who underwent neck and back operations, especially fusions often have significant facet arthritis. This is probably due to changes in biomechanics with the facet joints taking a higher stress load at and below and above the operated part of the spine.

What can be done for facet joint pain? The first step is to establish a diagnosis. Unfortunately, there are no good ways to diagnose facet joint pain but with nerve blocks. There is poor correlation with imaging studies. An x-ray image, CT or MRI showing bone spurs at the facet joints does not prove that the pain is coming from that structure. The corollary is that a normal  appearing facet joint can indeed be causing significant pain. Some studies suggest that paramedian tenderness (meaning tenderness 1-2 inches off the mid line) can correlate with facet joint arthritis.
The gold standard for the diagnosis of facet joint pain is the differential local anesthetic block meaning that you inject at two different times two different kinds of local anesthetics (with various duration of action)  and have the patient give you feedback about the duration of relief. If the patient has good relief with both local anesthetics but longer with the longer acting local anesthetic then the probability of the pain coming mainly from the facet joints is very high. It is quite common for the patient to have very good pain relief for the duration of the local anesthetic (comparable to the time it takes for your cheek to feel normal after some local anesthetic injection by a dentist) only to have the pain go back to the original level rather abruptly after the local anesthetic wears off. The most common comment I hear is “The pain came back with a vengeance”.  The successful test injection shows patients how comfortable they were in the past with the decrease or absence of pain being called “striking”.

Once it has been established that a major part of the pain is coming from these facet joints, the therapeutic options are to either inject a neurolytic (nerve-destructive agent) into the joint or the nerve innervating the joint (medial nerve branch) or more commonly nowadays use heat (radio-frequency ablation also called rhizotomy) to denervate the medial nerve branch.

Facet joint denervation: Usually the nerve branch (medial nerve branch of the dorsal ramus) will be heated with a radiofrequency (RF) cannula to about 80 centigrade for about 90 seconds. Before the heating it is checked to make sure that the needle tip is not too close to the main nerve root. This is done by sending electric impulses through the cannula. Patients will feel some tingling, pressure, pain or pulsating in their necks and low backs. These test impulses should not be felt in the arms and very rarely below the hips. The “burning” of the nerve usually silences the nerve for 8-12 months at which time it slowly regenerates. Most patients enjoy the relief from the RF and come back to have the procedure done again.

What happens if the facet joint blocks (test injections) do not provide the patient with any meaningful (usually over 50%) relief? If that is the case and there were no technical issues, then it means that the pain is not coming from the facet joints but from other structures like the intervertebral discs or in the low back from the sacro-iliac joints.