Given that 25% of adults in the United States have reported experiencing lower back pain in the prior three months (CDC), it is important to know that many options exist to help alleviate this pain.
Dr. Bryan Marascalchi, a pain management expert who is an assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, offers helpful tips to readers of The Honest Migraine for minimizing, managing, or resolving back pain. He also sheds light on what he hopes the future holds in this sector of medicine.
While no one wants to experience agonizing pain and its’ impairment on quality of life, Marascalchi makes an excellent point: “It’s actually extremely common” and thus, “because it’s extremely common, [there are] a lot of options to treat it, compared to perhaps to coming in with a diagnosis of a rarer [nature], where you may not have as many options.”
Marascalchi said there are two methods to follow in treatment, “There’s always non pharmacologic (non-medical) things and then medical things.”
Non-medical remedies for lower back pain, he said, “is weight loss and it can also be things like physical therapy, could be things like a TENS Unit, which are minimally invasive over the counter electrical stimulating units to provide a soothing sensation in an area where there’s pain.”
Marascalchi also said food that you ingest is also relative. Another reminder that foods we consume play into our health. “You could also think about foods that we eat and supplements that we take, things like Vitamin C, magnesium, Vitamin D have been suggested in various different pain conditions. And also, certain foods that we eat such as refined carbohydrates and red meat can be pro-inflammatory, which could affect arthritis conditions.”
Understanding that many back pain sufferers are either unable to exercise or significant modifications would be required, Marascalchi said “as far as weight loss goes, [it’s] obviously very challenging [as] somebody in pain can’t really workout to lose weight.”
He suggested in those cases “to do that through diet.” He regularly informs patients that “that while debatable 1 pound of body fat roughly equals 3,500 calories.”
One solution he mentioned was a patient could “cut out small amounts of calories per day with the goal to lose 1 pound per week – about 3,500 calories.”
Medications commonly enter the picture for chronic pain. Depending on the condition, Marascalchi said, “There’s a lot of medications for pain.”
When it’s for arthritis, “Ibuprofen and Tylenol are a great combination or alternatively a selective non-steroidal anti-inflammatory agent can help, like meloxicam.”
If the pain is stemming from a nerve, “such as from a pinched disc that’s herniating a nerve, you have medications like anti-convulsants or anti-depressants that work on those nerves.”
“For lack of a better word, [they can] calm nerves down and stop them from being irritated,” said Marascalchi.
Experiencing muscle spasms? “There’s anti-spasmodic medications or a muscle relaxant,” he said. “You have topical agents, Lidocaine or Capsaicin (which is hot chili pepper). Capsaicin can cause regression of nerve endings and can reduce pain in an area.”
As we are very familiar – opioid medications are also prescribed for pain. As Marascalchi reiterates, opioids “are highly dangerous and have a lot of side effects and usually a last resort, as well as kept to a minimum. There is a theoretical maximum or safe dose.”
Given the rising number of opioid deaths over the last many years in America, we know the opioid crisis is here and doesn’t appear to be minimizing in the near future. In 2018, U.S. Dept of Health and Human Services statistics show that 2 out of 3 drug overdose deaths involved an opioid. In 2019, an estimated 10.1 million people, aged 12 or older, misused opioids during the preceding year.
If a doctor suggests a prescription for an opioid, it is important to discuss the pros and cons thoroughly with him or her. And if you think about creating your own “cocktail” of prescription drugs, the result can be deadly in a hurry.
Marascalchi stated quite clearly that mixing opioid medications “with alcohol, illicit substances including marijuana, benzodiazepines or muscle relaxants increase your risk of harm even more. And the opioid crisis is just that – too many people dying from opioids.”
As for the majority of things in life, there are limits. “Just like your blood pressure medication might be maxed out at 100 milligrams, opioids get maxed out,” said Marascalchi. “There’s a reason why [your blood pressure medication] only goes up to 100 milligrams. Same thing for opioids. But in the past, there was no theoretical maximum and people just kept going, going, and going. But now we understand clearly that maximum where benefits are less than the risk.”
In addition to prescription medications, there are alternative therapy options that Marascalchi finds very interesting for patients. One of those being “low dose Naltrexone for certain conditions. Not necessarily for back pain, but for various things like fibromyalgia.”
If more relief is needed, doctors turn to procedures and surgical options. One possibility is radiofrequency ablation or RFA, “where you burn the nerve that supplies the area of the back with pain sensation. They grow back in a few months, but you [can] do it again.”
Another remedy can be an epidural steroid injection. “You can place [liquid injection] steroid near the spine in multiple different techniques and procedures,” explained Marascalchi. “That’s very simple and quick. Within a few minutes, under x-ray guidance, [it] can provide many months of pain relief.” A simple way to explain how it works is “it’s kind of like calming down inflammation and then [if/when] the inflammation comes back, you do it again.”
On the advanced spectrum for lower back pain, Marascalchi said, “You can also consider spinal cord stimulators, which is a device like a pacemaker of the spinal cord and it kind of scrambles the pain signal either in the neck and/or lower back.”
The desired outcome is that with “anything below [the spinal cord stimulator] you don’t feel the chronic pain, or at least that’s the hope,” he said. “It’s a pacemaker-like device that is permanently put in after completion of a successful temporary trial.”
As a last resort, spinal surgery can be discussed.
Marascalchi said addressing and treating back pain involves a very large spectrum, ranging from non-medication regimens to medication options, therapies, procedures, and surgeries. It takes time to see what is reasonable for each patient.
The Good Body amplifies the prevalence of back pain in our society, stating “Americans spend at least $50 billion annually on treating back pain.”*
Struggles with back pain resonate with me. I can think of two very close friends, a parent, and an aunt that either experience back pain on a daily basis or have had recurring up and down battles with it.
I hope if you’re temporarily experiencing or living each day with back pain, it inspires you to seek out proper medical evaluation by an orthopedic specialist, undergo testing, and work together with your provider(s) to ascertain what treatments options may best alleviate your pain.
When asked what he feels is the most underserved or most challenging condition out there in pain management, Marascalchi said, “Fibromyalgia – we really don’t understand it that well. Also, Chronic Regional Pain Syndrome (CRPS), and some abdominal pain and pelvic pain. We have options, but fewer options.”
Marascalchi said one benefit in today’s pharmacology choices is that “some medications work for multiple, different diagnoses.”
“A lot of what happens in pain medicine is that there is a big overlap,” he said.
He provides the medication Duloxetine, marketed as both an antidepressant and a nerve pain medication, as an example. “You could use an anti-depressant to treat multiple different conditions – like peripheral neuropathy, fibromyalgia, and chemotherapy-induced neuropathy,” said Marascalchi. “It is also considered for use with chronic musculoskeletal pain, like arthritis.”
And we know just how impactful arthritis is as “15 million people report experiencing severe joint pain related to arthritis. Additionally, nearly half of adults with arthritis have persistent pain.”**
With Marascalchi’s strong knowledge and positive drive for better health for his patients and society as a whole, I was curious what he hopes the future holds insofar as advancement of pain medicine options.
He mentioned there are a few things he hopes for strides in. One, he said is hoping that “spinal cord stimulators and peripheral nerve stimulators have even more clinical success, quality-of-life improvement, and longevity of treatment.”
As well, Marascalchi said he hopes to further be able to use technology to enhance patient health, “An ability to use neuromodulation to augment pain – where that’s going – most people think that’s the future. If I can put something in and augment pain; is that not kind of the ultimate thing?”
But in the here and now, “trying to get safe drugs, medications that reduce pain significantly, but don’t have the side effects such as with the opioid class,” is the goal, he said. Finding more non-opioids would be very beneficial.
This is so important for our society, both in health and wealth.
“However, some non-opioid analgesics like Ketamine, an NMDA receptor antagonist, are also drugs of abuse,” said Marascalchi. “Pregabalin a non-opioid anticonvulsant is also a controlled substance, but has great efficacy for neuropathic pain and fibromyalgia.”
One drug I commonly hear individuals talk about – claiming they find it sustainable to go to work on, travel with, or just for general day-to-day illness or conditions is Tramadol. Many people say it’s a “safer” drug. Marascalchi clarified that “Tramadol was originally considered to be a non-opioid, but as efficacious (effective) as an opioid, but turned out to be an opioid with a similar side effect and risk profile. It’s kind of a challenging thing in drug discovery.” This information should really shed new light on Tramadol for those who believe it is without risk.
“[I] wish we had better drugs that people can’t abuse, that don’t have street prices, and will be safe and effective for patients,” Marascalchi reflected.
Marascalchi’s passion for his work and compassion radiate through. It’s truly a gift to have him in the medical community and share his valuable expertise with readers.
Watch for more from Dr. Marascalchi on February 17, 2022
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