America’s Pain Crisis
Judy Foreman was educated at Harvard, and has been a Lecturer on Medicine at Harvard’s Medical School. In 2014, she published a book titled (1):
A Nation in Pain
Healing Our Biggest Health Problem
Ms. Foreman notes that of the 238 million adults in America, approximately half of them have chronic daily pain. The conservative estimate of the direct costs and lost productivity resulting from this pain is up to $635 billion yearly.
Americans pay $113 billion yearly for Social Security Disability benefits (2), and it’s not enough. Our Social Security Disability program is paying out $200 billion yearly. Political newspapers are buzzing about the prediction that the Social Security Disability Trust Fund will go broke next year (2016) (3). Fifteen million Americans are on Social Security Disability, and new applications average 200,000 monthly (2). The primary condition for which Americans apply for and are granted Social Security Disability is “musculoskeletal system and connective tissue” disorders, primarily back pain (2).
The drugs used to treat chronic pain are themselves creating yet another crisis. The political magazine, Time published a cover article titled (4):
They’re the most powerful painkillers ever invented;
And they’re creating the worst addiction crisis America has ever seen;
The price of Relief; Why America can’t kick its painkiller problem
This article makes these points:
Also in 2015, the newspaper the Wall Street Journal reviewed a booked titled Dreamland in an article titled The Great Opiate Boom (5). This article makes these points:
In June 2015, the front page of the newspaper USA Today published an article titled Heroin use surges among women, middle-class (6). This article makes these points:
In 2013, the Wall Street Journal quantifies chronic pain location by citing the Centers for Disease Control and Prevention, and the World Health Organization (7):
28.1% Low Back Pain
19.5% Knee Pain
16.1% Severe Headache or Migraine
15.1% Neck Pain
09.0% Shoulder Pain
07.6% Finger pain
07.1% Hip Pain
Back pain is at the center of America’s pain and disability crisis. It has been know for 40 years that the structure primarily responsible for back pain, especially for chronic back pain, is the intervertebral disc:
“The intervertebral disc is most likely the cause of the pain.”
“The lumbar intervertebral discs are supplied by a variety of nerves.”
“Clinically, the concept of ‘disc pain’ is now well accepted.”
“We know that 10% of back ‘injuries’ do not resolve in 2 months and that they do become chronic.”
“Persistent pain in the back with referred pain to the leg is largely on the basis of abnormalities within the disc.”
“Where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most rational approach to relief of this painful condition.”
“Back pain could be produced by several lumbar tissues, but by far, the most common tissue or origin was the outer layer of the annulus fibrosis.”
“Many investigators have reported the existence of sensory nerve fibers in the intervertebral discs of animals and humans, suggesting that the intervertebral disc can be a source of low back pain.”
“Both inner and outer layers of the degenerated lumbar intervertebral disc are innervated by pain sensory nerve fibers in humans.”
Pain neuron fibers are found in all human discs that have been removed because they are the source of a patient’s chronic low back pain.
The nerve fibers in the disc, found in this study, “indicates that the disc can be a source of pain sensation.”
“Our data confirm the intervertebral disc as the most common etiology of chronic low back pain in adults.”
“Spinal pain, and especially low back pain (LBP), represent the second leading cause for a medical consultation in a primary care setting and is a leading cause of disability worldwide.”
The most frequent cause of LBP is “internal disc disruption and is referred to as discogenic pain.” “Internal disc disruption refers to annular fissures, disc collapse and mechanical failure, with no significant modification of external disc shape, with or without endplates changes.”
Discogenic pain is “considered as the most frequent cause of chronic low back pain.” Discogenic pain secondary to internal disc disruption is the main cause of chronic LBP and disability.
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A central theme in the back pain literature is that discogenic back pain is prevalent, and probably accounts for the majority of back pain complaints within the American Society. Chiropractic / manipulative management of patients with back and/or leg pain secondary to nerve compression has a long and impressive history of good clinical outcomes with very low risks. Representative studies include:
“The conservative management of lumbar disk lesions should be given careful consideration because no patient should be considered for surgical treatment without first having failed to respond to an adequate program of conservative treatment.”
“From what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.”
“This study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80 – 95% satisfactory) are impressive in comparison with any form of therapy.”
“Manipulation. Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc. This treatment is regarded as controversial and a form of quackery by many men. However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery. Occasionally, the results were dramatic.
Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis. The uppermost arm is placed backward behind the patient, pulling the shoulder back. The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward. The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back. When this is felt, the relief of pain is usually immediate. The maneuver is repeated with the patient on the opposite side.”
In their study, they performed a series of eight manipulations on 517 patients with protruded lumbar discs and clinically relevant signs and symptoms. Their outcomes were quite good, with 84% achieving a successful outcome and only 9% not responding. Only 14 % suffered a reoccurrence of symptoms at intervals ranging from two months to twelve years. Based upon their results, Drs. Kuo and Loh make these statements:
“Manipulation of the spine can be effective treatment for lumbar disc protrusions.”
“Most protruded discs may be manipulated. When the diagnosis is in doubt, gentle force should be used at first as a trial in order to gain the confidence of the patient.”
“It is emphasized that manipulation has been shown to be an effective treatment for some patients with lumbar disc herniation.”
“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.”
“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”
“Patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.”
“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”
“The treatment of lumbar disk herniation by side posture manipulation is not new and has been advocated by both chiropractors and medical manipulators.”
“The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.”
“Based on our results, we postulate that a course of non-operative treatment including manipulation may be effective and safe for the treatment of back and radiating leg pain.”
“Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.”
“At the end of follow-up a significant difference was present between active and simulated manipulations in the percentage of cases becoming pain-free (local pain 28% vs. 6%; radiating pain 55% vs. 20%).”
“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain.”
“No adverse events were reported.”
“The proportion of patients reporting clinically relevant improvement in this current study is surprisingly good, with nearly 70% of patients improved as early as 2 weeks after the start of treatment. By 3 months, this figure was up to 90.5% and then stabilized at 6 months and 1 year.”
“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.”
“Even the chronic patients in this study, with the mean duration of their symptoms being over 450 days, reported significant improvement, although this takes slightly longer.”
“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low- amplitude side posture spinal manipulative therapy reported clinically relevant ‘improvement’ with no serious adverse events.”
“Spinal Manipulative therapy is a very safe and cost-effective option for treating symptomatic lumbar disc herniation.”
In America, it is not uncommon for persistent back pain to be treated surgically. An analysis of America’s low back surgery rate compared internationally to other nations was published in the journal Spine in 1994 (30). The authors were from the Department of Health Services, University of Washington in Seattle. They compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher in the United States than in other developed countries. Their findings include:
“The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland.”
“Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country.”
In this regard, an interesting article was published in the journal Spine in 2013, designed to predict the major reason for back surgery as compared to the utilization of less invasive approaches (31). A team of investigators from Dartmouth Medical School, the University of Washington School of Medicine, and Ohio State University College of Public Health, completed a prospective cohort study to identify early predictors of lumbar spine surgery within 3 years after occupational back injury.
The authors note that back injuries are the most prevalent occupational injury in the United States, and that back pain is the most costly and prevalent occupational health condition among the U.S. workers. After adjustment for medical and general inflation, costs for occupational back pain increased over 65% from 1996 through 2002, and spine surgeries represent a significant proportion of these costs. Yet, they note:
“Spine surgeries are associated with little evidence for improved population outcomes, yet rates have increased dramatically since the 1990s.”
“Reducing unnecessary spine surgeries is important for improving patient safety and outcomes and reducing surgery complications and health care costs.”
Previous studies have shown that those with occupational back injuries who first saw a chiropractor had lower odds of chronic work disability, and that those seeing chiropractors for occupational back pain had “higher rates of satisfaction with back care.”
In this study, after controlling for injury severity, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, and workers whose first visit was to a chiropractor had significantly lower odds of surgery (by 78%). The authors stated:
“42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.”
“Approximately 43% of workers who saw a surgeon had surgery within 3 years, in contrast to only 1.5% of those who saw a chiropractor.”
“There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.” [such as symptom severity]
“It is possible that these findings indicate that who you see is what you get.”
Seeing a chiropractor as the first provider for a back complaint significantly reduced odds of surgery.
These authors suggest that it is wise to use a “gatekeeper” for patients who suffer occupational back injury. This article presents substantial reason for why such a gatekeeper should be a chiropractor. The reduction of back surgeries in those consulting chiropractors for back pain represents a substantial costs savings, and also the highest levels of back care satisfaction.
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