Back pain and the patient’s alternatives

Why should you see an osteopath when you can seek the advice and care of doctors and physiotherapists for free on the NHS? Surely doctors, as the most qualified healthcare professional, are the best to provide help with something that can be debilitating? These are the questions osteopaths in the UK are asked every day.

In the latest study on the effect of drugs on lower back pain in Spine in October 2011, the authors note that there are three pharmacological approaches:
- non-steroidal anti-inflamatories (NSAIDs, such as ibuprofen, voltarol, aspirin)
- opioids (cocodamol, tramadol)
- antidepressants (SSRIs, MAOs etc)

NSAIDs have some small evidence of pain killing effect marginally greater than placebo.  The stronger and the higher dose of NSAID, the more significant the effect. Opioids have significant evidence of pain killing effect that diminishes with time, requiring ever higher doses due to habituation. Antidepressants have no significant evidence of any effect on back pain.

The same study also looked at the adverse effects of treating back pain with drugs.
- It found significant serious adverse effects from NSAID that become more pronounced with higher doses.
- Opioids were found to have diminishing effectiveness and sometimes caused paradoxical effects (increase in pain), significant adverse effects and have bad outcomes in terms of patient dependence.
- Antidepressants had many adverse effects increasing with dose.

The article’s recommendations were:
1) use strong NSAIDs as a front line treatment for lower back pain,
2) use weak opioids as a second line treatment for lower back pain, and
3) use antidepressants if all else failed despite there being no evidence of effectiveness.

My analysis of the article is somewhat different. I agree that you may be able to kill pain with NSAIDs and particularly Opioids. I agree that antidepressants have no effect on back pain. I disagree with the term back pain. Back pain is not a single disease, with a single disease process. Subscribing to this view is the same as describing both myocardial infarction (heart attack) and gastric reflux (heartburn) as “chest pain” and treating them with pain killers.

NSAIDs have significant adverse effects on gastrointestinal and cardiovascular systems leading to peptic ulceration and haemorhage, arrhymias and heart attacks. They also impair healing in bone and in connective tissues. NSAIDs are paradoxically exactly the sort of thing you would give if you wanted the patient not to get better. Why then does the article recommend it as the front line treatment? Because:
1) the outcomes for opioids are that much worse
2) antidepressants do nothing, and
3) there is no alternative.

But there is. Osteopathy.