Research: Patients with back pain related to depression or intensified by depression should avoid painkillers and NOT be recommended to spinal surgery
Chronic back pain is caused by an anatomical problem. An anatomical problem can be made much worse in a patient susceptible to problems of depression and anxiety.
In research published in the medical journal Spine, a multi-national study led by the University of Sydney found a significant association between chronic low back pain and increased risk of depression and/or anxiety. But it is not clear whether back pain caused symptoms of anxiety and depression or if depression and anxiety caused symptoms of back pain. (1) So what came first? They suggest that no matter which one came first, when combined, anxiety, depression, and back pain acted on each other and caused accelerated worsening of symptoms.
- If you have questions about your back pain, get help and information from our Caring Medical staff
This agrees with a recent study published in the Journal of the Pakistani Medical Association which showed that the symptoms of depression and somatization (symptoms are worse than they should be physically) were prevalent among low back pain patients. Functional disability was also higher in the patients.(2)
Research: Patients suffering from back pain related to depression or intensified because of depression should avoid painkillers and NOT be recommended to spinal surgery
As these studies show, depression and anxiety and their relationship to back pain can be a complicated subject for health care providers. What is the focus of treatment then? A second group of researchers from the University of Sydney published their findings that health care providers should be on the lookout for future episodes of back pain in depressed patients:
- “Individuals with symptoms of depression have an increased risk of developing an episode of low back pain in the future, with the risk being higher in patients with more severe levels of depression.”3
As we know, chronic back pain under conservative care may mean pain medications for as long as possible until such time that surgery will be recommended because pain medications are no longer effective.
Further compounding this research is a study from Brigham and Women’s Hospital and Harvard Medical School that questions if opioid pain killers are effective for patients with depression and anxiety. Here the researchers found in patients with chronic low back pain psychiatric comorbidity (specifically, high levels of depression and anxiety) was a significant predictor of poor opioid treatment outcomes compared with chronic low back pain patients with low levels of depression and anxiety, including almost 50% less improvement in pain, increased side effects, and 75% more opioid misuse.4 Our article presents more research findings to suggest Narcotic pain killers can increase chronic pain.
In a study published in December 2016, doctors from Kuopio University Hospital and the University of Eastern Finland found that preoperative life dissatisfaction and the long-term life dissatisfaction burden were associated with poorer 10-year surgical outcomes.5
Here is what they said:
- Depressive symptoms are very common in chronic pain patients.
- Studies have reported prevalence of 30-80% of patients with some depressive symptoms and 20% of patients who fulfill the criteria for a true major depressive disorder.
- There is increasing evidence that the fear of pain, along with the fear of hurt or harm, are major influences. They note that “yellow flags” indicating diverse psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain are often present.
- Additionally, depression and psychosomatic disorders are common in patients receiving multidisciplinary pain programs.
- Therefore, with the existence of these risk factors, surgical intervention is not recommended due to the increased incidence of developing postoperative pain and chronic problems.6
In the journal Nature – doctors said: “Over the past few decades, there has been a paradigm shift in our understanding of chronic low back pain. Nowadays, this condition is accepted as a biopsychosocial phenomenon in which anatomical injury interplays with psychosocial factors.
The considerable progress made in discovering the true source of patient’s pain and the sharp increase in related health-care costs have not translated into a decreased prevalence of chronic low back pain or the development of therapies with markedly improved efficacy and safety.
Classic medical–technical interventions(surgery et al.) for for chronic low back pain always need to be placed in a broader therapeutic framework comprising physical, psychosocial and behavioural strategies, and must address the patient’s welfare in a holistic context. “7
Antidepressants for back pain?
Recently, researchers from the Harvard Medical School and Beth Israel Deaconess Medical Center sought to examine the safety and effectiveness of opioids (pain-killers), nonsteroidal anti-inflammatory drugs (NSAIDs), and antidepressants for treatment of chronic low back pain.
In addition to assessing the effectiveness of these drugs, they also evaluated whether certain people respond more favorably to pharmacological management.
The researchers acknowledged that medications are a mainstay of low back pain management, but there is uncertainty as to the optimal use of commonly prescribed medications such as opioids, antidepressants, and NSAIDS.
After examining the medical literature, these are the conclusions they reached:
1. Opioids and NSAIDs are effective for chronic low back pain, while antidepressants have no meaningful clinical benefit.
2. Based on the significant rate of side effects with opioids and the lack of convincing superiority over NSAIDs, opioids are not recommended as a treatment for chronic low back pain.
Here are their recommendations:
1: NSAIDs should be considered as a treatment of chronic low back pain. There is evidence demonstrating favorable effectiveness, but also significant side effects that may have meaningful clinical consequences.
2: Opioids may be considered in the treatment of chronic low back pain but should be avoided if possible. There is evidence demonstrating favorable effectiveness compared to placebo, similar effectiveness compared to NSAIDs, and with significant side effects including decreasing effectiveness related to habituation when used long-term.
3: Antidepressants should not be routinely used for the treatment of chronic low back pain. There is evidence that they are not more effective than placebo with respect to pain, functional status, or depression.
And they conclude that based on the hypothesis that chronic low back pain is a symptom reflective of a heterogeneous group of disorders, categorization of certain patient specific subgroups may be helpful in guiding future treatment decision making.7
As we read through the article, we basically see a lot of contradiction. Use NSAIDs but only if necessary because the side effects are great. Opioids and painkillers: consider them, but in reality avoid them if you can. The one thing that is not contradictory is antidepressants – don’t use them.
Anxiety’s role in chronic pain
Anxiety is a common byproduct of chronic pain and new research is suggesting that patients coping with chronic pain should be evaluated for anxiety disorders.8 Researchers evaluated 250 patients with moderate to severe chronic joint or back pain for which pain medications were not helping. They tested for the following conditions:
- generalized anxiety, characterized by persistent worry;
- panic, or sudden, repeated attacks of fear;
- social anxiety, characterized by overwhelming anxiety in everyday social interactions;
- post-traumatic stress, or a repeated feeling of danger after a stressful event;
- obsessive-compulsive disorder, characterized by repeated thoughts or rituals that interfere with daily life.
They also evaluated health-related quality of life issues, ie fatigue, sleep habits, and work productivity. The results showed that 45% of the patients tested positive for at least one or more of these common anxiety disorders. Many of these were present in combination with depression. Patients with anxiety disorders also presented with more pain and worse quality of life issues.
Addressing the cause of chronic pain
In many of these cases, researchers pointed out that patients may not necessarily need treatment for the anxiety as they may just have the symptoms related to the disorder, although they did predict that one in five patients may have an anxiety disorder.
This research shows that the source of anxiety is chronic pain.
The standard treatment of pain medications was not working so it’s clear that an effective treatment of the chronic pain is warranted. Prolotherapy is a treatment that addresses chronic joint and back pain, attacking the origin of pain that is ligament and tendon injury or laxity. Patients who choose Prolotherapy no longer have to cope with pain, or the byproducts that come with it. They find a permanent cure, ceasing the anxiety, depression, fatigue, sleeplessness and decreased productivity that accompany chronic pain.
Citing our own published research on low back pain, we followed 145 patients who had suffered from back pain on average of nearly five years. We examined not only the physical aspect of Prolotherapy, but the mental aspect of treatment as well. In our study, 55 patients were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients were told by their doctor(s) that surgery was their only option. The results of Prolotherapy for low back pain in these 145 patients were remarkable:
- Pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- More than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
- 75% percent were able to completely stop taking pain medications.10
Back pain – treating the whole patient
It is always important to realize the significance of a patient’s anxiety, depression and overall disability as a human being and not treat them as a “spine.” Researchers in the Journal of Orthopedic Science also looked at these factors in trying to predict which patients with lumbar back pain would be “disabled” by the pain.
Researchers in the Journal of Orthopedic Science also looked at these factors in trying to predict which patients with lumbar back pain would be “disabled” by the pain.
Here is what they said: “Lumbar disc herniation may influence patients’ daily activities and social interactions; however, no predictive models of disability could be found for patients with lumbar disc herniation.”
So they went looking for those quality of life aspects that would predict “disability” in these patients: What they found was “the most influential factor affecting the disability level was the pain level, followed by the fatigue level, and depression level.
The depression level was directly affected by the fatigue level and the pain level. The fatigue level was directly affected by the pain level, and the pain level was directly affected by age and previous surgery. 11
Low back pain: quality of life
Writing in the medical journal Pain Medicine researchers, not surprisingly, noted that when low back pain was not resolved – patients had catastrophizing thoughts, state anxiety, anger, and depressive symptoms. Mostly a lot of anger, especially after failed back surgery.12
This is the challenge that faces many Prolotherapy doctors. A patient that visits a Prolotherapy doctor can express the symptoms of anger, depression, fatigue and exhaustion from their pain. The Prolotherapy doctor was not the first choice but the fifth, sixth, seventh choice and only after a failed regiment of pain-killers, epidurals, spiraling back pain, and failed surgical expectations. These patients are of course very skeptical of the medical profession on all levels.
Can Prolotherapy heal all these patients? No. If the pain source is not being generated by ligament and tendon weakness and instability, then the realistic goals of Prolotherapy should be immediately discussed with the patient. Can Prolotherapy help many of these patients? In our experience YES!
This is supported by other independent Prolotherapy research that found that pain and disability problems significantly improved after Prolotherapy treatment.13
Effective Treatment for Chronic Low Back Pain is effective treatment for depression and anxiety
An interesting note here is that the researchers state low back pain is a symptom reflective of a heterogeneous group of disorders. In other words, back pain is not simplistic of a single diagnosis.
You can be diagnosed with a herniated disc, but it may be ligament damage that is causing your pain. You could be diagnosed with spinal stenosis, but that may not be what is generating the pain. This is in agreement with a philosophy of many Prolotherapy doctors who practice comprehensive Prolotherapy. Prolotherapy in our opinion is not one injection of one ingredient at one spot. Back pain is diffuse and as such needs to be treated with multiple injections at multiple sites.14,15
If you have questions about your back pain, get help and information from our Caring Medical staff
1: Fernandez M, Colodro-Conde L, Hartvigsen J, Ferreira ML, Refshauge KM, Pinheiro MB, Ordoñana JR, Ferreira PH. Chronic low back pain and the risk of depression or anxiety symptoms: insights from a longitudinal twin study. Spine J.2017 Mar 4. pii: S1529-9430(17)30076-1. doi: 10.1016/j.spinee.2017.02.009. [Google Scholar]
2. Bener A, Dafeeah EE, Salem MO. Determinants of depression and somatisation symptoms in low back pain patients and its treatment: global burden of diseases. J Pak Med Assoc. 2015 May;65(5):473-9. [Google Scholar]
3. Pinheiro MB, Ferreira ML, Refshauge K, Ordoñana JR, et al. Symptoms of depression and risk of new episodes of low back pain. A systematic review and meta-analysis. Arthritis Care Res (Hoboken). 2015 May 18. Google Scholar]
4 Wasan AD, Michna E, Edwards RR, Katz JN, Nedeljkovic SS, Dolman AJ, Janfaza D, Isaac Z, Jamison RN. Psychiatric Comorbidity Is Associated Prospectively with Diminished Opioid Analgesia and Increased Opioid Misuse in Patients with Chronic Low Back Pain. Anesthesiology. 2015 Oct;123(4):861-72. [Pubmed] [Google Scholar]
5. Pakarinen M, Tuomainen I, Koivumaa-Honkanen H, Sinikallio S, Lehto SM, Airaksinen O, Viinamäki H, Aalto T. Life dissatisfaction is associated with depression and poorer surgical outcomes among lumbar spinal stenosis patients: a 10-year follow-up study. International Journal of Rehabilitation Research. 2016 Dec 1;39(4):291-5. [Pubmed] [Google Scholar]
6. von der Hoeh NH, et al. Impact of a multidisciplinary pain program for the management of chronic low back pain in patients undergoing spine surgery and primary total hip replacement: a retrospective cohort study. Patient Saf Surg. 2014 Aug 8;8:34. doi: 10.1186/s13037-014-0034-5. [Pubmed] [Google Scholar]
7. Morlion B. Chronic low back pain: pharmacological, interventional and surgical strategies. Nature Reviews Neurology 9, 462-473 (August 2013) | doi:10.1038/nrneurol.2013.130 [Pubmed] [Google Scholar]
8. White AP, Arnold PM, Norvell DC, Ecker E, Fehlings MG. Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S131-43. [Pubmed] [Google Scholar]
9. Kroenke K, Outcalt S, et al. Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain. General Hospital Psychiatry. 2013. [Pubmed] [Google Scholar]
10. Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155. [CMRS Research paper]
12. Moix J, Kovacs FM, Martín A, Plana MN, Royuela A; Spanish Back Pain Research Network. Catastrophizing, state anxiety, anger, and depressive symptoms do not correlate with disability when variations of trait anxiety are taken into account. a study of chronic low back pain patients treated in Spanish pain units [NCT00360802]. Pain Med. 2011 Jul;12(7):1008-17. doi: 10.1111/j.1526-4637.2011.01155.x. Epub 2011 Jun 13. [Pubmed] [Google Scholar]
13. Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010 Dec;16(12):1285-90. doi: 10.1089/acm.2010.0031. [Pubmed] [Google Scholar]
15. Hauser RA, Hauser MA. Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study. Journal of Prolotherapy 2009;1:145-155 [CMRS Research paper]