BACK PAIN, MEDS, AND NONCOMPLIANCE

I listened to a phone call between a patient and our secretary last week. The patient wanted to come in a week before she was due for a refill of her Methodone and Dilaudid as she would be on vacation the next week. She was informed that this was fine, but that she would need to bring in her two bottles of narcotic to confirm that she had a week's worth left. She was told that this was standard policy. We did not refill patients early if they ran out of their narcotics early. The patient was outraged. She stated that this had never been required before and demanded to know why she was being singled out. She railed against the possibility that we did not believe her. She yelled at our secretary that we were being unfair, unreasonable, and unprofessional. She demanded that she be able to speak to the office manager, and aggressed against her as well - for almost 20 minutes. Eventually, she refused to come in early if we could not trust her, and stated she would see us after her vacation. Clearly, she expected to remain a patient even after her tirade.

These interactions happen all the time in a typical pain clinic, but patients almost never see them. Everybody is special, everybody is trustworthy, everyone should get special treatment. Patients should be able to structure their treatments, refills, etc., any way they want. Everybody thinks we should break the rules just for them. This patient demanded that we refill the two strongest narcotics in the history of the world 7 days early out of 28 simply because she wanted us to. The common sense, minimally important request to bring in her bottles outraged her. Objectively, this was not a big deal - if she had the last week of her meds. We'll never know since she felt too outraged and betrayed to bring her meds in and so will fill her script after her vacation - the clear implication being, it will be our fault when she goes through withdrawal.

This patient's behavior was completely inappropriate, aggressive, and rude, and demonstrated grossly poor judgement. She yelled at the secretary and office manager for 30 minutes combined and expects to remain a patient of this clinic. She would probably threaten malpractice if we terminated her over this incident, which in fact we have every right to do.

Your doctor is not your mother, father, best friend, or priest. We don't have to care why you're being noncompliant, or inappropriate, or having a bd day - just that you are. The purpose of rules is to prevent us from having to figure out if you're telling the truth or not - that's for criminal courts and parents. We're neither. And we absolutely have the right to terminate your care if you act out. Always. The next time, you get angry because the doctor or staff won't bend the rules for you, remember this blog. And knock it off.

Dr. Tim

BACK PAIN AND PAIN MEDS

Every pain program I consult to, and there are dozens of them, is monitoring medications, especially narcotics, much more closely that ever before. You are expected to fill your meds on time, not early, and be responsible with them. Your doctor is neither the police, nor your parents. Having a good reason to be out of meds early is not the same as being on time. Whether you overconsumed, lost them, or they were stolen matters less than you think. Whether or not we believe your story matters less than you would think. Everybody gets one or two or even three free passes and then your doctor will probably confront you. No matter the reason, you are not a good candidate for strong pain meds if you cannot manage them. This morning a patient was outraged that she had to bring her meds with her to an appointment where she was filling her narcotics a week early so she could go on vacation. She was angry that we did not "trust her." The angrier she got, the more inappropriate. If she had the last week of her meds, why was it such a big deal to bring in her meds? Why does she think that the rules don't apply to her, that she is so special, she should be above everyone else? At best, she's being narcissistic, at worst she's using aggression to cover up being noncompliant with her narcotics. This happens all the time, the kind of interaction most patients never see but affects how pain doctors practice medicine. Be responsible with your meds, and if you run out, don't think your reason is important. It's not.

Dr. Tim

LIMBREL - A NEW ANTI - INFLAMMATORY

Limbrel is a relatively new prescription anti-inflammatory that is FDA approved for osteo-arthritis, but used off-label for a variety of inflammatory problems. Limbrel is not classified as a drug, but rather a medical food product. It inhibits the COX (cyclooxygenase) and LOX (lipoxygenase) enzyme systems. It is the first and only medical product that balances both COX-1 and COX-2 metabolism equally. It consists of flavocoxib, a blend of flavonoids from the two plants Scutellaria baicalensis and Acacia catechu, both well recognized for their aniti-inflammatory and anti-oxidant proerties. Anti-oxidants aborb free radicals in the joints that have been found to break down cartilage over time. Patients report effects within 4-10 days of taking the product. Side effects are minimal. Ask your doctor if he/she thinks Limrel might be effective for you.

BACK PAIN SURVEY OF TREATMENT SATISFACTION

A national, SpineUniverse survey of patient satisfaction with a range of back pain treatments yielded interesting results. Herbal remedies, over the counter pain medications, and acupuncture produced the greatest patient disatisfaction. Prescription pain medication, massage, exercise, and weight loss produced the greatest patient satisfaction. Less than half of the patients who underwent spine surgery were satisfied with the outcome of their surgery. If you are considering spine surgery, you may want to reread that last sentence. It is interesting to note that prescription pain medication and massage are treatments that are done to you. You have no real control over the outcome. Exercise and weight loss, both behavioral strategies are treatments that you do to and for you. You have complete control over them - but they are more work for you. You don't get to just passively lie there and be worked on. They are free, painless, and available to everybody. They also make every other treatment more effective. To read about the complete survey, go to:


http://www.spineuniverse.com/article/back-pain-3167.html

BACK SPASMS AND PAIN CONTROL

I had another back spasm earlier this week. The first in several years. It happened while I was typing an article about back pain. I don't care what Freud would say. My back locked up and I could hardly move. I'd say 8-9/10 pain. This time I laid on the floor and did the neutral spine exercise (Tim's Trick). The spasm eased in a minute or two but I stayed where I was for a half hour. I was left with the familiar, hot stiff ache that lasts for a few days to a few weeks.
I remembered:

How hard it is not to walk like the tin man
How serious I can get when I hurt
How much I avoid any jerky movements
How difficult it is to stand perfectly straight
How painful it can be to drive
How much I have to vary my activities
How to roll out of bed on my stomache - and how weird it looks
How easy it would be to take time off work

I'm mostly back to baseline aches and pains - my normal. I feel truly blessed that my spasms are infrequent. I have patients who go through this a couple times a week. That's a hard life. Perspective.

Good light,

Dr. Tim

BACK PAIN, NO INSURANCE, LITTLE MONEY

Back pain patients across the U.S. obtain phone consultations with me to achieve pain relief and a common reason is because they lost their health insurance, they hurt, and they can't afford to go to the doctor. What's the most cost effective way to get back pain relief with severe financial limitations and no insurance?


1) Take a low dose, over the counter, anti-inflammatory, like Advil. Inflammation is a pain trigger for almost everyone. Instant pain relief is not the goal, decreasing inflammation is.

2) Take a multivitamin, drink 6-8 glasses of water per day, eat multiple small meals.

3) Practice good sleep hygiene. Take a sleep aid from time to time. Go to bed and get up at the same time each day. Avoid long naps during the day. See # 6.

4) Consider taking St. John's wort, available at most grocery stores, which will increase your Serotonin levels and can improve your mood and your pain tolerance.

5) Do gentle back stretching exercises from daily to multiple times per day.

6) Get in the water (pool) and begin getting some non weight bearing, nonimpact exercise. If this is not possible, try a stationary bike - something to get your blood moving.

7) Vary your body mechanics from walking to sitting to standing to lying down every 10-30 minutes.

8) For $6.00, you can download a copy of my pain book, ABC's of Pain Relief and Treatment: Advances, Breakthroughs, and Choices with hundreds of treatment and self management suggestions.

9) For $19.95, you can consult with me for 15 minutes after completing an intake form. I can give you specific suggestions based on your unique situation.

10) Learn the back pain relief strategy of the neutral spine. Lie on the floor with your legs up on a chair facing you so your things and your calves form a 90 degree angle. this makes your low back straighten, similar to what happens with traction. try this several times per day for 5-15 minutes.

Back pain relief on the cheap!

Dr. Tim

BACK PAIN, EXERCISE, AND COMMON MISTAKES

The biggest mistake made by people with back pain is to not exercise at all, even after a course of physical therapy. Immediately after the therapy ends, so does any attempt at exercise. This is often the result of the underlying approach to exercise in which people with persistent back pain try to strengthen their back with exercise, increase their pain dramatically, and then stop exercising altogether, having learned that exercise hurts. The years pass with episodic attempts at exercising the injured back, usually in physical therapy, with only increased pain to show for their efforts.

The second biggest mistake people in pain make is to focus all their exercise efforts on their painful back or legs and ignore the rest of their body, which gets as weak as their back over time. With persistent pain, focus on your noninjured body parts first and only months later your injured back. Get some aerobic exercise through a stationary bike or in the pool - not so much that your pain increases. Then focus on strengthening your noninjured, non-back body parts so they can compensate for your injured back - not so much that your pain increases. Only then should you exercise your with the main goal of maintaining range of motion through gentle stretching - not so much that your pain increases. This is the most effective strategy for rehabilitating a persistently painful back. You should be doing some type of exercise 1-2 times every day. Are you?