Medications are not the first choice of treatment for low back pain

Low back pain is very common. The vast majority of people reading this sentence have had low back pain at some time in their lives. It is one of the most common reasons for physician visits in the U.S. and results in an estimated $100 billion in annual costs. Given the very high prevalence of low back pain, you would think that we would already have noninvasive treatments that are proven to be safe and effective. You’d be wrong.

Recently the American College of Physicians (ACP) reviewed existing studies about noninvasive treatments for low back pain. (Noninvasive means that they did not consider surgery or injections. These invasive treatments are required in only a small minority of cases.) In February the APC used this evidence review to publish new recommendations for the treatment of low back pain.

For patients with acute (less than four weeks) or subacute (four to twelve weeks) low back pain, the ACP recommendations remind us that most patients improve regardless of treatment. Treatment without medication is recommended first (for example, with superficial heat). If medications are desired by the patient and the physician, nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants are recommended.

For patients with chronic (longer than twelve weeks) low back pain, the ACP again recommends nonpharmacological treatment with exercise, rehabilitation programs, acupuncture, or mindfulness-based stress reduction. If that doesn’t help, the first-line medicines to consider are NSAIDs. The second line medications are tramadol (Ultram) or duloxetine (Cymbalta). Opioids should only be considered in patients for whom the above options have been ineffective and if the potential benefits outweigh the risks for the individual patient.

The recommendations above are based on moderate-quality evidence. (The ACP uses a formal ranking of the quality of evidence in the studies reviewed.) Some of the recommendations are based on low-quality evidence, which I didn’t include above.

The striking difference between the current recommendations and the previous ones is that medications are no longer recommended as first-line treatment. This isn’t because the nonpharmacological treatments are proven to be so effective. It’s because we’ve learned how modestly effective medication is for low back pain, and we’ve come to appreciate the side effects that medications can cause.

So these are not so much new recommendations about new effective treatments for low back pain, but rather a retraction of the prior recommendations because of how much we realize we don’t know. The recommendations don’t include any high-quality evidence, because there have been no large well-designed randomized trials evaluating various therapies for low back pain.

The bottom lines are these. For chronic low back pain none of the known therapies are extremely effective, and all medications have side effects, so the prevailing philosophy is: if you’re going to prescribe placebo, at least make it a safe one. For acute and subacute back pain, almost everyone gets better regardless of treatment. So the best treatment is time. Perhaps that’s why we call you patients.

Learn more:

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain (summaries for patients, Annals of Internal Medicine)
Low Back Pain Treatment (American College of Physicians video)
No Drugs for Back Pain, New Guidelines Say (Wall Street Journal)
Forget the drugs, the answer to back pain may be Tai chi, massage (USA Today)
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians (Annals of Internal Medicine)

My previous posts about prescription pain medicine abuse:

The Scourge Of Prescription Pain Medicine Abuse (2014)
Surgeon General Vivek Murthy Releases Report On Addiction Epidemic (2016)

Demjanjuk’s death hastened by medication, complaint says

An attorney for convicted Nazi war criminal John Demjanjuk filed a complaint with German prosecutors claiming that his death was hastened by medication administered at a nursing home in Bavaria.

Ulrich Busch asked prosecutors in Rosenheim, Bavaria, in a 12-page complaint to open an investigation of five doctors and a nurse, The Associated Press reported Wednesday.

The complaint posits that a specific pain medication, common in Germany but banned in the United States, led to Demjanjuk’s death in March as he awaited an appeal of his conviction last year by a Munich court for his role in the murder of 27,900 people at the Sobibor death camp in Poland.

Born and raised in Ukraine, Demjanjuk immigrated to the United States following World War II. In 1986 the Cleveland-area autoworker was sent to Israel to face trial on charges of being the notorious Treblinka guard “Ivan the Terrible.” An Israeli court sentenced Demjanjuk to death, but the Israeli Supreme Court ordered him released due to reasonable doubt while noting that substantial evidence emerged during the trial identifying him as a guard at Sobibor.

Demjanjuk returned to suburban Cleveland in 1993 and resisted multiple attempts to strip him of his U.S. citizenship and deport him again. But in 2009, U.S. authorities deported him to Germany, and in May 2011 he was convicted for his crimes in Sobibor. Demjanjuk was sentenced to five years in prison.

Substance Abuse a Senior Problem, Too


When Amy Kaplan heard about Betty (not her real name), a Jewish Family Service client in her early 70s who said she couldn’t afford all of her medications, Kaplan suspected there was more to the story. Kaplan, a social worker and addiction specialist, visited Betty’s home and confirmed her suspicions: Betty was taking 24 prescription medications, some of which were duplicates or even triplicates. Betty was drowsy, unsteady, financially strapped — and addicted.

“The numbers are astronomical,” Kaplan said. “I’d say 90 percent of our clients are affected by addiction in some way, either themselves or through a family member, a close friend or a neighbor.”

According to the Substance Abuse and Mental Health Services Administration, prescription drugs and alcohol abuse among adults 60 and older is one of the fastest growing health problems in the country, affecting up to 17 percent of older adults. With baby boomers beginning to turn 60 this year, the incidence will continue to climb without intervention.

“This is a significant problem which has been underidentified and under-recognized,” said Karen Leaf, director of Jewish Family Service of Los Angeles’ (JFS) Valley Storefront in North Hollywood. “Given the scope of the problem, we decided we needed to be better equipped to deal with it.”

With grants from the Archstone and Jewish Community foundations, JFS instituted the Senior Substance Abuse and Mental Health Initiative last summer. Kaplan, who had previously worked at the Betty Ford Center in Rancho Mirage, was recruited to develop programs for JFS. The agency’s first priority involved educating and training its own social workers and case managers — who deal with thousands of seniors in the course of a year — to better recognize and assist clients with substance abuse problems.

Kaplan now leads a weekly Alcoholics Anonymous meeting at the Valley Storefront location, and JFS hopes to add more locations in the future. Dr. Alan Schneider, a psychiatrist specializing in the elderly, has given presentations about mental health and medication management during brown-bag lunch sessions at area senior centers. To increase public awareness of the issue, Kaplan and others have made presentations at health fairs, meetings and other community events.

Older adults are usually “accidental addicts,” according to Carol Colleran, director of older adult services at the Hanley Center in West Palm Beach, Fla., and co-author of “Aging and Addiction” (Hazelden, 2002). She said that seniors often develop problems when they continue to take prescription medications that were intended for short-term use. This is common with a class of drugs called benzodiazepines, medications prescribed for insomnia and anxiety. Benzodiazipines, which include Valium and Xanax, are addictive.

Colleran said that late-onset addiction can be triggered by loss, such as the loss of a spouse, a job or a sense of purpose. To cope with these losses, individuals may self-medicate with prescription drugs and alcohol.

Problems are compounded because the body processes alcohol and drugs less efficiently as it ages. Older adults may find that they can no longer tolerate the same amounts of alcohol that they consumed in the past. And alcohol’s effects are intensified when it is mixed with prescription or over-the-counter drugs.

“Safe drinking for older adults is one drink per day,” Colleran noted. One drink equals a 12-ounce beer, 1 1/2 ounces of liquor or 5 ounces of wine.

Underdiagnosis of alcohol and prescription drug abuse among older adults is common because symptoms — including fatigue, depression, irritability, insomnia, frequent falls, chronic pain, impotence and congestive heart failure — are often misinterpreted as signs of other medical conditions. Symptoms may be attributed to dementia, Parkinson’s, depression or simply products of aging.

Addiction is not on the radar screen for most physicians, according to the National Center on Addiction and Substance Abuse at Columbia University (CASA). In a CASA physician survey presenting a hypothetical case of a mature woman who showed the typical early symptoms of alcohol and prescription drug abuse, only one percent of the doctors considered substance abuse as a possible diagnosis.

“We need to get the word out about this,” said Colleran, who believes ageism and sexism are additional barriers to recognition of the problem.

On the positive side, she said that older adults have the highest success rate in treatment of any age group.

Jews and Addiction

Although JFS is a nonsectarian organization, addiction specialist Kaplan estimates that 50 percent of the agency’s senior clients who suffer from addiction are Jewish. The perception that Jews don’t drink, she said, is a myth. Further, a 2001 study published in the Journal of Addictive Diseases refuted the perception that Jewish alcoholics have lower educational, financial or religious levels.

While the JFS initiative does not incorporate Jewish content, there are programs that address addiction through a Jewish lens. Unlike the JFS initiative, however, they are not targeted exclusively to older adults. New York-based Jewish Alcoholics, Chemically Dependent Persons and Significant Others (JACS), which offers numerous resources on its Web site, holds programs in several Los Angeles locations. Beit T’Shuvah, which provides both residential and out-patient treatment, addresses addiction using Jewish spirituality, the 12-Step program originated by Alcoholics Anonymous and psychotherapy.

Congregation Or Ami in Calabasas has offered a variety of programs addressing addiction, including Madraygot (Steps), a monthly program that looks at the intersection of Judaism and the 12-Step program. The synagogue commissioned a rabbinic intern, Rebecca Hoffman, to develop a curriculum designed for congregations to offer their own Jewish 12-Step program.

“I’ve worked at three Los Angeles area synagogues, and the minute I started talking about addiction, people started coming out of the woodwork,” Or Ami’s Rabbi Paul Kipnes said. “My goal is to break down the walls of silence and talk about it ….Individuals who are suffering from addiction have a place in the community and the community needs to respond.”

Signs of a Problem

by Gabriel Meyer

Medicine and alcohol misuse can happen unintentionally. According to the Substance Abuse and Mental Health Services Administration, the following signs may indicate an alcohol or medication-related problem:


• Memory trouble after having a drink or taking medicine


• Loss of coordination (walking unsteadily, frequent falls)


• Changes in sleeping habits


• Unexplained bruises


• Irritability, sadness, depression


• Unexplained chronic pain


• Changes in eating habits


• Desire to stay alone much of the time


• Failure to bathe or keep clean


• Difficulty finishing sentences


• Difficulty concentrating


• Difficulty staying in touch with family or friends


• Lack of interest in usual activities

Problems Abound in Pampering Parents

My mother and father are both in diapers. I wasn't at all prepared for this possibility. Dealing with the visual and olfactory aspect of my son's end products when he was a baby was an expected part of being a mom, but it's a completely different matter when it's my parents wearing the Pampers.

My mother was first. A few years ago, she was on a medication for dementia that instead of keeping her memory, loosened her bowels. Both my sister and I had the traumatic experience of being out in public with mom, hearing her gasp, rushing with her to the nearest restroom and then trying to figure out what to do.

It was demoralizing for my mother and very distressing for my sister and me. We learned to carry extra clothes and diaper wipes with us.

Fortunately, my sister and I both have rather sick senses of humor, and we could later laugh (albeit slightly hysterically) when sharing these nightmares with each other. My mother could even laugh about it, but it was colored by obvious pain about her aging and loss of control.

My mother is no longer on that medication and blissfully unaware (because of her dementia) of the fact that she wears diapers. Well, in fact, she actually does notice it, but forgets a few minutes later.

Mom lives in a board and care where, thankfully, someone other than me gets to handle her potty needs. I'm adjusting to the fact that my mother is old and child-like in many ways.

My 86-year-old father is still functioning fine mentally. He's still counseling clients and writing a book about handling fears. He's funny and together and basically still “my dad.”

But two years ago, a stroke left dad partially paralyzed on his right side. A fiercely independent man, this was a real blow to his pride and his view of himself. (The good news is that it forced him to stop driving, something we'd desperately wanted for years.)

After the stroke, dad was a prize student for the occupational and physical therapists, and he can now dress and feed himself, walk with a cane and even slowly type on his computer. He desperately wants to do everything for himself.

But the stroke left him with occasional loss of bowel control, and prostate problems have caused him incontinence. He wears pull-ups.

Dad hates it, and he is terribly frustrated and angry when he has an accident. I went to visit him in Ohio last August, and there was no doubt when an accident would occur, because dad announced it loudly, like a wounded or trapped animal. It was clearly horrible for him to be so powerless.

Much to my dismay, (yes, I confess, I was not thrilled) he often needed help with the clean up after such an accident. He would make his way into the bathroom, close the door, deal with the situation by himself and then he'd shout my name.

The first time I heard him yell, it sounded like panic, and I thought he'd hurt himself. I flew from the living room and threw open the bathroom door.

There he was, sitting on the thrown, his Depends around his ankles. My first thought was, “Oh good, he's OK.”

Then I felt irritated that I was being called to witness him in that state. Then came a childhood memory: dad, sitting on the can, his pants around his ankles, reading the entire Sunday Cleveland Plain Dealer, while my sister and I impatiently asked him when he was going to be done.

But this was different. We are now adults, and I haven't seen my father's rear end for about 48 years. Worse than that, he was ashamed and embarrassed at having to ask for help.

The circumstances during that visit brought up a lot of intense feelings about aging (both his and mine) and about mortality (both his and mine). And there was a deep sense of loss of the father I used to have — really until just a few years ago — who was vibrant, active and independent. We were both grieving.

One morning during my visit, I woke up with a full bladder and headed to the aforementioned one-and-only bathroom. The door was closed.

“Dad, are you in there?” (duh.)

“Hey, good morning sweetie. Don't worry, I won't be long!”

An hour later, he was still in there. Need I say, I was really uncomfortable. I looked in the garage for a pot of some sort. No luck.

Then I thought about squatting in the backyard, but there aren't fences between homes in this small Ohio town. So, I did what any desperate, agile person with a full bladder would do — I used the kitchen sink.

My father was still in the bathroom, so I called my sister. I described the entire scene, and we both had one of our “this-is-terrible-but-we-have-to-do-it-so-let's-find-it-amusing” giggles, which helped.

I have to admit that those first three days with my dad seemed like a month. I felt guilty that I couldn't wait to leave. For most of my life, I had my father on a pedestal.

He could fix anything — including personal problems. He skied and played tennis into his late 70s. He always had words of wisdom when I was in a crisis. He's still a sharp, vibrant man.

But since his stroke, it seems like he's shrinking in many ways. His ability to think of things beyond his physical challenges has diminished, which means a decrease in our usual stimulating, fun interactions.

However, after a few days, dad regained control of his bodily functions, and we did have a final day to talk before I returned to Los Angeles.

As often happens with people facing their later years, dad went back in time. He reminisced about his grandparents and his parents. He cried as he talked about how much his mother and father gave to others and how he admired them.

He recalled what a mensch his oldest brother was and what a bully his other brother was. He confessed to skinny-dipping with my mother before they were married. (Something I wish I'd known when she made such a big deal about me necking in the car with my high school boyfriend.)

Then dad switched to my childhood, laughing as he recalled me (at 3 years old) telling the towering 6-foot, 4-inch gentleman next door that it wasn't “nice to spit.” He also enjoyed reminiscing about the time he bought my sister boxing gloves so that she could hit me when I picked on her. Our shared laughter felt wonderful.

My father's hearing aids weren't working, which meant that most of our two-hour conversation that day involved him loudly saying, “What?” and me shouting my responses at him. I was exhausted and hoarse by the time he informed me — loud enough for the neighbors to hear — that he had to go to the bathroom.

And it was fine.

Ellie Kahn is a freelance writer, oral historian and owner of Living Legacies Family Histories. She can be reached at