Surgery is much less science-based than the rest of medicine. It is almost impossible to subject it to studies that are double-blind and placebo-controlled. Surgical guidelines are therefore necessarily much more anecdotal than based on evidence.
Lots of elective surgery is probably unnecessary, and back operations are the most notorious example. Back pain is an inevitable and fairly ubiquitous complication of the human condition, arising from our incomplete postural adaptation to bipedal locomotion and the fact that we now live much longer than our backs are adapted for.
Back surgery is performed when the patient has a combination of pain and imaging pictures that show spinal abnormalities. The natural assumption is that what shows up in the pictures must be causing the pain. But that assumption is wrong. Lots of people have very messed-up pictures but no pain, and lots of other people have very pretty pictures but lots of pain. And as you get older, your spine shows progressively more imaging findings best considered indicative of normal aging, not disease.
And things have gotten even worse since Big Pharma began pushing prescription narcotics as a panacea for all pain. While helpful and safe for some, prescription opioids have become a major public-health nightmare. The drugs are prescribed carelessly even though they are frequently addicting. Remarkably, prescription drugs now kill more people than car accidents or street drugs.
So back pain invites two dangers: unnecessarily invasive surgery and unnecessary, life-threatening addiction. Operating on the basis of pictures, not the person, often leads to no benefit or even harm. Giving out powerful meds like candy can lead to addiction and death.
For years I have been advising friends, relatives, and patients to avoid the knife and the pill and depend instead on rehab, exercise, and distraction. Some listen. Many don't. Usually the reply is that I don't understand how badly they feel. To reinforce the message, I have asked a present sufferer of back pain to share her experience. Lynn writes:
When I got sciatica, I went through one doctor after another and through one treatment after another -- chiropractic, acupuncture, 2 rounds of not aggressive physical therapy, numerous MRI's, trigger point shots of cortisone and lidocaine, and so forth. Surgery was recommended by several different surgeons.
The opinions were all over the place and I was getting increasingly confused and discouraged. The pain got worse and often I couldn't think of anything else.
My GP prescribed an opioid for me. I was concerned the pills could become addictive but she (like two other doctors) blythely and incorrectly told me this would not be a problem. I think doctors prescribe opioids so carelessly just because they want to get you out of the office and have been brainwashed by drug salesmen to minimize the risks.
I reluctantly tried the pills but luckily just didn't like them. They made me constipated and kept me awake at night, actually causing nightmares.
Then I found a doctor who set me straight and changed everything. He bluntly told me that I was in a chronic cycle of pain and that the fear or anticipation of pain only exacerbates the pain. No pain pills in the world can prevent fear of pain. He told me that I needed to take a much more aggressive rehab and exercise approach to the sciatica problem.
Frankly, I was disappointed to discover that I was part of the problem. I wanted a quick medical or surgical solution to my problem, an easy fix. But there isn't one.
Part of the remedy was to realize that I was part of the problem. Yes, in anticipating pain, I was causing more pain. When we anticipate pain, we actually tense up more, which leads to more anxiety, which leads to more tightened muscles and then more pain.
So how did I overcome my fear of and preoccupation with my pain? It isn't easy, but it works. I practice mindfulness in additional to the very intensive physical therapy. The PT is a gradual process, but I am now lifting dead weights using my back with the goal of lifting 50 pounds. I am up to 40 pounds and feel confident I will make it the rest of the way. Of course there are a series of other weight exercises I do, all tough, and all exceeding my previously perceived capacity. And I do lots of stretching.
Mindfulness has also been a big help. The idea is to notice pain, but then come back to what you are doing at the moment. Right now I have some pain but I am concentrating instead on typing this note. Rather than focusing on my pain, I note it just like you might notice a bird flying by, but then go right back to what I am focusing on doing. It takes mental work, but it does work. Focusing on breathing techniques is also part of the mindfulness technique.
The book that helped me the most is called, "Back Sense, a Revolutionary Approach to Halting the Cycle of Chronic Back Pain," Siegel, Urdang, and Johnson. When I was reading it two things occurred: 1) I thought I was reading a book just about me and my situation and 2) I realized that I can fix this. Believe it or not, the pain began to diminish almost immediately. Once I realized that I'm in charge, I felt better. Really, absolutely true.
Opioid drugs often only disguise the pain and are NOT the best remedy for fixing or alleviating it. They are only making the drug makers rich. Plain and simple. I would recommend not starting them at all and if you are on them slowly get off. It may be hard because of withdrawal and must be done under a doctors supervision, but do it. Skip a dose and take a walk.
Thanks so much, Lynn. Certainly there are situations where back surgery is clearly necessary (and sometimes urgently so), and other situations where it is a last resort, after all else has been tried. But the knife should be used sparingly and judiciously, only after all other possibilities have been considered and have failed.
Decisions about surgery are too important to be left exclusively in the hands of surgeons. They have inherent financial, intellectual, emotional, professional, ego-driven and guild conflicts of interest that make them predisposed toward quick decisions and excessively aggressive treatment. Rehab doctors are more likely to be patient and disinterested.
Doctors who carelessly prescribe opioids are little better and just as dangerous as drug pushers. The unscrupulous marketing of prescription narcotics by Big Pharma has been heavily fined and labeled criminal, but it continues because it is so profitable. The FDA has been asleep at the wheel.
Patients beware and be informed.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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TRENTON >> Doctors see the toll smoking takes on a daily basis.
So before city council voted to raise Trentons tobacco purchasing age from 19 to 21 on Thursday, medical practitioners from local hospitals told of the horror stories.
As a doctor, frankly, Im tired of treating adults with emphysema, lung disease and lung cancer due to smoking, Dr. Robert Remstein, of Capital Health, said at the meeting. Its sad every time I see that. Too many young patients have suffered and died.
Just this week, Remstein said a smoker had part of their lung removed.
In Trenton, we have a chance to make a difference for our youth with this ordinance, the doctor said.
Trenton council heeded the advice.
All but one of the council members voted to approve the ordinance that will increase the cigarette buying age in Trenton to 21.
Councilman Alex Bethea, a self-described health fanatic, begrudgingly threw his support behind the measure, which he failed to see the significance of. The councilman still thinks a smoker who is 15 or 16 can still get someone who is older to buy them a pack of smokes.
I would like to take a stronger approach, Bethea said. I just dont know what impact its going to have in the community immediately. I still think its just Band-Aid on a major surgery, but Im compelled to say yes.
The city has been floating the idea of passing the ordinance, which also includes prohibiting the sale nicotine delivery devices, such as e-cigarettes, to people under 21, since it was introduced in January. It was recently reworked to also stop the sale of non-nicotine delivery devices to people under the 21.
With the approval, Trenton became the 22nd municipality in the state and second largest behind Paterson to raise the tobacco purchasing age to 21. Trenton joins Princeton, which bumped the tobacco purchasing age to 21 in May 2015, as the second municipality in Mercer County to enact the law.
The states tobacco purchasing age is 19, so the lone member to oppose the measure, expressed concerns that the city was overreaching with a law already on the books.
Youre actually imposing an additional restriction on adults, Councilwoman Marge Caldwell-Wilson said. Youre telling these adults between the ages of 18 and 20 that they cannot purchase cigarettes. Because the children who get access to cigarettes are always going to get access to cigarettes. Someone is always going to purchase for them. So Im not sure that changing the age limit is going to make a huge difference.
Last year, a push to increase the statewide tobacco purchasing age to 21 died when Gov. Chris Christie pocket vetoed the measure after it secured both Assembly and Senate approval. The ordinance was proposed by the citys Division of Health.
Trenton Health Director James Brownlee previously explained he wanted the law passed because tobacco addiction continues to be a paramount public health concern.
Dr. James Romano, a chief medical officer at St. Francis Medical Center, disclosed Thursday that tobacco remains the leading cause of preventative disease of pre-mature deaths in the U.S.
In 2016, nearly 6 percent of the emergency department at St. Francis Medical Center thats over 300 visits were for patients under 21 with pulmonary conditions directly or indirectly related to smoking, Romano said, adding the new law would reduce smoking deaths by 10 percent. For adolescents alive today, 4.2 million years of life will be saved by virtue of instituting this simple, logical policy change. The law, which will take effect in 20 days, will be enforced by the citys health and police departments. It penalizes the retailers and not the young people who might attempt to purchase the cigarettes illegally.
Employees or retail owners who sell tobacco products to people under 21 will be fined $250 for the first offense, $500 for the second violation, and $1,000 for each subsequent offense.
Stamping out smoking in Trenton, city council approved last July to ban smoking in all city parks and recreational areas. The measure bans the use of smoking cigars, cigarettes, pipes and electronic smoking devices in the public spaces, and fine violators from $50 to $500 depending on the number of offenses.
New Jersey Municipalities that have raised the tobacco purchasing age to 21
East Rutherford 5/19/15
Fair Lawn 7/21/16
Highland Park 4/17/15
Union City 9/1/15
West Orange 7/1/16
Information provided by Preventing Tobacco Addiction Foundation