aka Socrates and Sophistry 004
The inspiration for today’s S and S section, comes from (1) LITFL friend, and Twitter’s @RFDSdoc, Minh who mused on an Aristotelian quote:
“We are what we repeatedly do. Excellence, then, is not an act, but a habit.”
and (2) the inimitable and peerless @precordialthump who suggested the thorny habit of benzodiazepines and back pain/muscular spasm as a topic.
Aristotle was the next generation of Greek Philosopher. He was the student of Plato (the chronicler of our man Socrates), and a tutor of Alexander the Great. His philosophical legacy was extensive, and he pondered as much on science as philosophy, with treatises on topics such as biology, physics, metaphysics, as well as politics, ethics and rhetoric.
He also had much to say on ‘habit’. The derivation of the above quote is unutterably complex, and beyond the scope of this section, but I would refer you to the IEP article on Aristotle: Ethics if you have a spare lobe of your brain you are not using for a couple of days.
But – ‘habit’ in medicine? It can be ‘excellence’, but alternatively, can also be questionable, and sometimes downright wrong. The habit of prescribing benzodiazepines for back pain; in particular diazepam for the muscular spasm that accompanies this:
Are there GABA receptors we’re not aware of?
Does this have a role centrally?
More importantly, does it work?
Is this just reflex, mechanical prescribing masquerading as habit?
Or, does it work – does it add to the tricky pharmaceutical management of this common presentation?
Take it away, readers. All ideas worthy. Nothing is wrong. Let’s examine our habits.
Addendum 12th July 2012
If you read the comments below you’ll see talk about a podcasting duel on this subject between Casey Parker and Minh Le Cong — check out PHARM Podcast 27 – Benzos for Back Pain to see what unfolded!
Feel free to submit ANY answer to the comments section – we would love to hear your own thoughts, first principle analysis, expert exegesis or revel in revered references. Remember NO answer can be wrong…otherwise we’d know the right answer already! If you want to discuss ‘Socrates and Sophistry’ topics on Twitter, use the #LITFLSAS hash tag.
If you have your own question, please submit it to… Michelle @ lifeinthefastlane.com
About Michelle Johnston
no, it doesn’t work from a therapeutic standpoint if we’re talking about “muscle relaxation” (a bogus concept to begin with). it’s crap. no wonder that the scourge of Rx addiction has exploded-just go to the ED or the clinic and say your back hurts and walk away with some oxy&benzos-and a not for a week off of work too. sweet!
Boldly worded, and likely quite true. Surprising though, that a therapeutic intervention so widespread would have NO basis in reason. Anyone able to justify it out there??
Have a patient on the ward who fell last week.
MSK back pain.
doing well on 10mg diazepam QID with extra when needed.
Usually has 3-6L wine daily so covering my bases.
KeeweeDoc
controversial Michelle!
If there is a component of insomnia with acute back pain , then in my opinion it is reasonable to trial a short course of benzodiazepines. The muscle relaxation thing is fanciful, more like mind relaxation is its main benefit . Which in pain management, has a role in selected cases. If there is no mind, is there pain? If you alter the mind, can you alter the pain or does it remain the same, like an inflammed appendix or fracture? Is pain a mind construct or a purely physical manifestation of an injured body?
I had lots of debate with my teachers on this when studying medical acupuncture…and no easy answers came forth!
Hey Minh , when the residents use the ” muscle relaxant” argument, I usually suggest they go and inject some rocuronium. Now that is a real muscle relaxant! C
“Pain” is unpleasant perception of noxious stimulus, no? So if the mind cannot perceive, the stimulus may still be noxious but the perception is absent.
Isn’t that the premise on which all anaesthetists operate?
Show me a doctor who routinely prescribes benzos for acute back pain and I will show you a doctor who hasn’t changed their practice since graduation!
Seriously -- no good evidence of positive effect, We all know about the harm thy do.
this study http://www.ncbi.nlm.nih.gov/pubmed/20362397
Showed equivalence to physio + Analgesia, but longer stays in hospital.
you are about to open up a whole can of worms , mate! Evidence base practice and pain management, especially for chronic disorders is problematic. You could argue acupuncture has virtually no good scientific evidence base yet I and many colleagues have seen it work and relieve suffering. Every modality and therapy has a place at some point in time for most patients in pain. If we were to strictly apply a biomedical model of pain, then counselling and cognitive behavioural therapy should not work to alleviate pain. yet they do. How does clinical hypnosis work in pain management? Michelle, what would DesCartes say about this?
Descartes (heralded as the father of modern philosophy), had much to say. He coined the term being a ‘seeker of the truth’, encouraged us all to ‘not only have a good mind, but to use it well’, and was also the chap to come up with “I think, therefore I am”. He also remarked beautifully “It is easy to hate and difficult to love. This is how the whole scheme of things work. All good things are difficult to achieve; and bad things are very easy to get” . Which, of course, is ENTIRELY unrelated to this debate. And also equally inapplicable, I would encourage you all to toggle across to twitter to watch @RFDSdoc and @broomedocs slapping each other with gauntlets, and squaring up for a bloody philosophical duel with the subject of management of back pain the handkerchief waving subject in the middle.
no I referred to Descartes in regard to his development of the philosophical concept of mind body dualism…which is relevant to any debate on treating pain. which brings us to the premise behind the Matrix trilogy.
I have caved in and given benzos to stiff anxious patients with musculoskeletal pain and have seen them unstiffened an hour later.
Conicidence? Might well be.
I think they are an option if the patient is anxious.
Having said that, Rob Orman has famously said that all patients who self-present to the ED have two diagnoses -- one of them is anxiety. Why else would they be there?
But I always give analgesics first.
C
of course Chris, pain is all in the mind! why should marijuana alleviate cancer pain?
I suspect (can’t quote any evidence) that there is a vicious circle of pain-anxiety/fear-pain that often appears in patients with acute/acute-on-chronic back pain, particularly the ones that pitch in at 3am. If a single dose of a benzo helps break that cycle (accepting that it works on the head, not the muscles), why not? No benzos-to-go though.
Explanation and patients understanding are extremely important in treating lower back pain; proper analgesia is likely equally important.
, and often achieve the wanted result on the second round.
Sometimes the brain needs to be “treated” for the explanation and advice to be heard!
It might not be evidence-based, but I see not much harm in a single dose in selected patients, and do use benzo’s on back pain patients were PROPER analgesia and explanation do not work; they get a second trial of analgesia, now combined with a benzo, followed by thorough explanation (and sometimes understanding
I agree. EMS crew arrived last night with a pt presenting with spasmodic back pain who had received 20mg morphine and 75mcg fentanyl and was still screaming on the stretcher. Touch of diazepam worked like a charm.
I agree. When I have a regular person with terrible acute on chronic back pain, I’m happy to give a bit of diazepam in the hope that it helps. Just in the ED.
This is a bit old now but I do remember back in 2005 that the evidence did not really fit with my beliefs.
http://www.bestbets.org/bets/bet.php?id=878
My belief? That benzos just calm everyone down and reduce the anxiety associated with back pain. Arguably there are better ways to alleviate anxiety, like talking to the patient and explaining what’s happening……but that takes time and effort and some people prefer pills!
I’m still sceptical about the evidence but do occasionally add benzos if I am running out of theraputic and psychological therapies. It does make me feel bad though.
S
Thanks for the link to your Best Bet Simon -- and great to see http://stemlynsblog.org -- looks great!
Chris
Right lets come up with a solution here: Randomised double-blind trial, benzo v placebo along with other standard therapy, multi-centre (we’ll get our numbers in no time). Most appropriate outcome measure: pain score @….., hospital discharge, return to normal activity? Who’s in? How would ethics feel about this?
Sounds good John. Potentially useful treatment -- probably; potentially harmful treatment -- probably; clinical equipoise -- see above! Shouldn’t be a problem with ethics. Interesting to judge the Hawthorne effect of extra attention/communication just from being in a trial though…..back pain patients are suddenly interesting
Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration.
van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM; Cochrane Back Review Group.
Spine (Phila Pa 1976). 2003 Sep 1;28(17):1978-92. Review.
There are some randomised, placebo controlled trials but there does not seem to be a lot of high quality data out there. Just based on a quick review of the available studies in PubMed revealed the review above. Looks like there is at least one RCT that shows benefit of valium over placebo for acute low back pain.
Hi, Neurointensivist here. I’m not an ED doc but i can empathize with the outpatient drug addicted/dependent world (from my days as a neurologist trainee). We routinely use centrally-acting muscle relaxers and occasionally BZD’s for treatment of postoperative muscle spasm, mostly cervical spine surgery.
Diazepam works well for spasticity by effecting the spinal cord GABA receptors decreasing resting tone in muscles, centrally through effecting the reticular formation. And as an added bonus it can, as some of you mentioned, “break the cycle” of anxiety for pain.
As synergy for back/neck pain i think it has good efficacy but probably only in the short term treatment unless there is central neurologic injury and the pain is from true muscle spasticity.
Oh, and kudos on a Socrates and Sophistry section. Who said that emergency docs weren’t thinkers?
.
Have seen a combination of benzo/opioid (given in the ED) work beautifully to relieve acute back pain in larger patients. Generally, by the time the patients come off of mechanical ventilation, the back pain is no longer the primary issue.
Brilliant!
C
I agree with Minh. Pain control is more than a simple physical issue. I find a short course of benzodiazepine useful particularly in the tense anxious patient. I find the black and white rejection a little harsh. I assume none of these physicians have had personal experience of this pain. I am honestly of the opinion that not every back pain is drug seeking addicts. However I do limit the course of benzo to 2-3/7 and discuss concerns re evidence and dependence.
How reassuring to read the comments of those who discuss dependence or only use small doses short-term. The tolerance and dependency repercussions of long-term use of benzodiazepines, -- regardless of pre-existing problems -- are devastating for many. To know that concerns re evidence and dependence are discussed is encouraging. Over the past few years our helpline has dealt with more than 5,000 patients struggling with benzodiazepine withdrawal, some of whom were prescribed it for back pain and other medical conditions. I urge everyone who uses this website to please research withdrawal effects (in particular papers written by Professors Malcolm Lader and C. Heather Ashton) and not dismiss anecdotal evidence on the Internet as histrionic patients with underlying psych issues. What our charity sees is shocking. If you can find an alternative drug for treatment of any chronic condition, you will be reducing potential harm to patients.
all good comments. I will give up to 2 total doses of diazepam if it seems like it could be helpful, but no more. I base this on the observation that administration of benzos decreases patient reports of symptoms…
I am not accustomed to use benzos in back pain but this could be a reasonable therapeutic option. We don’t give benzos for tension headache already, do we? Is that the excellence? I don’t think so but it may help
It seems anecdote is alive and well. Personally never give it. Therapeutic dose of oral opiate provides adequate analgesia when combined with NSAID. Verbal reassurance for anxiolysis-IMO.
I’m thinking 3 arms in this trial now: placebo vs stat dose vs short course (2-3 days as per Brian and Minh)
In addition to, or instead of, standard analgesia?
Chris
Obviously vexed, and complex. An excellent debate thus far, with available evidence lacking (yes -- thank you Simon for the Bestbet reference, and Brian for the Cochrane review).
We’re still stuck on the lack of true physiological/pharmacological effect, but perhaps allowing for some removed pharmacodynamic effect in a complex presentation that extends further than just the symptomatology of pain in the back… perhaps over to the Irish epicentre for a trial??
If you are doing a trial of benzos for back pain, then some of the outcomes measured should be “benzo dependence” at x months in the future, time off work / lost productivity, depression / chronic mental health problems….
These are all the problems the GP sees long after the back pain is ” controlled” -- cause or effect, not sure, but a definite pattern we see in the community.
every journey starts with a single step, every chronic pain / dependent patient starts with a single prescription….
Sorry, too much waffle. A bit of shadow boxing leading into the big debate with @rfdsdoc
anecdote is alive and well..and so is prejudice. It seems odd..in fact absurd..that many may regard the prescription of benzo / opioid infusion for intubated patients to be appropriate for humane care and alleviation of iatrogenic suffering, yet patients withback pain may receive the opioid but not the benzo…because they might become addicted? what are we doing in ICU then..creating legions of addicted?
certainly not.
so the patient with a lumbar spine fracture who cant sleep just gets escalating doses of opioids and NSAIDS? where is the evidence that is beneficial!?
quote from a wise doctor below on patient consult skills
1. They want to know the doctor is listening to them
2. They want to know that the doctor cares
3. They want to make sure the doctor understands what is going on
4. They want the Doc to “get it right” – that is make the right call / decision / do the right test etc…
5. They want to know what to do next “what will happen to me now?”
I think the first thing we need to do is separate acute from chronic back pain. Chronic is so interlaced with personality overlay that I will not even delve into the morass. Benzos may very well have a role here, though antidepressants probably are a better long term solution.
Acute, true back pain without structural damage is muscle spasm. Like any muscle spasm, if as soon as it starts, you simply stretch the muscle and work through the spasm, it would get better fairly rapidly. Unfortunately, most folks unless they are hard core yogis have no ability to stretch the muscles of the lower back in a way that breaks the spasm. As a result they stop moving, start splinting and things get worse and the cycle builds.
The dorsal root ganglion keeps getting more and more pain feedback and sends out increased signals for the involved muscles to spasm. The only way to break the cycle is to get the patient pain free., rapidly until they can start moving again and slowly work through range of motion and break the cycle.
I am sure benzos make the patient feel better and may even convince them to leave your ER, but let’s not kid ourselves, these are working centrally as sedatives and have no muscle relaxant effect. If i hit your thumb really hard with a hammer, you will tolerate it much better with some valium than without.
If you really want to break the spasm cycle, you need to get these folks rapidly pain free. When I really believe what the pt is telling me, I place a small IV, and titrate in fentanyl q5 minutes until they are pain free enough to easily walk around the ED. At that point if you give them 2 days of apapl/hydrocodone or just ibuprofen and tell them to take it even if the pain is not there for those 2 days, I have found you can break the acute back pain cycle. Poorly treated acute back pain can turn into chronic back paina nd burden us for years to come.
I have found it very helpful to give patients handouts for back extension exercises as well to break the spasm.
So my opinion based on reading a lot of the pain literature but by no means EBM is benzos are useless and may make things worse in acute back pain. Do whatever you want for chronic b/c you are probably screwed from the get go.
If not benzos, how bout a swig of whiskey?
Chris
One for the doc and one for the patient would increase both parties’ satisfaction immeasurably.
I accept that what you do in the ED for acute back pain is somewhat of a separate issue to chronic back pain disorders but to be honest its pain either way..or to put it more accurately..suffering.
Now drug dependency and addiction is a major problem and benzos and opioids are significant players in this space. But the notion that one or few doses of benzos is going to lead to life long addiction is about as fanciful a myth as one or few doses of opioids leading to similar life long addiction. It may happen but its not rampantly common.
The other absurd contradiction played out here by medical practitioners is the fact that patients with palliative conditions such as terminal cancer , we have no issues prescribing infinite amounts of benzos and opioids to alleviate suffering.
Yet the patient in acute or chronic back pain is regarded as suspicious of prone to addiction so we need to limit our prescribing?
The fact is the goal as physicians in acute pain is not to eliminate pain completely but to alleviate suffering and restore a reasonable degree of daily functioning.
Scott quite rightly has pointed out there is a spinal and central nervous system response to pain. Pain after all is a perception. you can’t measure it like a BP or HR or SpO2. Therefore is it not logical that a central acting sedative may help alter the perception of pain..therefore help alleviate suffering?
Women give birth and endure labour pain, people can self amputate limbs without any anaesthesia in the right setting/situation, people can remain completely still in deep meditation whilst burning themselves to death. The central nervous system has a profoundly infinite control over our pain experience.
I there fore don’t think you can condemn the role of benzos in acute back pain, certainly not until you have suffered yourself the very condition that you judge others for.
Listening to and really enjoying Minh and Casey’s podcast on this. I have no time or funding for this trial I was talking about but wouldn’t it be amazing if an RCT was borne out of an LITFL post like this. Well done Michelle on stimulating this discussion. Clearly there is clinical equipoise on this issue and therefore (being ultrasimplistic about it) an RCT would be warranted.
The issues would be 1) which patients would you include/exclude 2) what treatments would you test and 3)how would you measure outcomes/efficacy/safety?
1) The problem here is that this is a very heterogenous group. One would want to perhaps just look at acute back pain and exclude chronic pain patients. But many of these patients as we know are acute on chronic and have a complex history -- do we exclude patients with a long(er) history? with previous actual pathology/surgery?
2) Would have to be benzo vs placebo obviously. + standard analgesia regimen/treating physician’s choice of analgesia as this is quite a heterogenous group. As mentioned previously having 2 benzo arms (stat dose and short course) would be interesting, but a 3-arm study is a bit of a nightmare statistically
3) Perhaps most interestingly, what Primary Outcome would you look at? For an RCT you would want something that’s objectively measurable, but what’s most important here for the patient? What are we aiming for?
-ED discharge/hospital admission
-Pain score @ 30min, 1hr, 2hrs, 2days, 1wk, 1mth?
-Patient satisfaction @ what time interval? -- might be a better way to take into account the “suffering” as Minh eloquently puts
-Return to ED/Healthcare practitioner
-Return to ADLs
-Clearly side effects/adverse events would have to be looked at
-Short term: depressed cons state, respiratory depression
-Benzo dependance? How to measure and when? I’m sure there’s a standard way to do this in the lit?
More questions than answers…
One could reference this post and discussion in the intro for the paper -- the NEJM people would love that….;)
jc
Lower back pain is not very enjoyable and can keep you from having fun. It’s always nice to feel good throughout your day!
I have been on Benzodiazepines for 9 years and have been tapering off them for about 7 months. What is interesting is that my back has slowly gotten worst since the taper. The reason I am even on this site is to gather information to see if this is true. I am somewhat convinced that Benzo’s have eased my pain for the last few years. The down side is that Benzo’s are a horrible drug to be adddicted to and very difficult to get off of. At least this has been my experience. I have degenerative disk disease and cannot stand for very long and have constant pain in my lower back. I will, no doubt, end up having surgery and hope this decision doesn’t ruin my life. Good luck to all in pain.