To Treat or Not to Treat – That is the Question

Sometimes saying no is in the best interest of the patient. The day began with a 21-year-old patient seeking help for what he describes as his severe, chronic low back pain. He tells us that he is ready to do something about his back because it is "ruining his life," -interfering with his ability to work and to have a social life. The patient was last seen more than a year ago, sent for imaging that revealed a bulging disc in his back and referred to an orthopaedic surgeon specializing in disorders of the back. Before the referral, the patient had multiple prescription for Norco, a strong pain-relieving narcotic. He failed to follow up for the consultation with the back specialist, citing lack of insurance as a reason and telling us that he didn't want his back to be a "sponge" from having surgery.

This young patient went on to explain that he works with a family member in the construction/re-modeling industry. He stated that he is in excruciating pain at the end of the day and that the only way he can get through the day is to take some pain pills given to him by a friend of his father. The patient very much wanted a prescription for these "pain pills." The visit goes on with x-rays ordered that reveal arthritic changes in the patient's back – he undoubtedly has an "old" back for being such a young man.

We talk with the patient about the need to seek specialty evaluation for possible consideration of back surgery or perhaps a steroid injection in his back. The patient finally agreed to go for the referral, but when offered non-narcotic medication to control his pain, he maintained that this medication will not do anything. He would really like some of the "pain pills" given to him by a friend. The patient did not know the name, he called his father who also did not know the name of the medication. Patient finally made it clear that while he does not have what he describes as "drug seeking" behavior, he really needs some narcotics for pain. We explained that narcotic management of chronic back pain is inappropriate and will truly "ruin his life" if he becomes addicted to the medication.

It's a hard call sometimes about whether the patient is legitimately in pain and truly difficulty obtaining needed care due to insurance or other personal obstacles or if there is an underlying addiction issue that is the real source of the problem. Chronic pain is tricky – does treatment of chronic issues produce narcotic addiction or does an addiction make pain uncontrollable, thereby contributing to chronic pain. Which came first, the chicken or egg? In the case of this young man, we opted not to provide any narcotics. He has access to the medical specialist who can truly address his needs, and he was offered a non-addictive treatment for his condition. To date, the patient has not returned to the office. We have also not received a consultation report from the specialist that the patient was supposed to see.