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Stabbed in the Back: Confronting Back Pain in an Overtreated Society

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Using back pain as his subject, Nortin Hadler, M.D., presents a forceful critique of much of what is wrong with the American health-care system today and the disability bureaucracy that sustains a broken conception of illness and health. "Stabbed in the Back" is a lucid, informed and well-researched discussion of one of modern post-industrial society's greatest and costliest sources of physical and mental suffering -- regional low back pain. He excludes from the analysis unusual sources of back pain such as cancer, infection and inflammatory diseases and focuses on the run-of-the-mill suffering that causes millions of Americans every year to complain to their doctors, "I threw my back out and I don't know if I can go back to work."
Back pain is an unavoidable reality of modern life, Hadler argues. About 75 percent of cases are inherited. Disc degeneration, thought to be the primary culprit in back pain, is a normal part aging, somewhat like grey hair or balding. Modern medicine simply has not found a way to relieve back pain, despite a huge industry whose existence depends on the notion of back pain as a disorder or illness warranting a cornucopia of treatments (none of which work over the long term).
If Hadler had his way, doctors would tell back-pain patients to tough it out and go back to work. "Individuals with regional backache might fare less poorly by managing as best they can," Hadler writes, "perhaps with some lay advice, than by choosing to become patients."
He suggests pain sufferers would be best off telling their doctors, "I can't cope with this backache," rather than seeking an elusive cause and cure for their travails in a medical system that promotes illness rather than health. But such an approach is unlikely in the current system in which so much is at stake for physicians, surgeons, physical therapists, chiropractors, medical device makers and drug companies, to name just a few.
Hadler acknowledges that his view will be met with resistance and outright hostility by pain sufferers, who are tired of being told their pain is "all in your mind." Hadler does not go so far as to say patients imagine their pain, but he comes close by pointing to studies that link psychological difficulties with back pain.
Low back pain ranks second only to the common cold as a reason for doctor's visits in the United States, and the cost of diagnosing, treating and indemnifying, through worker's compensation or Social Security Disability Insurance, is staggering, somewhere around $100 billion annually in the United States. Upwards of 80 percent of the population experiences low back pain at some point in life The Lumbar Spine: Official Publication of the International Society for the Study of the Lumbar Spine. And yet there is no cure.
Surgery, increasingly in the form of hugely invasive and expensive fusion procedures that immobilize the painful part of the spine through titanium screws and rods and metal implants designed to promote a rigid bony construct, accounts for much of the direct cost of back pain, Hadler notes. The use of fusion surgery is rising precipitously despite any scientific support for its effectiveness in reducing pain. In fact, various studies have found that surgical patients fare no better than physical therapy patients in attaining long-term back pain relief.
The path to surgery is always paved by modern technological innovation, the holy grail being magnetic resonance imaging, or the MRI scan. The extraordinary sensitivity of MRI technology in detecting herniated discs, pinched nerves and irritated spine joints gives patients the "evidence" that their pain is not imaginary, and that they have a "disease" called degenerative disc disease, or DDD. And it gives surgeons the crucial rationale for getting back pain sufferers into the operating room, at tremendous cost to society as the bill for a typical fusion surgery runs from $50,000 to easily upwards of $150,000, depending on how much of the spine is fused.
Hadler, however, points to research showing that MRIs are essentially useless in finding the source of low back pain. Even people with no pain will have bulging discs and other signs of degeneration in an MRI scan. And many people with great pain will show no sign of any problem on an MRI.
Hadler goes on to discuss the role of various indemnification schemes in the United States, such as disability insurance and worker's compensation, in promoting and prolonging back pain and expensive treatments. "Disabled" workers, in particular, are prone to think of themselves as chronically ill to ensure that their benefits are not taken away.
In the end, Hadler makes a convincing case for changing the current system of benefits and rewards in approaching low back pain. He gives a timely critique of the U.S. medical system and the various social contracts that perpetuate useless and senseless treatments of injuries that are really not injuries but are a normal part of life.
There is, as Hadler acknowledges, a certain insensitivity to individual sufferers in this discussion of systems, modalities, social constructs and indemnification schemes. An experienced physician specializing in rheumatoid arthritis, Hadler knows first-hand the suffering that pain produces.
My main critique of this book centers on this insensitivity, bordering on callousness. Hadler shows no compassion for the millions of people who try to cope daily with debilitating, awful, indescribable low back pain. This is a pain that goes far beyond the muscle strain or discomfort that follows prolonged sitting, for example, or a hard workout at the gym. It is unbearable.
While those seeking worker's compensation benefits or social security insurance may well be tempted to exaggerate their suffering, millions of others continue working, or take relatively short breaks from work to try to find relief.
Hadler pays no heed to the voluminous scientific evidence showing that repetitive motions, particularly bending, twisting and lifting heavy loads, or sitting at an office desk all day, actually cause spine discs to herniate and produce immediate unbearable pain that can leave people virtually immobilized or terribly soar for many months. Much of this evidence is presented in great detail, and very scientifically, in Stuart McGill's Low Back Disorders, Second Edition, an excellent book for anyone interested in causes and treatments for low back pain.
McGill acknowledges the literature pointing to psychosocial factors in low back pain but discusses in detail the very real injuries, to use a word that Hadler hates, that produce horrible pain.
It's important to remember that intense low back pain, like any pain, is by definition undesirable. Life is spent pursuing pleasure and avoiding pain, after all. People will go to great lengths, embracing just about any treatment that seems reasonable, to avoid pain. The fact that pain is associated with psychological stress is not at all surprising: perhaps pain causes the psychological stress in the first place. In any case, modern pain medicine, which increasingly rejects the Cartesian distinction between mind and body, knows very well that physical and psychological pain are but two sides of the same coin. Both types of pain are experienced in the same parts of the brain. Major depression is every bit as painful as the worst imaginable physical injury.
The real culprits are the purveyors of "cures," treatments and remedies that have no track record of success and often make pain sufferers even worse. How many millions of people have undergone barbaric fusion surgeries only to find themselves worse off than before their operations? Those with back pain are besieged with snake-oil salesman in white gowns and surgical scrubs masquerading as healers when they really just want to get rich.
I still recommend Hadler's book as an excellent expose of a system gone wacky, one that is no better than ancient or medieval superstition about the cause and treatment of illness. But do not turn to this book seaking solace in your suffering.

"Stabbed in the Back is an expose of a contrived "disease" and the enormous enterprises it has spawned that conspire to its "cure" and provide fallback when a "cure" is elusive. That industry has developed a life of its own, despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American's wherewithal to cope and persevere, and the American pocketbook are paying a heavy price. An assault on the backache industry is long overdue. No reader finds all of the chapters that follow resting easily within his or her preconceptions."

The above words are from Dr. Nortin hadler's new book Stabbed in the Back: Confronting Back Pain in an Overtreated Society.

Dr. Hadler is is a professor of medicine and microbiology/immunology at University of North Carolina at Chapel Hill, author of Worried Sick: A Prescription for Health in an Overtreated America and 14 other books, and more than 200 medical papers. He is also a consultant to ABC News.

Stabbed in the Back is an overview of the history of back pain, its many diagnoses and treatments over the decades, as well as its personal, financial, and social cost. Dr. Hadler's care and concern for patients with regional back pain permeates throughout the book as he discusses the many aspects of this "contrived disease."

My favorite chapter is Chapter Six, titled "Invasion of the Spine Surgeon," where he takes on the surgical treatment for back pain showing that there is no evidence for efficacy of surgery and that most surgeons financially benefit from recommending and performing surgery. This has contributed to the high cost of treating back pain. One ineffective surgery is spinal fusion, which has become a multibillion dollar industry, where one screw costs $1000.

This book gives a comprehensive look at current state of diagnoses and treatments for back pain, which helps readers decide what is the best course of action and perhaps, most importantly, which treatments to avoid.

This is a well documented expose of the failures of current concepts and therapy for axial back pain. The major portion of the work comes across as very negative with few if any positives. The major shortcoming is the failure to clearly deal with those instances where spinal disease does impact the spinal nerve roots resulting in sciatica or neurogenic claudication. On the whole it is insightful and should be required reading for all health care professionals and policy makers who deal with the back pain problem in our society. The question is, can the current culture of spinal over-treatment, be reversed?

Maybe in real life, Dr. Hadler is a caring and compassionate doctor. If this is the case, it does not come through in this book. I have read some of Dr. Hadler's other work, and I do think that what he says is often important, especially since he's so often at odds with mainstream system. And I certainly agree with his belief that Americans are overtreated and that many routine tests are probably unnecessary.

However, his continual emphasis on people who "choose" (his word) to be patients is incredibly frustrating for one who has had trouble seeking relief from pain. A chapter of this book is devoted to fibromyalgia, which Dr. Hadler has another name for (I don't quite understand what he accomplishes by not calling it fibromyalgia). Basically, Dr. Hadler does not believe that fibromyalgia exists. He points out that there are not tests for it, but it's quite possible that tests will eventually be discovered. Similarly, because low back pain does not seem to have any correlation to physical problems with the back, Dr. Hadler basically says that people with pain should quit "choosing" to be patients and get back to work. As someone who has had to go to the emergency room in an ambulance because back pain literally kept me from standing up, I find this attitude dismissive and borderline offensive. I recognize that both low back pain and fibromyalgia may have psychological components, but that does not mean that sufferers can simply decide not to be patients anymore (and when Dr. Hadler suggests that people who claim they can't work actually can, I wonder if he's ever held a blue collar job involving hard physical labor - perhaps he did as a young man, but the effect of physical labor is not as debilitating for the young). The fact that modern medicine has not found a solution to these problems does not mean they aren't very real. And I think it's important to bear in mind that ulcers were once attributed largely to stress - that was not because there wasn't a biological component. It was because it had not been discovered yet. The researchers who actually discovered the bacterium that causes ulcers had trouble getting funding because scientists were so sure that ulcers were caused by stress. Who knows what will eventually be discovered about the causes of fibromyalgia and low back pain? Just because medicine can now do little for these conditions does not mean that it never will be able to.

Dr. Hadler spends a lot of time talking about Workmen's Compensation (which he calls a "scheme") to the point that I started wondering if he has financial ties to the insurance industry.

As I said, I do think there's a psychological component to low back pain, and I recommend the work of Dr. John Sarno for those who are interested in pursuing this. Dr. Sarno offers not just the possibility of relief from pain, but also the kind of compassion one wants to find in a doctor.

As a full-time Primary Care Physician, I whole-heartedly recommend this book to all of my patients suffering from any type of chronic musculoskeletal pain syndrome (affecting the back). Dr. Hadler's opinion certainly carries the weight of many, many years of both clinical & research experience. His ultimate message is very important in our current over-medicalized American society-->Back Pain is a natural consequence of human living & has been forever. Unfortunately modern science & medicine has not yet figured out how to truly relieve this suffering in the long run. The best thing that we all can do is cope (as best as we can) with the pain & the limitations is imposes on our lives (& get on w/life). In one sense this is a bummer since modern medicine has so many wonderous tools at it's disposal. But in another sense, the message is liberating because we don't need bother ourselves with unnecessary drugs, physical manipulations, or surgical procedures.

Hadler could have covered the information regarding the failure of back treatment in an essay. However, to turn it into a book he had to go way beyond back treatment. And, this included a long history of disability insurance since its onset by Bismarck in the 1880s. He also goes at length about technical differences between Social Security Disability Insurance vs Supplemental Security Income. The long last chapter is Hadler proposal to reform our entire health care system. That's all interesting stuff, but it is way beyond the subject of the book.

Within his other excellent books such as The Last Well Person: How to Stay Well Despite the Health-Care System and Worried Sick: A Prescription for Health in an Overtreated America (H. Eugene and Lillian Youngs Lehman), Hadler takes on the entire medical establishment. Given his general subject, he is free to address a multitude of ailments (cancer, cardiovascular disease, obesity, diabetes, etc...) and topics (insurance, hospital management, Medicare, doctor practices). Those mentioned books are invariably excellent. However, when Hadler wrote this book he forgot he was supposed to focus on back treatment, and instead mounted his customary broad-based attack on American health care. By doing so, he may exhaust the readers focused on back treatment. Nevertheless, if you can overcome this hurdle there is a lot to like in this book.

According to Hadler, lower back issues are normal. He starts the book by stating: "To live a year without a backache is abnormal." And, he repeats this theme throughout the book. People with spine with many visual symptoms feel no pain. Others with near perfect spine are in chronic pain. Hadler expands on this conundrum in chapter 4. He shares surveys that convey that overall patients with back pain are no different than ones without as far as their spine structure is concerned. He states on page 40: "a person who displays a great deal of degenerative change is no more likely to have back pain than one who does not." He adds on page 105: "Regional back pain has little to do with ruptured discs... The specific causes of regional back pain continue to elude scientific inquiry. "

Imaging technology is very profitable, but is no help in diagnosing. Hadler states on page 40: "imaging studies of the spine... are irrelevant at best..." He mentions, however, that such imaging is very profitable. And, so far no treatment has really proven effective. Thus, the less you do the better.

Hadler chapter 6 on back surgery is scathing. None of it works, including fusing the spine, injecting into the disc, removing disc, and inserting artificial discs. He backs up his findings by referring to the Cochrane Collaboration, the Quebec Task Force on Spinal Disorders, the former Agency for Health Care Policy and Research. On page 124, he adds: "Even for prolonged low back pain, there is no science to support a surgical option." Interestingly, JFK was one patient who suffered through a botched back operation. Hadler feels that back surgery is a major case of Type II Error Medical Malpractice (doing something that is not necessary and potentially harmful). He feels like the American treatment of cardiovascular disease is another major case of Type II Error.

Hadler considers that the main driver of how you will fare is how you enter the health care system. There are three options. The first one is you take care of it yourself with anti-inflammatory. The second one is you seek help from a doctor or chiropractor. The third option is you consider your chronic back ailment a work related injury and you seek indemnification through disability insurance. Those three channels will have very different typical outcomes. The person going at it alone will be fine. The patient visiting a doctor may spend a lot more on X-Rays, MRIs, etc... and eventually will be fine as long as they avoid surgery. The third one seeking indemnification is apparently condemned to a life long suffering caught in a system that gives incentives for not getting better. Hadler notes that Germany has way more chronic back ache sufferers associated with a far more generous disability insurance system. Hadler advances that chronic back pain relates to job dissatisfaction. Apparently, Kafka developed his cynicism by working within the Workers' Accident Institute in Prague processing disability claims (pg. 130).

Hadler indicates how the placebo effect can be stronger when associated with a physical intervention. He shows how they tested acupuncture vs a sham acupuncture procedure. And, acupuncture was no better than placebo. But, the placebo effect (sham acupuncture) was much stronger than when just giving a sugar pill (table 6. pg. 60).

Hadler reviews the history of chiropractic medicine. He shows the result of the University of North Carolina Trial of Spinal Manipulation (fig 4. pg. 69). And, the latter indicates that spinal manipulation did reduce pain level faster for patients that had lower back pain for 2 - 4 weeks. However, as time passed the pain level between the test and control group converged. For patients with pain for 2 weeks or less, spinal manipulation had no effect relative to the control group. Also, Hadler is in disbelief how chiropractors believe that twisting the spine can cure asthma or diabetes. Those claims are of course absent of any scientific grounding.