Naomi Morgan reached her limit when her doctor recommended a third surgery for chronic back pain.
Tired of being cut open only to have the pain return, Morgan, a 65-year-old nursing assistant, began looking for a less invasive and hopefully more effective way to treat her ailment, which she thinks started from lifting patients or moving furniture. She turned to a chiropractor, whom Morgan credits for helping her manage her back pain for the past 21 years with stretching, realignments and other treatments.
As the country continues to reel from a fungal meningitis outbreak — linked to a tainted steroid used to treat back pain — that has sickened 386 people in 19 states and killed 28, the medical industry is debating again about how back pain is treated.
The outbreak revived old arguments about whether back pain sufferers have become too dependent on drugs and surgeries as quick cures — and whether these treatments even work in the long run.
Back pain is the second most common neurological ailment in the United States behind headaches, according to the National Institute of Neurological Disorders and Stroke. More than a quarter of adults experienced lower back pain in the last three months, according to a recent report by the National Center for Health Statistics.
"A lot of times primary care doctors, or even patients, get into certain patterns where, if it hurts, they go the extreme route first instead of trying something natural and more conservative," said Dr. Alan Sokoloff, a Glen Burnie chiropractor who treats Morgan.
The American Academy of Pain Medicine promotes a multi-disciplinary approach and agrees that drugs should be used after other, less invasive methods are given a shot. But pain doctors also say that medications shouldn't be scapegoated and that drugs can be the best treatment for some patients.
"Too often we look at problems in a dichotomous way," said Dr. Lynn Webster, a Salt Lake City anesthesiologist and president-elect of the pain medicine group. "There is not either or. There is a spectrum of back pain problems that range from minimal pain to those who are totally incapacitated and can't walk. They may all require different treatments."
Shots of the steroid preservative-free methylprednisolone acetate, which has been linked to the meningitis outbreak, has become a common way to treat the pain. Roughly 14,000 people may have received contaminated shots of the steroid, which came from the New England Compounding Center in Framingham, Mass. In Maryland, 22 people have been sickened and one died.
Pain doctors around the country have heard from patients afraid to get the steroid shots, Webster said. Many may switch to oral pain killers. While he said the fear is justified, the medical industry has to be careful of moving too far to the extreme, he said.
The chiropractic industry is using the outbreak to advocate for more conservative, less invasive approaches to treating back pain, including yoga, acupuncture and, of course, chiropractic care.
The Foundation for Chiropractic Progress in California issued a position paper after the outbreak criticizing what it calls an overuse of drugs to treat back pain. The group said the use of drugs creates addicts and masks pain rather than treating underlying conditions.
"While living in a society where we expect to live pain-free, America may now be convinced that there needs to be a safer way to address back pain, with chiropractic care becoming a preferred option," the foundation's paper read.
In a phone interview, Dr. Gerard Clum, a foundation spokesman, said the use of drugs among doctors is inconsistent.
"There is a spectrum of behavior," Clum said. "There are some physicians that will hold surgery and epidural injections as the last resort and others who jump to it very quickly."
The type of doctor a patient sees may determine what treatment is recommended for back pain. If your primary care physician sends you to an orthopedic surgeon you may be more likely to end up in surgery, for example.
Surgeons say most of their patients with back pain don't end up on the operating table.
Patients with pain limited to the back can get physical therapy and use muscle relaxers such as Bengay, said Dr. Raj Rao, a spokesman for the American Academy of Orthopaedic Surgeons. Most patients just need to have patience and give the pain time to go away.
Surgery is more common for patients who feel pain in the legs or buttocks as well as the back, Rao said. That is a sign of nerve compression. But even these patients can be treated without surgery, he said.
"Most well-trained surgeons will exhaust non-operative measures before turning to surgery," Rao said.
Some Baltimore-area chiropractors said they've noticed more referrals from primary care doctors since the meningitis outbreak. They also are fielding more questions about the safety of steroid injections.
Chiropractor Adam Fidel, president of the Maryland Chiropractors Association, said he has had more patients want to try other options before moving to steroid injections or other invasive procedures.
"I think more people are more comfortable with going to a chiropractor than ever before," Fidel said. "And more primary care physicians are recommending them."
But even chiropractors said there is room for drugs in treating back pain.
Many chiropractors work with pain management doctors. White Marsh chiropractor Timothy Gober said people shouldn't write off drugs for treating back pain. The meningitis outbreak is an anomaly, he said. Gober said he believes in starting with conservative treatment options and using pain killers if needed. Sometimes he'll send a patient to get a steroid injection so he can perform a realignment without discomfort for the patient.
"A lot of times doctors try to fit patients in a box," Gabor said. "We try to see what is best for patients."
Morgan, the nursing assistant from Glen Burnie, said she still feels some aches and pains despite the treatments prescribed by her chiropractor. It's just something she has to deal with as she gets older. But her condition is better than it once was, she said. And she is not opposed to other treatment options, such as cortisone shots, if her condition ever worsened.
But she's almost sure she'll never get surgery again.
"The only way I would ever have surgery again is if I wasn't able to move my legs, back or anything else," she said. "I'd have to be in pretty bad condition."