Are Doctor’s Ignoring Guidelines for Back Pain Treatment?

Despite recommendations to treat back pain conservatively, the number of people being prescribed powerful pain killers or referred for surgery and other expensive care has increased in recent years, according to a new study.

“This is kind of concerning,” said Dr. Steven Cohen, an anesthesiologist and critical care doctor at the Johns Hopkins School of Medicine in Baltimore.  Surgery, injections and scans for back pain “have all gone up pretty dramatically,” he told Reuters Health.  Given that 1 in 10 of all primary care visits are for lower back pain, these findings are significant.

The American College of Physicians and the American Pain Society recommend that people with low back pain consider treatment with Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs), as well as heating pads and exercise.

The groups say doctors should only order CT and other scans when they suspect nerve damage.  Opioids are only recommended for patients with “severe, disabling pain” that doesn’t get better with over-the-counter medicines – and their risks, such as for abuse and addiction, should be weighed against potential benefits.

Dr. Bruce Landon from the Harvard Medical School in Boston and his colleagues tracked nationally-representative data on outpatient visits for back and neck pain collected between 1999 and 2010.  The researchers had information on about 24,000 visits, which represented a total of 440 million appointments across the U.S.

During that span, they found the proportion of patients prescribed over-the-counter medications such as Tylenol and NSAIDs dropped from 37 percent to 25 percent. At the same time, the proportion given narcotics like OxiContin rose from 19 percent to 29 percent.  Other studies have found that opioids help only slightly with acute back pain and are worthless for treating chronic back pain.

About 11 percent of people with back pain had a CT or MRI scan in 2009 and 2010, compared to seven percent in 1999 and 2000.  While the scans are not harmful, they are very costly and in most cases, they don’t find anything wrong.

Finally, although the rate of referrals to physical therapy held steady during the study period, the proportion of patients referred to another doctor – likely for surgery or other treatments – doubled from seven to 14 percent, the researchers reported in JAMA Internal Medicine.

“Physicians want to offer patients treatments that are going to work sooner and patients are demanding them and sometimes it’s just easier to order the MRI or order the referral,” Landon said.  But, he added, “They often lead to things that are unnecessary and expensive and maybe not better in the long run and maybe even worse,” such as surgery or injections that haven’t proven to be effective.

According to the National Institutes of Health, eight out of ten people have back pain at some point in their lives.

A journal commentary accompanying the study says that doctors should be given a little slack, because guidelines have been conflicted on back pain treatment until recently, and it takes 17 years, on average, for new treatment standards to be widely adopted.  It suggests that creating checklist-type guidelines for doctors would help speed that process, as well as requiring patients to pay more of the cost of expensive imaging.

One of the difficulties of treating back pain, Cohen said, is that there are so many possible causes – including disc, joint and nerve problems.  He said the strongest evidence supports treating the pain with exercise, including stretching and some aerobic activity.

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