Back pain treatment often not in line with guidelines
By Genevra Pittman
NEW YORK (Reuters Health) – Despite guidelines to treat back pain conservatively, the proportion of people prescribed powerful painkillers or referred for surgery and other specialty 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 who didn’t participate in the research.
Surgery, injections and scans for back pain “have all gone up pretty dramatically,” he told Reuters Health.
“We have increased utilization, yet we don’t have better treatment outcomes.”
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.
For the new study, 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 Tylenol and NSAIDs dropped from 37 percent to 25 percent. At the same time, the proportion given narcotics rose from 19 percent to 29 percent.
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.
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 Monday 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.
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.
Landon said 95 percent of patients will recover from back pain with a little bit of time and conservative treatment.
“They key thing for patients is, give it time,” he told Reuters Health.
“Patients expect and want it to get better in seconds and that’s not always going to happen. But if you give it time, work on it, do stretching and physical therapy exercises, that’s what’s going to make it better in the long run.”
SOURCE: bit.ly/LvmYaB JAMA Internal Medicine, online July 29, 2013.