Arthritis Today

Back Pain Guidelines Often Not Followed

Many medical fixes for bad backs do more harm than good.


According to the Centers for Disease Control and Prevention, nearly 30 percent of adults in the United States have experienced back pain in the last three months. The good news is that most people who have back pain get better without prescription opioid drugs, expensive imaging tests or surgery.

The bad news, researchers at Beth Israel Deaconess Medical Center in Boston found, is that many back pain patients still receive those treatments despite strong evidence showing they don't help and can even do harm. The findings appeared in a 2013 issue of JAMA Internal Medicine.

Treatments Prescribed Against Recommendations

Lead author John N. Mafi, MD, a fellow in the division of general medicine and primary care at Beth Israel Deaconess Medical Center, says established clinical guidelines call for conservative back pain treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy.

Diagnostic imaging, opioid painkillers and aggressive therapies such as surgery aren't recommended for most patients.

The study authors hypothesized that because several new guidelines were released during the last 10 years, the use of recommended treatments would increase and the use of non-recommended treatments would decrease. What they found was the opposite.

During the 12-year period, researchers found a substantial increase in treatments that run counter to current guidelines. For example, although use of approved medications like NSAIDs and acetaminophen declined from almost 37 percent to just less than 25 percent, prescriptions for opioid painkillers – which are generally not recommended – increased from 19 percent to 29 percent.

Overtreatment Bad for the Body and Bank Account

"[Opioids] are not a proven therapy and have great potential for harm,” Dr. Mafi says. “They should never be a first line treatment and should only be used after proven therapies have failed.”

Significant increases were also seen in the number of computed tomography (CT) and magnetic resonance imaging (MRI) scans, even though studies show they don't help people with routine back pain get better care.

Equally concerning to the study authors was a 106 percent increase in referrals to surgeons and other specialists, often leading to costly spine procedures that are rarely effective and potentially life-threatening.

Overtreatment isn't just bad for patients. It's also bad for the bottom line. Back pain accounts for nearly $86 billion in health care expenditures each year, with an additional $20 billion annually in lost productivity costs.

"A lot of the money spent on back pain is wasted because fancier, more expensive procedures aren't necessarily effective," Dr. Mafi says.

Roger Chou, MD, an associate professor in the department of medicine and medical informatics and clinical epidemiology and an internist at Oregon Health & Science University in Portland, directed the development of the American Pain Society/American College of Physicians clinical guidelines for the management of low back pain referred to in the study.

"Unfortunately, the results of this study are not that surprising,” he says. “We have been seeing persistent trends towards increased use of MRI as well as surgery and opioids over the last 10 to 20 years. The increase in use of opioids is especially troubling, given the alarming increase in accidental overdose deaths associated with opioid use, and the fact that low back pain is the most common reason for prescribing opioids despite data showing that benefits are limited."

Patience and Time: A Powerful Prescription

Robert Keenan, MD, MPH, an assistant professor of rheumatology at Duke University School of Medicine, hypothesizes that the guidelines may be ignored due to outdated beliefs that still exist.

“The truth is that most patients with lower back pain will feel better in six to eight weeks with very little treatment,” Dr. Keenan says. “But, a lot of old dogma persists that patients should do things like avoid exercise and go on bed rest with lower back pain, even though the guidelines clearly call for patients to stay active. A lot of old wives tales live on, which cause physicians to sometimes ignore the recommendations.”

Mafi suspects that doctors also may be responding to patients’ desires for instant gratification.

"Patient demands and expectations are definitely part of it,” he points out. “We live in an era where patients have more say and autonomy in managing their health care, and they sometimes expect instant solutions. And we do have instant solutions for some things that really work, but not for back pain."

Both Chou and Keenan highlight the importance of incorporating exercise, cognitive-behavioral therapies and other treatments the guidelines recommend.

“Exercise therapy for the lower back has shown efficacy in patients, and spinal manipulation also has a role in the treatment of some types of lower back pain,” Dr. Keenan says. “Acupuncture and dry needling also have provided benefits to patients with low back pain.”

While every patient experiences pain and responds to treatment differently, Mafi believes patience can go a long way.

"The biggest message for patients with new-onset back pain is that it will likely resolve on its own with Tylenol in two or three months,” Dr. Mafi says. “Folks have to understand that sometimes patience and time are superior to the fanciest technologies."