Back Pain Is Overdiagnosed and Overtreated, Study Says
Numbers are up for expensive options like imagery and surgery, even when other options for treatment are widely available.
Back pain treatment can be costly, and it frequently includes the overuse of treatments unsupported by clinical guidelines, according to a new study by researchers at Beth Israel Deaconess Medical Center. A recent report by Harvard Health found that many doctors have been ordering tests, narcotics, and referrals for surgery for back pain—and that most of it is unnecessary.
Even though “routine” back pain may not feel so routine, surprisingly, doctors say the best treatment is usually conservative: over-the-counter pain relievers, ice, heat, and gentle exercise. Or you can try yoga. Researchers at Boston Medical Center recently found that just one yoga class a week can help back pain as much as medication.
“Most routine back pain will improve on its own with conservative therapy in three months, often shorter than that,” says Dr. Bruce E. Landon, professor of health care policy at Harvard Medical School. “Even more importantly, when we do more aggressive things—such as injections, imaging, and surgery—the long-term outcomes don’t change at all. These things have very little impact on what is going on, and they have the potential to make things worse.”
In a new study published in JAMA Internal Medicine, Landon and his colleagues examined data from 1999 through 2010 on nearly 24,000 outpatient visits for acute, new onset, or chronic flare-up back pain to see if these people were treated according to established, evidence-based guidelines. Here are those guidelines:
1. Call for treatment with nonsteroidal anti-inflammatory drugs (NSAIDS, such as ibuprofen and naproxen) or acetaminophen (Tylenol and generic).
2. Call for referral to physical therapy when appropriate.
3. Advise against early referral for imaging (such as MRI and CT scans) except in rare cases where “red flags” suggest something other than routine back pain.
4. Advise against prescribing narcotics.
5. Advise against early referral to other physicians for injections or surgery.
The study found that the above guidelines were not used most of the time. In fact, in the United States, health care for neck and back pain adds up to about $86 billion each year. When people with routine back pain are referred for MRI imaging, they’re eight times more likely to have surgery. “It is hard to not do anything aggressive, especially when you are having a lot of pain,” Landon says. “So people ask for these more advanced things and, unfortunately, doctors are often willing to prescribe them because that’s the path of least resistance.”
The study found that non-steroidal anti-inflammatory drugs or acetaminophen use per visit decreased from 36.9 percent in 1999-2000 to 24.5 percent in 2009-2010. However, narcotic use increased from 19.3 percent to 29.1 percent. Although physical therapy referrals remained unchanged at approximately 20 percent, physician referrals increased from 6.8 percent to 14 percent.
So basically, recommending over-the-counter medication use for back pain is down, and prescriptions for hard-core drugs and expensive referrals for surgeries is up.
The study’s first author, Dr. John Mafi, tells Harvard Health that people with back pain sometimes ask for off-guideline treatments, and doctors may not feel that they have the kind of time it takes to explain the options. “It is hard to reason with people when they’re in a lot of pain,” Mafi says. “I’m in favor of the honesty route. I tell people with first-time back pain that narcotics don’t necessarily help and, frankly, they are a risk. Instead of reaching for the narcotics, I suggest that if they start with the acetaminophen or ibuprofen and get rest and use ice, the vast majority of the time this will get better on its own.”