Take Home Messages:

In the United States, doctors are increasingly using scans of the spine, Opioid prescription, injections and surgery to treat back pain. However, evidence suggests that outcomes are not improving. In fact, work disability related to back pain is actually on the increase.

To replace these unhelpful strategies, new models of caring for individuals with chronic back pain are recommended, especially:

• Improving the patient’s understanding of their condition;
• Ensuring they have realistic expectations; and
• A sustained commitment form health care providers to help patients help themselves rather than attempting to provide a cure-all solution.

Why the research matters:

Chronic back pain is experienced by 50% of the community in any one year and a significant proportion of sufferers report that their pain leads to disability. In addition to the personal suffering involved, low back pain makes up a significant proportion of long term disability claims and compensation costs.

There has been an expansion of investigation and treatment for back pain, without significant improvement in outcomes. Complications and deaths relating to pain management have been increasing.

What the research involved:

The authors of the paper are respected experts in the field. The paper summarises and comments on:

• The management of back problems;
• Significant risks; and
• Treatment patterns.

Summary of research findings:

The study was based in the United States, and most of the information was relevant to the United States.

Imaging

The authors point out that despite guidelines counselling against regular use of imaging, there has been a 300% increase in the use of MRI scans for the low back over a twelve-year period.

The authors consider the factors that caused the increase include:

• Patient demand;
• The engaging nature of being able to see inside the relevant area;
• Fear of law suit; and
• Financial incentives to complete scans.

The authors point out that imaging results that are not relevant can often be conveyed to the person as having some meaning. Findings that are present in people without back pain, such as disc bulges and degenerative changes, can be interpreted as significant pathology, increasing the likelihood of disability.

Opioids

The prescription of opioids for low back pain and muscular skeletal problems has increased significantly. Opioid prescriptions increased by 100% in the seven-year period to 2004. Deaths from prescription Opioids have increased to close to 4,500 per annum, more than the combined total of deaths from cocaine or heroin.

Significantly, patients with depression and other psychiatric disorders are more likely to:

• Be prescribed Opioids;
• Continue with opioid use for longer;
• Misuse opioids; and
• Dismiss the pain relieving benefits of analgesics.

Injections

Spinal injections have limited value as a way of treating low back pain. Epidural injections do not reduce the rate of subsequent surgery. Despite limited benefit, there has been a 270% increase in injections over seven-year period.

Surgery

In the US there has been a regular comparison of the rates of surgery for back problems across the different states of the country. In the state of Maine, the best surgical outcomes occurred where surgery rates were the lowest and the worst results occurred in areas where surgery rates were the highest.

There was a 220% increase in the rate of lumbar spine fusion from 1990-2001, and this rise accelerated after a specific new type of instrument used to fuse the spine was approved. The authors suggest that promotion of that device may have contributed to the rise in the surgery rates. The rates increased despite no measurable improvement in outcomes.

Treatments overall

The authors conclude that increases in scans of the spine, Opioid prescription, injections and surgery may be justified if there was significant improvement in the patient outcomes.

However, evidence suggests that outcomes are not improving. They point out that work disability secondary to muscular skeletal problems, much of which is back pain, increased from 20%-25% between 1996 and 2004.

New models of caring for individuals with chronic back pain are recommended, particularly focusing on improving a patient’s understanding of the condition, ensuring they have realistic expectations, and a sustained commitment form health care providers which helps the patients help themselves rather than endeavouring to provide a cure-all solution.