More Not Always Better for Back Pain


Following routine treatment guidelines could cut health care spending 

Does your back bite back? You are far from alone: Back pain ranks fifth among reasons people make doctor’s appointments. But even with expensive tests and treatments, outcomes are not improving. 

Patient care could be enhanced and the health care system could see significant cost savings if health care professionals followed published clinical guidelines to manage and treat back pain, researchers at Harvard Medical School and Beth Israel Deaconess Medical Center reported in the July 29 issue of JAMA Internal Medicine.

“Back pain treatment is costly and frequently includes overuse of treatments that are not supported by clinical guidelines, and that don’t impact outcomes,” said lead author John Mafi, an HMS instructor in medicine and a fellow in the Division of General Medicine and Primary Care at Beth Israel Deaconess. “Improvements in the management of spine-related disease represent an area of potential for improving the quality of care and for potential cost savings for the health care system.”

Americans spend approximately $86 billion annually on back or neck pain-related health issues. It is ranked as the fifth most common reason for doctor visits, which accounts for more than 10 percent of all appointments made with primary care physicians.

Lost productivity adds approximately another $20 billion per year. It is predicted that expenditures will continue to grow along with the rise of chronic back pain.

Published guidelines for routine back pain advise use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy. Prior research shows that within three months of these treatments, back pain usually resolves.

The guidelines, which have remained consistent since the 1990s, suggest that imaging or advanced treatments are typically unnecessary, as most cases of routine back pain improve with these conservative measures. Other discordant recommendations would include prescription of a narcotic or referral to a specialist, presumably for the consideration of a procedure.

However, if acute neurological compromise or other warning signs such as past history of malignancy are connected with the back pain, further steps can be taken to investigate.

The researchers identified 23,918 visits for spine problems, representing 73 million visits annually, using nationally representative data from the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care surveys between 1999-2010. 

They studied the changes in utilization of diagnostic imaging, physical therapy or referral to other physicians, and the use of medication when treating patients who complained of back pain or were diagnosed with back pain.

“We observed a significant rise in the frequency of treatments that are considered discordant with current guidelines, including the use of advanced imaging, such as CT or MRI, referrals to other physicians (presumably for procedures or surgery), and the use of narcotics,” said Mafi. “We also have observed a decline in the use of first-line medications such as NSAIDs or acetaminophen, but no change in referrals to physical therapy.”

The researchers also noted that although opiate prescriptions increased markedly during the survey window, certain people were less likely to receive such narcotic drugs, including patients who were female, black, Hispanic or members of other minority groups. Mafi said this gap could reflect potential disparities in pain management that other studies have previously found.

Unnecessary treatment is not only expensive, but also can come with complications. A meta-analysis concluded that narcotics offer minimal benefit to relieve acute back pain and have no proven efficacy in treating chronic back pain.

The data also revealed that 43 percent of the patients had concurrent substance abuse disorders. Researchers believe that the increase in narcotic prescriptions is connected with the rise of narcotic overdose deaths, which is creating a public health crisis.

The steady increase of doctors’ requests for advanced diagnostic imaging has become a concern as well. 

Overuse of imaging may not result in immediate problems but exposure to ionizing radiation can lead to further health complications, such as cancer, Mafi noted. He added that a study that linked geographic regions with higher MRI use found an increase in back surgeries, which can be a very costly process and require recovery time.

“Increased use of advanced imaging represents an area of particular concern,” said senior author Bruce Landon, HMS professor of health care policy. “Early in the course of back pain, such imaging is almost always wasteful. Moreover, there are almost always some abnormalities, which increases the likelihood that a patient will undergo expensive spine surgery that might not improve their outcomes over the longer term.”

“Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians and use of narcotics, with a concomitant decrease in NSAIDs or acetaminophen use and no change in physical therapy referrals. With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care,” said Mafi.

The work was supported by an NRSA training grant (T32HP12706) from the US Health Services and Research Administration and by Harvard Catalyst (NIH Award #UL 1 RR 025758).

Adapted from a Beth Israel Deaconess news release.