Overtreating Chronic Back Pain: Time to Back Off?
Abstract and Introduction
Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.
Pain complaints are a leading reason for medical visits. The most common pain complaints are musculoskeletal, and back pain is the most common of these. The prevalence and impact of back pain have led to an expanding array of tests and treatments, including injections, surgical procedures, implantable devices, and medications. Each is valuable for some patients, but use may be expanding beyond scientifically validated indications, driven by professional concern, patient advocacy, marketing, and the media.
More tests and treatments do not simply reflect a greater incidence of back pain. The proportion of office visits attributed to back pain has changed little since 1990. In recent National Health Interview Surveys, approximately a quarter of US adults reported back pain during the past 3 months, broadly consistent with previous surveys.
There are important implications of expanded testing and treatment for back pain. Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing. Despite uncertainties, manufacturers aggressively promote new drugs and devices. However, trust in the science supporting these products is eroded by revelations of misleading advertising, allegations of kickbacks to physicians, and major investments by surgeons in the products they are investigating.
We focus here on common management decisions in primary care related to imaging, medication, and referral for injections or surgery. Our goal was not to conduct systematic reviews of each of these or to provide a treatment guide, but to summarize data on recent trends, highlight certain risks, provide conclusions from systematic reviews on efficacy, and comment on practice patterns.