We treat low back pain badly

In December 2019, I attended a National Academies of Sciences workshop on the role of non-pharmacological approaches to pain management. At the end of the meeting, as expected, the panelists concluded that further research was needed. However, to my surprise, several scientists also called for immediate action on the treatment approach for low back pain. They called on clinicians to implement the evidence we already have in clinical practice; for policy makers to enact payments reform that would support such implementation; for all of us to commit to making the cultural changes necessary to ensure that patients have access to the right care from the right provider at the right time.

Where does this answer come from? This stems from the fact that low back pain has been over-medicalized, which compounds a very serious problem, and from the need to realign the incentives that encourage clinicians to follow current evidence and treatment recommendations.

No health condition leads to greatest handicap Or higher costs than low back pain, and commonly used medical treatment approaches often do more harm than good. The imagery is rarely needed to develop an evidence-based treatment plan and can exacerbate catastrophic pain, as well as lead to incidental “rabbit holes” findings. Prescription drugs may help some patients in some circumstances, but overall, risks often outweigh the benefits. According to the CDC, over 260,000 deaths in America from 1999 to 2020 involved prescription opioids. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause intestinal bleedingparticularly in the elderly, and are associated with a higher incidence of myocardial infarction. Surgery and corticosteroids may provide short-term pain relief in some patients, but results are often not long-lasting or superior to less invasive options.

More importantly, many of these medical diagnoses and treatments approaches — early imaging, surgical consultations, corticosteroid injections, prescription opioids and NSAIDs — may actually increase the number of patients who go from acute pain to chronic pain.

The problem is not the lack of evidence. THE CDCTHE Veterans Health Administrationand the American College of Physicians (ACP) have published comprehensive guidelines supported by very converging evidence for the management of low back pain. Recommended first-line treatments include non-pharmacological approaches such as exercise, education, self-care options, spinal manipulation, acupuncture, and massage. The ACP guideline in particular calls on patients and clinicians to consider using non-pharmacological treatment approaches for low back pain before trying prescription medications.

The problem is that we don’t follow the evidence. There are many obstacles to the widespread implementation of known best practices. Health systems are slow to change, especially when such change may not be in their financial best interest. Orthopedic surgeons are consistently ranked among the top revenue earners in the healthcare system, reporting on average $3.3 million per year. Primary care physicians may not have learned about non-pharmacological treatments in medical school and often work with frightened patients who naturally want a clear explanation of their pain and a quick fix – a pill, an injection, or even surgery.

Moreover, there is a clear disconnect between the existing payment policy and best practice in low back pain. Payers provide solid reimbursement for prescription drugs, corticosteroid injections, and surgery. In contrast, private and public insurers often place important limitations on coverage of guideline treatments such as chiropractic care, acupuncture and massage. Such policies provide little incentive for clinicians and health systems to change.

If we want real change, it will take a whole team of “engaged citizens.”

Health systems can ensure they are staffed with providers whose clinical practices are better aligned with guideline recommendations. Payers can change their policies to align payment with guideline recommendations. Some health systems and insurance companies are moving in the right direction. Duke University Health System instituted the Spine Health Program provide coordinated and guideline-compliant care for patients with low back pain. United Healthcare does not charge co-payment for members who first see a chiropractor or physiotherapist for low back pain. Traditional health insurance has recently begun to offer blanket for acupuncture.

We also need to promote the education of clinicians on the evidence for the proper diagnosis and treatment of low back pain. We can familiarize ourselves with the ACP directive and read the excellent Lancet series on low back pain. We can tell our patients that MRIs can lead to poorer outcomes, that surgery is rarely needed, and let them know that the ACP recommends the use of non-pharmacological treatments before prescription medications. More importantly, we can, in the absence of red flags, refrain from ordering these tests or treatments unless they are clearly needed after the patient has committed to a comprehensive non-pharmacological treatment based on proofs.

I can’t ignore the fact that part of the problem is systemic: America’s healthcare system is built on the belief that patients benefit from seeking care. But this is often not the case for low back pain. By ignoring the evidence, over-medicalizing this condition, and continuing to condone policies that encourage mistreatment, we are causing real harm to those who trust us to care for them.

Christine Goertz, DC, PhD, is Professor of Musculoskeletal Research at the Duke Clinical Research Institute in Durham, North Carolina, Vice President for Implementing Spine Health Innovations in the Department of Orthopedic Surgery at Duke University, and Professor principal at the Duke Margolis Center for Health Policy.