One out of 10 patient visits with primary-care physicians in the United States is for back pain. It’s the fifth most common reason patients see their doctors, and accounts for a staggering $86 billion in direct health-care costs each year.
Yet, according to a troubling new study from Harvard University, many patients with back pain are not receiving care that follows long-established medical guidelines. In fact, doctors are less likely to follow those guidelines than they were a decade ago.
Instead, primary-care physicians are increasingly exposing patients with back pain to unnecessary imaging tests and potentially addictive prescription pain medications. They are also referring greater numbers of patients with this common condition to specialists, who are likely to perform ineffective and potentially dangerous spine surgery.
“Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines,” the authors of the study conclude.
Guidelines call for conservative treatment
For the study, the Harvard researchers examined the records of a nationally representative sample of 23,918 doctor visits made by patients for routine back pain from January 1999 through December 2010. They eliminated any records with medical “red flags” (such as fever, neurologic symptoms, weight loss or a history of cancer) that would indicate the pain might be caused by an underlying disease or illness and therefore justify treatment beyond the clinical guidelines for routine back pain.
Since the 1990s, those guidelines have instructed physicians to not do any early imaging of the patient’s spine, either with an X-ray, an MRI (magnetic resonance imaging) scan, or a CT (computed tomography) scan. The guidelines also tell doctors to avoid recommending aggressive treatments, such as surgery. The recommended treatment is much more conservative: over-the-counter pain medications and a referral to a physical therapist.
Most cases of routine back pain will improve within three months with this “less is more” approach to treatment.
Three key findings
To their surprise, however, the Harvard researchers discovered that doctors have been diverging from those guidelines at an increasing pace. Here are their three key findings:
- The use of opioid pain medications (such as Oxycontin and Vicodin) for the treatment of patients with routine back pain increased by more than 50 percent between 1999-2000 and 2009-2010, from 19.3 percent to 29.1 percent. At the same time, the use of over-the-counter pain medications as a first-line treatment dropped by more than 50 percent, from 36.9 percent to 24.5 percent.
The rapid increase in the prescribing of opioids for back pain “raises significant concerns,” write the study’s authors. “A recent meta-analysis revealed that narcotics provide little to no benefit in acute back pain, they have no proved efficacy in chronic back pain, and 43% of patients have concurrent substance abuse disorders.”
“In 2008,” they add, “overdoses in narcotic analgesics led to an estimated 14,800 deaths [in the U.S.] — more than cocaine and heroin combined.”
- The number of patients receiving X-rays for routine back pain remained stable at 17 percent during the 12-year course of the study. But the number of MRIs and CT scans increased by 56.9 percent, from 7.2 percent to 11.3 percent of patients.
The Harvard researchers note that six randomized controlled trials have found that the early imaging of patients with routine back pain offers no clinical or psychological benefit. But the imaging does present risks to the patient.
“The overuse of diagnostic imaging leads to more exposure to ionizing radiation,” the researchers explain. “In 2007, a projected 1,200 additional future cancers were created by the 2.2 million lumbar [back] CTs performed in the United States.”
In addition, write the researchers, “the significant increase in spine operations seen during the last decade is almost certainly related to the overuse of imaging. One study revealed that early MRI for acute back pain was associated with an 8-fold increased risk of surgery, whereas another found that regions with more MRIs perform more operations, with 22% of the variability in spine surgery rates explained by rates of spin MRI use — more than twice the predictive power of patient characteristics.”
- The researchers also found that although the number of patients with routine low back pain who were being referred by their primary-care physicians to physical therapists remained stable at 20 percent over the course of the study, the number being referred to specialists increased by 106 percent, from 6.8 percent in 1999-2000 to 14.0 percent in 2009-2010.
This “is a previously unrecognized and important finding because such referrals likely contributed to the recent increase in costly, morbid, and often ineffective outpatient spine operations observed in other studies,” they write. “Recent meta-analyses and research of lumbar fusion surgery have not revealed improvement in patient outcomes and demonstrate that these procedures lead to significant adverse consequences, including 5.6% with life-threatening complications and 0.4% mortality.”
A variety of possible causes
Why are so many physicians ignoring — and increasingly so — the clinical guidelines for routine low back pain?
In a commentary that accompanies the Harvard study, Dr. Donald Casey, medical director of New York University’s Langone Medical Center, cites several possible reasons. They include the greater availability of imaging technology, concern among the public and the health profession that doctors are not treating patients’ pain adequately, too little time during office visits for doctors to do a systematic and detailed evaluation of a patient’s back pain, patients who demand quick answers and solutions to their symptoms, fear of malpractice suits, and a lack of concern by both doctor and patient about the financial cost of health care services.
One solution to the “discordance” between the guidelines and clinical practice, Casey says, would be to implement more appropriate economic incentives for both patients and physicians, such as requiring patients to pay higher out-of-pocket co-pays for expensive imaging and linking doctor payments to improved patient outcomes rather than to how many patients they see or procedures they order (in other words, rewarding “value over volume”).
Casey also points out that it often takes an average of 17 years for physicians and other medical professionals to incorporate evidence from randomized clinical trials into their practice. And although the conservative clinical guidelines for the treatment of routine low back pain have been in place since the 1990s, convincing evidence to support those guidelines, he argues, has only been around since 2007.
That may be. But I’m not sure patients — or the overburdened health-care system — can wait until 2024 for doctors to accept and prescribe evidence-based treatment for routine back pain.
The abstract of the Harvard study can be found on the JAMA Internal Medicine website, but, unfortunately, the full study and the commentary are behind the journal’s paywall.