If you have low back pain, chances are increasing that you won’t be treated based on best evidence

That’s the strong suggestion of a study published in JAMA Internal Medicine, “Worsening Trends in the Management and Treatment of Back Pain.” It concludes:

“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 (nonsteroidal antiflammatory drugs) 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….

The 106% increase in referrals to other physicians 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. 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. Further, when comparing visits with the patient’s self-identified primary care physician (PCP) vs those with another health care professional, we found that non-PCPs were much more likely to order advanced imaging. Presumably, this group includes those who perform procedures such as spinal surgery. …

We also found a 50.6% decrease in first-line NSAID (nonsteroidal antiflammatory drugs) or acetaminophen use accompanied by a 50.8% increase in narcotic prescriptions, including a near doubling among patients presenting with chronic back pain. These results are unexplained by a change in the frequency of short-term vs long-term presentations or the extent to which patients were seen by their PCP vs another physician because similar trends were observed for each of these groups in our stratified analyses. Although some of the decrease in NSAID use might have been due to the decrease in use of cyclooxygenase-2 inhibitors, the marked decrease in use of first-line therapies accompanied by the rapid increase in narcotic prescriptions raises significant concerns. 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, with aberrant medication-taking disorders as high as 24% of cases of chronic back pain. …

Our findings also confirm an inappropriate increase in advanced diagnostic imaging that has been seen previously, with use of CT or MRI increasing by 56.9% in our study sample. Six randomized controlled trials have found that imaging in the acute care setting provides neither clinical nor psychological benefit to patients with routine back pain, and multiple prospective studies have found the lack of serious disease in the absence of red-flag symptoms. In addition to being of low value, the overuse of diagnostic imaging leads to more exposure to ionizing radiation. In 2007, a projected 1200 additional future cancers were created by the 2.2 million lumbar CTs performed in the United States. Finally, 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 spine MRI use—more than twice the predictive power of patient characteristics. “

People with back pain, consumers, and taxpayers should appreciate how powerful is the spine surgery industry in this country.  There are reasons why the best evidence is ignored.  We’ve written about some of them in the past, for example:

Excerpt: “In 1994, the North American Spine Society (NASS) was offended by an Agency for Health Care Policy and Research (AHCPR) report recommending against early spinal fusion surgery for back pain (based on data suggesting increased harms and no benefits). NASS successfully lobbied Congress to essentially defund the Agency.”

And in his book, “How We Do Harm,” Dr. Otis Brawley of the American Cancer Society recalled:

“The spine surgeons were upset that someone would dare to say that bed rest and physical therapy wre often more effective than spinal laminectomy.  The self-serving surgeons were saying the hell with what the science says, and everyone else was apathetic or worse.

That a federal agency could face a threat of ‘defunding’ and ultimately end up with a catastrophic budget cut as punishment for telling the scientific truth was noticed by the government. … Shortly after the AHCPR punishment, the National Cancer Institute director, Richard Klausner, was confronted with mammography-screening recommendations for women in their forties.  His final decision had to be based not on the science as much as on the politics.  Had he pissed off Congress, the NCI would get an AHCPR-like punishment.

His career would be over, too.

Naturally, he caved.”

So, you see, the pressure has been applied for a long, long time.  Not a new story.  Not very bright prospects that it will change anytime soon.


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