7/29/2013

by Cole Petrochko
Staff Writer, MedPage Today

Action Points

Trends in back pain management strategies in the U.S. are “discordant” with current guidelines, researchers found.

While the use of first-line therapy for back pain waned from 1999 to 2010, opioid prescriptions and use of nonguideline treatment rose, according to Bruce Landon, MD, of Harvard Medical School, and colleagues.

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen at a physician visit for back pain fell from 36.9% to 24.5% over the 12-year period, they wrote online in JAMA Internal Medicine.

Over the same period, use of narcotics rose from 19.3% to 29.1% and imaging with CT or MRI rose from 7.2% to 11.3%, they added.

“Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines,” they wrote, citing that more than 10% of personal care physician visits are related to back or neck pain and that such pain is associated with $86 billion in healthcare spending each year.

“Well-established guidelines for routine back pain stress conservative management, including use of NSAIDs or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases,” they added.

The authors studied changes in the treatment of back pain in the U.S. from Jan. 1, 1999, to Dec. 26, 2010, using data from 23,918 outpatient visits for spine problems recorded in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey.

Data were extracted on visits with a primary or secondary diagnosis of neck or back pain, and excluded those with concomitant fever, neurologic symptoms, or cancer. Outcomes included referral for physical therapy or to another physician, use of imaging, and use of medications, including NSAIDs, acetaminophen, muscle relaxants, and narcotics.

The number of healthcare visits for spine pain increased over the study period from 3,350 in 1999 to 2000 to 4,078 in 2009 to 2010. Also over this period, mean age increased from 49 to 53, as did the number of Medicare enrollees seeking back pain treatment (from 17% to 28.4%).

The number of narcotics used significantly increased over the 12 years while the number of NSAIDs and acetaminophen taken significantly decreased (P<0.001 for all). The use of muscle relaxants and benzodiazepines also rose significantly (from 19.6% to 23.7%, P<0.001), while the use of neuropathic agents more than doubled (3.4% to 7.9%, P<0.001).

Use of MRI and CT scans increased significantly from 7.2% to 11.3% (P<0.001). Referral for physical therapy remained steady at approximately 20% over the 12-year period, though referral to another physician rose significantly from 6.8% to 14% (P<0.001), which was more common among patients reporting chronic back pain versus acute back pain (P=0.01).

Patients who were black, Hispanic, another race, or female were significantly less likely than white and male patients to receive a narcotic treatment.

In an accompanying editorial, Donald Casey Jr., MD, of the New York University Langone Medical Center in New York City,reported that the findings should be addressed similarly to an addiction, with the first step being admitting to the problem. However, he also noted that the study “tells us little about how to improve the management of back pain.”

Casey offered a number of potential solutions, including a standardization of low back pain through checklist-based algorithms, more appropriate economic incentives for patients and physicians to follow such guidelines, and promotion of a common framework for evaluating back pain.

The authors said their study was limited by incomplete data on duration of symptoms, missing data on duration of symptoms and treatment patterns, and lack of measurement of comorbidities before 2005.

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 07.30.2013