Back Pain Guidelines Ignored As Imaging, Drug Costs Soar

Physicians increasingly ignore clinical guidelines for treating back pain, causing skyrocketing costs with approaches that put patients at risk from unnecessary surgery, overuse of narcotics, and other problems, according to a study in JAMA Internal Medicine.

“Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments. . . .” The study, “Worsening Trends in the Management and Treatment of Back Pain,” adds that “routine back pain will usually improve with such conservative treatments within three months.”

However, researchers at Beth Israel Deaconess Medical Center and Harvard Medical School, examining about 24,000 cases of back problems from 1999 to 2010, found a 51% increase in prescriptions for narcotic painkillers.

The authors suggest that this contributes to a rapid increase in narcotic overdose deaths, an increase that parallels a reported 300% rise of sales of such drugs since the 1990s. “In 2008, overdoses in narcotic analgesics led to an estimated 14,800 deaths — more than cocaine and heroin combined.”

Meanwhile, the use of CT and MRI scans increased by 57%. (Guidelines say that they are to be used only in rare cases.)

You cannot overlook the role primary care physicians play — or don’t play, says the study. There was a 106% increase in referrals from primary care to other physicians.

“When comparing visits with the patient’s self-identified 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. Thus, these referrals from PCPs are likely to result in substantial downstream use that is disconcordant with current guidelines.”

A commentary by Donald E. Casey, Jr., MD, MPH, MBA, that accompanies the study says that “more appropriate incentives are needed for patients and physicians, such as higher patient out-of-pocket insurance copayments for expensive imaging and linking of payments for clinicians to improved outcomes for populations of patients with back pain.”


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