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FAMILY MEDICINE AND THE HEALTH CARE SYSTEM
Overtreating Chronic Back Pain: Time to Back Off?
Richard A. Deyo, MD, MPH, Sohail K. Mirza, MD, MPH, Judith A. Turner, PhD, and
Brook I. Martin, MPH
Chronic back pain is among the most common patient complaints. Its prevalence and impact have
spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for
indications that are not well validated, leading to uncertainty about efficacy and safety, increasing com-
plication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expendi-
tures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307%
increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a
220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases
have not been accompanied by population-level improvements in patient outcomes or disability rates.
We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous
and independent trials of many treatments, a stronger regulatory stance toward approval and post-mar-
keting surveillance of new drugs and devices for chronic pain, and a chronic disease model for manag-
ing chronic back pain. (J Am Board Fam Med 2009;22:62–68.)
Pain complaints are a leading reason for medical
visits.
1
The most common pain complaints are
musculoskeletal, and back pain is the most com-
mon of these. The prevalence and impact of back
pain have led to an expanding array of tests and
treatments, including injections, surgical proce-
dures, implantable devices, and medications.
Each is valuable for some patients, but use may
be expanding beyond scientifically validated in-
dications,
2–4
driven by professional concern, pa-
tient advocacy, marketing, and the media.
More tests and treatments do not simply reflect
a greater incidence of back pain. The proportion of
office visits attributed to back pain has changed
little since 1990.
5
In recent National Health Inter-
view Surveys, approximately a quarter of US adults
reported back pain during the past 3 months,
broadly consistent with previous surveys.
5
There are important implications of expanded
testing and treatment for back pain. Innovation has
often outpaced clinical science, leaving uncertainty
about the efficacy and safety of many common
treatments. Complications and even deaths related
to pain management are increasing.
6,7
Despite un-
certainties, manufacturers aggressively promote
new drugs and devices. However, trust in the sci-
ence supporting these products is eroded by reve-
lations of misleading advertising,
8
allegations of
kickbacks to physicians,
9
and major investments by
surgeons in the products they are investigating.
10
We focus here on common management deci-
sions in primary care related to imaging, medica-
tion, and referral for injections or surgery. Our goal
was not to conduct systematic reviews of each of
these or to provide a treatment guide, but to sum-
marize data on recent trends, highlight certain
risks, provide conclusions from systematic reviews
on efficacy, and comment on practice patterns.
Imaging for Low Back Pain
Despite guidelines recommending parsimonious
imaging, use of lumbar magnetic resonance imag-
This article was externally peer reviewed.
Submitted 15 May 2008; revised 23 July 2008; accepted 29
July 2008.
From the Department of Medicine, Oregon Health and
Science University, Portland (RAD) and the Departments of
Orthopaedics (SKM, BIM) and Psychiatry (JAT), University
of Washington, Seattle.
Funding: Supported in part by grants # 5P60-AR48093
and #5K23AR48979 from the National Institute of Arthritis,
Musculoskeletal and Skin Diseases.
Conflict of interest: The research program of Drs. Deyo
and Mirza has benefited from a gift to the University of
Washington from Synthes, a surgical device manufacturer.
They have not received any personal financial support from
this source. Mr. Martin has received partial salary support
from this source. Dr. Turner has no conflicts to declare.
Corresponding author: Richard A. Deyo, MD, MPH, Fam-
ily Medicine, Mail Code FM, 3181 SW Sam Jackson Park
Rd., Portland, OR 97239-3098 (E-mail: deyor@ohsu.edu).
62 JABFM January–February 2009 Vol. 22 No. 1 http://www.jabfm.org
ing (MRI) increased in the Medicare population by
307% during a recent 12-year interval (Figure 1A;
previously unpublished data). Others have de-
scribed rapid increases in spine imaging and for
imaging procedures in general.
11,12
Spine imaging
rates vary dramatically across geographic regions,
13
and surgery rates are highest where imaging rates
are highest.
13
When judged against guidelines,
one-third to two-thirds of spinal computed tomog-
raphy imaging and MRI may be inappropriate.
14–16
Many factors probably underlie the growth of im-
aging, including patient demand,
17
the compelling
nature of visual evidence,
18
fear of lawsuits, and
financial incentives.
19
One problem with inappropriate imaging is that
it may result in findings that are irrelevant but
alarming. Positive findings, such as herniated disks,
are common in asymptomatic people.
20–22
In a ran-
domized trial
23
there was a trend toward more
surgery and higher costs among patients receiving
early spinal MRI than those receiving plain films,
but no better clinical outcomes. Six other random-
ized trials, involving a total of 1804 patients from
primary care without features suggesting a serious
underlying disease, compared some form of lumbar
spine imaging with none.
24–29
In these studies, im-
aging was not associated with an advantage in sub-
sequent pain, function, quality of life, or overall
improvement.
Based on an extensive systematic review, the
joint guidelines of the American College of Physi-
cians and the American Pain Society explicitly rec-
ommend against routine imaging in patients with
nonspecific low back pain (ie, no severe or progres-
sive neurologic deficits or evidence of serious un-
derlying conditions).
30
Opioid Analgesics
Prescription opioid use is steadily increasing, over-
all and for musculoskeletal conditions in particu-
Figure 1. Increases in the use of various services for low back pain. A: Lumbar spine magnetic resonance imaging
(CPT codes 72148, 72149, 72158); numbers of scans among Medicare beneficiaries from Part B claims. B:
Numbers of opioid prescriptions for spine conditions, national data from the Medical Expenditure Panel Survey.
11
C: Rates of lumbosacral injections in the Medicare population, age- and sex-adjusted. (Data are from reference 2,
adapted with permission.) D: Lumbar spine fusion rates for degenerative conditions, age- and sex-adjusted,
National Inpatient Sample. (From reference 3, reproduced with permission.)
doi: 10.3122/jabfm.2009.01.080102 Overtreating Chronic Back Pain 63
lar.
4,7,31–35
Among patients with spinal disorders,
the National Medical Expenditure Panel Survey
showed a 108% increase in opioid prescriptions
from 1997 through 2004 (Figure 1B). The combi-
nation of increasing use and higher drug prices
resulted in a 423% inflation-adjusted increase in
expenditures.
31
These trends have been driven at
least partly by concern for the under-treatment of
pain in the past, especially among patients with
cancer or terminal illness.
Emergency department reports of opioid over-
dose parallel the numbers of prescriptions.
4
Deaths
related to prescription opioids have increased; by
2002 there were 4451 deaths related to opioid an-
algesics, more than the combined total involving
cocaine or heroin alone.
7
Diversion of prescription
opioids is increasingly common, with broad societal
impacts.
4,36,37
Unlike advanced cancer or postoperative pain,
chronic back pain often persists for years or de-
cades. In this setting, the efficacy and safety of
long-term opioid use remain controversial. None-
theless, more than half of “regular” prescription
opioid users have back pain.
38
A systematic review
concluded that, for chronic back pain, short-term
advantages over nonopioid analgesics were modest,
whereas data beyond 16 weeks were unavailable.
39
The Cochrane Collaboration review of opioids
for chronic low back pain similarly concluded that,
“Despite concerns surrounding the use of opioids
for long-term management of chronic [low back
pain], there remain few high-quality trials assessing
their efficacy . . . Based on our results, the benefit of
opioids in clinical practice for the long-term man-
agement of chronic [low back pain] remains ques-
tionable.”
40
In population-based studies, many pa-
tients receiving opioids for noncancer pain have
persistent high levels of pain and poor quality of
life.
41
Ironically, patients with major depression and
other psychiatric disorders are more likely than
others to initiate and to continue opioid therapy,
42
yet they also are more likely to misuse medica-
tion
43,44
and may be less likely to experience anal-
gesic benefit.
45
Although depression and other psy-
chiatric disorders are common among patients with
chronic back pain,
42,46–48
patients with such disor-
ders are commonly excluded from trials of opioid
therapy,
42
which raises questions about the gener-
alizability of efficacy studies to routine practice.
Some adverse effects of opioid use may be un-
derappreciated, including hyperalgesia,
49,50
which
may result from changes in the brain, spinal cord,
and peripheral nerves.
51–53
In short, opioid use may
paradoxically increase sensitivity to pain. Hypogo-
nadism is another underappreciated consequence
of chronic use, resulting in reduced testosterone
levels, diminished libido, and erectile dysfunc-
tion.
54–56
The American College of Physicians/American
Pain Society guidelines conclude that “opioid an-
algesics are an option when used judiciously in
patients with acute or chronic low back pain who
have severe, disabling pain that is not controlled (or
is unlikely to be controlled) with acetaminophen
and nonsteroidal anti-inflammatory drugs. Because
of substantial risks . . . potential benefits and harms
of opioid analgesics should be carefully weighed
before starting therapy. Failure to respond to a
time-limited course of opioids should lead to reas-
sessment and consideration of alternative therapies
or referral for further evaluation.”
30
Spinal Injections
The efficacy of spinal injections is limited. Epidural
corticosteroid injections may offer temporary relief
of sciatica, but both European and American guide-
lines, based on systematic reviews, conclude they
do not reduce the rate of subsequent surgery.
57,58
This conclusion is based on multiple randomized
trials comparing epidural steroid injections with
placebo injections, and monitoring of subsequent
surgery rates.
59–62
Facet joint injections with cor-
ticosteroids seem no more effective than saline in-
jections.
57,63
Despite the limited benefit of epidural injec-
tions, Medicare claims showed a 271% increase
during a recent 7-year interval (Figure 1C).
2
Facet
joint injections increased 231%.
2
Earlier Medicare
claims analyses also demonstrated rapid increases in
spinal injection rates.
12,64
For patients with axial
back pain without sciatica there is no evidence of
benefit from spinal injections
57
; however, many in-
jections given to patients in the Medicare popula-
tion seemed to be for axial back pain alone.
2
Charges per injection rose 100% during the past
decade (after inflation), and the combination of
increasing rates and charges resulted in a 629%
increase in fees for spinal injections.
2
During this
time, the Medicare population increased by only
12%.
64 JABFM January–February 2009 Vol. 22 No. 1 http://www.jabfm.org
Spine Surgery
Although spine fusion surgery has a well-estab-
lished role in treating fractures and deformities, 4
randomized trials indicate that its benefit is more
limited when treating degenerative discs with back
pain alone (no sciatica).
65
Despite no specific con-
current reports of clarified indications or improved
efficacy, there was a 220% increase in the rate of
lumbar spine fusion surgery from 1990 to 2001 in
the United States (Figure 1D).
3
The rise acceler-
ated after 1996 when the fusion cage, a new type of
surgical implant, was approved.
3
Their promotion
may have contributed to both the rise in fusion
rates and increased use of implants. In the last 5
years of the 1990s, Medicare claims demonstrated a
40% increase in spine surgery rates, a 70% increase
in fusion surgery rates, and a 100% increase in use
of implants.
66
Higher spine surgery rates are sometimes asso-
ciated with worse outcomes. In the state of Maine,
the best surgical outcomes occurred where surgery
rates were lowest; the worst results occurred in
areas where rates were highest.
67
Multiple random-
ized trials suggest that adding surgical implants to
bone grafting slightly improves rates of solid bone
fusion but may not improve pain or function.
68–70
Implants increase the risk of nerve injury, blood
loss, overall complications, operative time, and re-
peat surgery.
68,69
In a large study of injured work-
ers, the rapid increase in the use of intervertebral
fusion cages after 1996 was associated with in-
creased complications but not with improved dis-
ability or reoperation rates.
71
We recently found
that reoperation rates after initial spine surgery
were higher in the late 1990s than earlier in the
decade, despite greater use of fusion procedures
and implants.
6
Are We Improving Outcomes?
Jumps in imaging, opioid prescriptions, injections,
and fusion surgery might be justified if there were
substantial improvements in patient outcomes.
Even in successful trials of these treatments,
though, most patients continue to experience some
pain and dysfunction. Population-level data on
back-related dysfunction are sparse. However, de-
spite a rise in costs related to spine problems, the
US Medical Expenditure Panel Survey showed that
self-reported functional limitations, mental health,
work limitations, and social limitations were worse
among people reporting such problems in 2005
than in 1997.
31
Furthermore, Social Security Disability Insurance
statistics suggest that disability from musculoskeletal
disorders is rising, not falling. Work disability attrib-
uted to musculoskeletal disorders, much of which is
back pain, increased from 20.6% of beneficiaries in
1996 to 25.4% in 2005 (Figure 2).
72
This was not a
growing proportion of a shrinking pie; the number of
Social Security Disability Insurance recipients in-
creased over these years. Although it is unclear exactly
what proportion of musculoskeletal disability is from
back pain, the data suggest that current management
of musculoskeletal pain is not highly successful. In
contrast, for conditions where effective prevention
and treatment have emerged, such as circulatory and
respiratory diseases, the proportion of disabled bene-
ficiaries fell.
Implications and Possible Responses
Prescribing yet more imaging, opioids, injections,
and operations is not likely to improve outcomes
for patients with chronic back pain. We must re-
think chronic back pain at fundamental levels. Our
understanding of chronic back pain mechanisms
remains rudimentary, including our knowledge of
spinal biology, central nervous system processing,
genetic factors, and psychosocial and environmen-
tal influences. Greater investment is needed in this
basic science research.
Clinicians may often be applying an acute care
model to a chronic condition. There are no “magic
bullets” for chronic back pain, and expecting a cure
from a drug, injection, or operation is generally wish-
Figure 2. Percentage of individuals with permanent
work disability (Social Security Disability Income
beneficiaries) disabled by various medical conditions.
(Data are from reference 24.)
doi: 10.3122/jabfm.2009.01.080102 Overtreating Chronic Back Pain 65
ful thinking. These approaches risk overlooking the
psychosocial, occupational, and lifestyle dimensions
of chronic pain. Although evidence remains incom-
plete and the magnitude of benefits may be modest,
data support the benefits of interventions that pro-
mote patient involvement and activity (eg, graded
exercise programs and group support).
73–77
These
therapies also have the advantage of being low risk.
A “chronic care model” would acknowledge that
chronic back pain, like diabetes or asthma, is a con-
dition we can treat but rarely cure. As with other
chronic conditions, care of chronic back pain may
benefit from sustained commitment from health care
providers; involvement of patients as partners in their
care; education in self-care strategies; coordination of
care; and involvement of community resources to
promote exercise, provide social support, and facili-
tate a return to work.
78,79
Patients need realistic ex-
pectations despite product marketing, media reports,
and medical rhetoric that promise a pain-free life.
Each treatment and test discussed here has a role
in managing back pain, but the evidence base for
judicious use remains inadequate. Greater federal
involvement in research about therapies and de-
vices may be necessary to provide independent as-
sessments. Initiatives in comparative effectiveness
research would be particularly welcome in this re-
gard. Research emphasis should shift from studying
fine points of procedural technique to determining
who benefits most. Instead of measuring only tech-
nical success (solid bony fusion or properly placed
injection), research should clarify a treatment’s
safety and its effects on pain, function, and return
to work. Serious complications and unclear benefits
highlight the need for more rigorous approval and
better post-marketing surveillance of both drugs
and devices for treating pain. Without stronger
evidence insurers may reasonably question cover-
age of newer drugs, devices, and procedures.
80
In
the meantime, we should fully inform patients
about available treatment options, including the
best available evidence for effectiveness, uncertain-
ties, and risks, and encourage them to play an
expanded role in therapeutic decision making.
77
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