Back pain is one of the biggest reasons for going to the doctor's office. Under national guidelines, certain basic pain medicines serve as a first-line treatment to ease back pain. But patients might not be told to use these medicines when they first visit the doctor. Despite published guidelines for treating back pain with basic pain medicines and physical therapy, treatment to relieve back pain varies across the country, a new study found.
Care for back pain involving the spine has not followed the national guidelines, according to this study's findings. Instead, care has swayed more toward use of advanced, expensive imaging techniques, referrals to other doctors and use of major pain medications.
John Mafi, MD, from the Division of Primary Care and General Internal Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and colleagues investigated management and treatment trends regarding back and spinal care across the nation.
Under the national and well-established guidelines, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Tylenol, Panadol, Mapap, Ofirmev, Feverall, Acephen) and referrals for physical therapy should be recommended first for routine back pain, according to these researchers.
The researchers looked at the data of almost 24,000 outpatient visits for spinal problems listed in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey.
The visits represented about 440 million total visits nationwide with 58 percent of the visits involving female patients. The included surveys spanned an 11-year period between January 1999 and December 2010.
The patients’ chief symptoms and primary diagnosis of back or neck pain were noted. The researchers also looked at any secondary symptoms and diagnoses of back or neck pain.
Methods used to diagnose back pain and any medications used to treat the conditions were tracked.
Visits which involved fever, neurologic symptoms and cancer were excluded from the study data.
Over the course of the study, patients’ ages increased from 49 years of age on average to 53.
The researchers found that back pain management relied more on care that does not necessarily follow current recommended guidelines.
Typical first-line medicines for back pain, including NSAIDs and acetaminophen, decreased from 36.9 percent in 1999-2000 to 24.5 percent in 2009-2010.
At the same time, narcotic use increased from 19.3 percent to 29.1 percent. Narcotics are often used for severe pain and short-term pain relief.
“Although we lack adequate data to make firm recommendations on narcotic medications...such increases in narcotic prescriptions may be contributing to a current crisis in public health: the rapid increase in narcotic overdose deaths parallels a reported 300 percent increase in the US sales of prescription narcotics since the 1990s,” the researchers wrote in their report.
New doctor referrals also increased from 6.8 percent to 14 percent. The number of physical therapy referrals remained stable at about 20 percent.
Concerning methods to diagnose back conditions, the number of radiographs remained stable at about 17 percent. The number of computed tomograms (CT scans) or magnetic resonance images (MRIs) increased from 7.2 percent to 11.3 percent.
The authors noted a few limitations to their study, including not having information on how long patients had symptoms. However, the researchers noted that short-term and long-term trends concerning symptoms showed similar patterns.
And although the researchers said they could not look at treatment patterns over time for individual patients, they said that trends over time are likely to reflect changes in practice patterns rather than changes in the patient population.
This study was published online July 29 in the journal JAMA Internal Medicine. No conflicts of interest were reported.
Funding for the research was provided by the National Research Service Award training grant from the US Health Services and Research Administration, the Ryoichi Sasakawa Fellowship Fund, and the Harvard Catalyst National Institutes of Health Award.