Overtreating Chronic Back Pain: Time to Back Off?

Abstract

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 complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures 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

Regional socioeconomic disparities in outcomes for workers with low back pain in the United States

“…Certain forms of care (such as chiropractic) associated with overtreatment are more common in populations with lower education and lower SES, and thus may account for the association with higher medical costs. More expensive and potentially unnecessary care is closely related to a higher occurrence of diagnostic testing and treatments that are not recommended by accepted evidence‐based guidelines,51, 52 which suggests lower quality care 19, 53. Thus, total medical expenses served as a suitable proxy for quality of care in our study.…”

“…Uncomplicated LBP is a common condition in working‐age populations where intensive interventions are rarely required and treatment guidelines are quite clear about the recommended course of care and expected recovery 17. However, the vast majority of working‐age LBP patients in the U.S. receive too much testing and treatment for their LBP as compared to guideline recommendations 18, 19. The objective of this study was to determine if SE characteristics of claimants’ geographic context were associated with WC benefits including intensity of medical care (as reflected by medical expenses) and length of time absent from work for acute uncomplicated LBP, after controlling for individual and state characteristics.…”

Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery

“…As a result, more than 16,000 deaths per year and USD 55 billion of increased costs have been attributed to overuse of opioids [7,29]. During the last one to two decades, there has been a dramatic increase in preoperative use of opioid medications in patients undergoing elective orthopaedic surgery [14,56]. Yet little is known regarding the effect of this trend on perioperative morbidity and mortality in this patient group.…”

“…Opioids often are prescribed for management of nonmalignant musculoskeletal pain [3,12,14,32,54] and orthopaedic surgeons prescribe more opioids than surgeons in any other surgical specialty and are third after primary care physicians and internists -even though these top two groups are more numerous [52]. Prescription opioids represent the fastest growing type of drug abuse, the most common cause of unintentional overdose, and lead to more deaths annually than all illicit drugs combined [23,29].…”

Low Back Pain

“…While many interventions have been dismissed as either ineffective or accompanied with small effect sizes, 80 recent reports in the literature suggesting that interventions based on sub-group classification have the potential to enhance effect sizes over studies where the identical interventions administered in a one-size fits-all approach. 34, 49, 105, 118, 199 …”