It is hands down one of the most widespread, painful and debilitating health conditions in America: Lower back pain. And now, an entire issue of Annals of Internal Medicine is devoted to it.
Among several conclusions is the fact that many treatments that don’t involve medications have been proven effective at least in part, but insurers are reluctant to pay for them.
However, there aren’t enough studies to show whether these treatments — particularly when used in conjunction with pharmacological treatments — work in “real world” clinical settings.
America is in the throes of an opioid epidemic, with thousands of people who inject heroin every day having got their first taste of the poison apple — opioids — while being given painkillers for low back pain.
In a systematic review of non-pharmacologic therapies for low back pain, researchers led by Dr. Roger Chou assessed a decade’s worth of medical literature that has emerged since the American College of Physicians last released non-pharmacologic pain guidelines.
Chou and colleagues examined the effectiveness of therapies including yoga, acupuncture, massage, spinal manipulation, psychological therapies, tai chi, mindfulness (also known as stress reduction by focusing on the present), exercise and a combination of therapies.
“Some evidence supports the effectiveness of several nonpharmacologic therapies for chronic low back pain, and limited evidence shows that acupuncture is effective for acute low back pain,” the authors wrote. “Exercise and multidisciplinary rehabilitation were associated with an increased likelihood in return to work.’
For the most part, these non-pharmacologic therapies only worked for the short term (less than three months) and were more effective at reducing pain than also getting people moving again. However, the use of medicines (pharmacologic therapy) has presented a similar quandary to doctors.
Try Exercise, Acupuncture or Mindfulness Therapy First
The American College of Physicians released new guidelines for treatment of acute (severe), subacute (less severe) and chronic (long-term) back pain in conjunction with the publishing of the new systematic review. They include:
- Because most patients with both severe and moderate back pain recover over time regardless of treatment, “clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence).” If a patient wants medication, doctors and patients are advised to use nonsteroidal, anti-inflammatory drugs or muscle relaxers.
For patients with back pain that doesn’t seem to go away, the best approach again should be treatment without medication. “Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography, biofeedback, low-level laser therapy, operant (motivational) therapy, cognitive behavioral (talk) therapy, or spinal manipulation (low-quality evidence).”
- For those who simply don’t respond to treatments that don’t use medications, the ACP recommends nonsteroidal anti-inflammatory drugs, then tramadol or duloxetine as second-line therapy. “Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients,” the ACP warns.
What Good Are Guidelines if Insurers Won’t Pay for Treatments?
It’s important to assess how realistic these recommendations are when it comes to real-world practice.
“Although de-emphasizing opiate medications makes sense, this approach is based more on the lack of evidence for long-term benefits and the growing perception about the risks of opioid use than on new evidence,” writes Dr. Steven Atlas in an accompanying editorial. “The new recommendations do not address how to compare these treatments with invasive procedures that often are considered for patients with low back pain. Finally, regarding some of the nonpharmacologic therapies, such as multidisciplinary rehabilitation and psychological or mind-body treatments, the problem lies in their limited availability and affordability for patients, often reflecting insurance coverage decisions.”
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A professional journalist nearly 30 years, David Heitz started his career at the Quad-City Times in Davenport, Iowa before moving to Los Angeles. He led the Glendale News-Press to best small daily newspaper in the state (CNPA) as managing editor and also worked as executive news editor of the Press-Telegram. He worked briefly as deputy news editor of the Detroit News before returning to the Quad-Cities, where he has worked as a freelance medical writer since 2012 for several national websites. He recently purchased his childhood home and says he truly is “living the dream.”