— Let’s reexamine the current approach to treatment
by Christine Goertz, DC, PhD April 14, 2023
In December 2019, I attended a National Academies of Sciences workshop on the role of non-pharmacological approaches to pain management. At the end of the meeting, as expected, panelists concluded that more research was needed. However, to my surprise, several scientists also called for immediate action on the approach to treating low back pain. They called for clinicians to implement the evidence we already have into clinical practice; for policymakers to enact payment reform that would support such implementation; for all of us to commit to making the cultural changes needed to ensure that patients have access to the right care from the right provider at the right time.
Where did this response come from? It stemmed from the fact that low back pain has been over-medicalized, making a very bad problem worse, and the need for realigned incentives that encourage clinicians to follow current evidence and treatment recommendations.
No health condition leads to greater disability or higher costs than low back pain, and commonly used medical treatment approaches often lead to more harm than benefit. Imaging is rarely necessary to develop an evidence-based treatment plan and can exacerbate pain catastrophizing, as well as lead to incidental findings “rabbit holes.” Prescription medications may be helpful to some patients in certain circumstances, but overall the risks often outweigh the benefits. According to the CDC, more than 260,000 deaths in America from 1999 to 2020 involved prescription opioids. Non-steroidal anti-inflammatory drugs (NSAIDs) can cause intestinal bleeding, especially in older adults, and are associated with a higher incidence of myocardial infarction. Surgery and corticosteroids can lead to short-term pain relief for some patients but results are often not sustained nor superior to less invasive options.
Most importantly, many of these medical diagnostic and treatment approaches — early imaging, surgical consults, corticosteroid injections, prescription opioids and NSAIDs — may actually increase the number of patients who transition from acute to chronic pain.
The problem is not the lack of evidence. The CDC, the Veterans Health Administration, and the American College of Physicians (ACP) have released comprehensive guidelines backed by highly convergent supportive evidence for the management of low back pain. Recommended first line treatments include non-pharmacological approaches such as exercise, education, self-care options, spinal manipulation, acupuncture, and massage. The ACP guideline in particular calls for patients and clinicians to consider the use of non-pharmacological treatment approaches for low back pain before trying prescription medications.
The problem is that we are not following the evidence. There are multiple barriers to widespread implementation of known best practices. Health systems are slow to change, especially when such change may not be in their financial best interests. Orthopedic surgeons are consistently rated among the top health system income generators, bringing in an average of $3.3 million per year. Primary care physicians may not have learned about non-pharmacological treatments in medical school and are often working with frightened patients who understandably want a clear explanation for their pain and a quick fix — a pill, an injection, even surgery.
Additionally, there is a sharp disconnect between existing payment policy and best practices for low back pain. Payors provide robust reimbursement for prescription medications, corticosteroid injections, and surgery. In contrast, private and public insurers often place significant limitations on coverage for guideline concordant treatments such as chiropractic care, acupuncture, and massage. Such policies offer little incentive for clinicians and health systems to change.
If we want real change, it will take an entire team of “committed citizens.”
Health systems can ensure they are staffed with providers whose clinical practices are better aligned with guideline recommendations. Payors can change their policies to align payment with guideline recommendations. Some health systems and insurance companies are moving in the right direction. Duke University Health System has instituted the Spine Health Program to offer coordinated, guideline-concordant care to patients with low back pain. United Healthcare does not charge co-pays for members who see a chiropractor or physical therapist first for low back pain. Traditional Medicare recently began offering limited coverage for acupuncture.
We also need to promote clinician education on the evidence regarding proper diagnosis and treatment of low back pain. We can become familiar with the ACP Guideline and read the excellent Lancet series on low back pain. We can tell our patients that MRIs can lead to worse outcomes, surgery is rarely necessary, and let them know that the ACP recommends the use of non-pharmacological treatments before prescription medications. Most importantly, we can, in the absence of red flags, refrain from ordering those tests or treatments unless they are clearly needed after the patient engages in a full course of evidence-based non-pharmacological treatment.
I can’t ignore the fact that part of the issue is systemic: the U.S. healthcare system is built upon the belief that patients benefit from seeking care. But that is often not the case for low back pain. By ignoring the evidence, over-medicalizing this condition, and continuing to tolerate policies that incentivize the wrong treatments, we are causing real harm to those who trust us to care for them.
Christine Goertz, DC, PhD, is a professor in musculoskeletal research at the Duke Clinical Research Institute n Durham, North Carolina, vice chair for Implementation of Spine Health Innovations in the Department of Orthopaedic Surgery at Duke University, and core faculty at the Duke Margolis Center for Health Policy.