Author Insights: Despite Recommendations, Increased Use of Narcotics and Imaging for Back Pain

John N. Mafi, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues found increasing use of imaging to assess and narcotics to treat back pain, despite guidelines promoting more conservative approaches. Image: John Mafi

John N. Mafi, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues found increasing use of imaging to assess and narcotics to treat back pain, despite guidelines promoting more conservative approaches. Image: John Mafi

A growing number of patients with back pain are receiving narcotic pain medications or imaging scans, despite consistent recommendations that more conservative approaches usually should be used first, according to a study published today in JAMA Internal Medicine.

Back and neck pain are among the most common conditions physicians treat, accounting for 10% of office visits and $86 billion in health spending, according to the study’s authors. Most patients will recover within a few months with minimal intervention, which has led professional organizations to recommend conservative approaches to treating most cases of new-onset back pain that aren’t accompanied by other symptoms that signal a serious medical problem.

But when the researchers analyzed data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, they found that a growing number of patients with back pain are getting treatment that is not consistent with these recommendations. The proportion of patients with back pain who received nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen declined from 36.9% to 24.5% between 1999 and 2010, while narcotic prescriptions for treating back pain increased from 19.3% to 29.1%.

The proportion of patients undergoing computed tomography (CT) or magnetic resonance imaging (MRI) scans also increased from 7.2% to 11.3% over the same period. Referrals to physical therapists remained constant at about 20%, but referrals to other physicians, such as surgeons or back specialists, increased from 6.8% to 14.0%.

Lead author John N. Mafi, MD, chief medical resident and fellow in general medicine at Beth Israel Deaconess Medical Center in Boston, discussed the findings with news@JAMA.

news@JAMA: What are the recommended approaches to treating back pain?

Dr Mafi: The guidelines have been pretty consistent since the 1990s. The basic approach is “less is more” for patients with routine back pain and who have no red flags such as fever, cancer history, neurologic symptoms, or weight loss: use of nonsteroidal anti-inflammatory drugs or acetaminophen and, when pain doesn’t resolve within a couple months, physical therapy. Most cases of new-onset back pain will resolve within a few months. Only after you’ve tried those approaches should you consider imaging or referral.

news@JAMA: How do the treatment trends you documented compare with the guidelines?

Dr Mafi: We saw a decline in use of NSAIDs that was discordant with the guidelines. The guidelines recommend it as a first-line treatment. What we are seeing instead is a rise in narcotic prescriptions. The guidelines are cautious about narcotics and say to be cautious and recommend them only as second- or third-line therapies.

There is also discordance between the guidelines and physician use of imaging. In patients with new-onset back pain, ordering an MRI or CT scan is not indicated in most cases. Finally, we saw a rise in referrals to specialists, though primary care clinicians are usually able to manage patients with routine cases of back pain themselves with minimal treatment.

news@JAMA: What do you think is driving physicians to pursue these more aggressive treatment approaches?

Dr Mafi: We are a society that demands instant solutions, but back pain doesn’t play by these rules. It takes time, and unfortunately, the fancier treatments haven’t been shown to decrease patient’s pain or increase their quality of life. That’s why we have to rely on the less-is-more approach.

news@JAMA: What do you think is driving the shift from NSAIDs to narcotics?

Dr Mafi: It is in part patient expectations and a sentiment that emerged in the 1990s physicians weren’t paying enough attention to patient pain. The Joint Commission made pain the fifth vital sign. In response, there has been an overcorrection and now narcotics are reached for first. Since that time, there has been a 300% increase in narcotic prescriptions and rise in narcotic overdoses and deaths. In 2008 almost 15000 people died—more than for cocaine and heroin overdoses combined. There are huge public health implications.

news@JAMA: What about the increase in imaging and referral?

Dr Mafi: Our data didn’t answer this, but I can speculate based on other studies. There is also sentiment among patients if my doctor ordered MRI he or she listened to me, that good care equals getting lots of tests. But randomized trials have found no clinical and no psychological benefit of imaging for back pain.

Time is also a factor. Sometimes it’s easier for physicians to send the patient to a back specialist or for imaging. Finally, there are financial incentives in the fee-for-service model to increase utilization of MRI or CT scanners and there are financial incentives to surgery. I think it’s a largely unconscious bias by physicians to recommend procedures.

news@JAMA: What do you think physicians or patients can do to change this?

Dr Mafi: The biggest message for the public is that for the most part, back pain will get better in time with conservative treatment. So instead of rushing to get a prescription for narcotics or an MRI, have patience. If it lasts longer than a couple of months, going to physical therapy to get some core strength training may help.

Another solution is to give physicians more time. They may be less likely to order tests, more likely to explain tests, and less likely to refer. That’s just my assessment. Changing the way financial incentives are aligned may also help.

We are not saying MRI, CT, or referrals are always wrong; there may be circumstances where they are appropriate. But we think the rapid rise in use of these tools for back pain is a problem.

Categories: Evidence-Based Medicine, Pain, Primary Care/Family Medicine, Uncategorized