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 post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.

Figure 1. Increases in Use of Various Services for Low Back Pain

(1a.) Lumbar spine magnetic resonance imaging (CPT codes 72148, 72149, 72158), numbers of scans among Medicare beneficiaries, from Part B claims; (1b.) Numbers of opioid prescriptions for spine conditions, national data from the Medical Expenditure Panel Survey, reference 11 (1c.) Rates of lumbosacral injections in the Medicare population, age- and sex-adjusted. Data are from reference 1, adapted with permission.(1d.) Lumbar spine fusion rates for degenerative conditions, age- and sex-adjusted, National Inpatient Sample, from reference 2, reproduced with permission.

Figure 2. Percentage of individuals with permanent work disability (Social Security Disability Income beneficiaries) disabled by various medical conditions. Data are from reference 24.