Overtreating Back Pain
Overtreating Back Pain
Written by Dr. Daniel J. Murphy D.C., D.A.B.C.O.
TAC, Research Review , Volume 31, Issue 7
Published:
Key Points from Dr. Dan Murphy
1. “Pain complaints are a leading reason for medical
visits. The most common pain complaints are
musculoskeletal, and back pain is the most common of
these.”
2. “The prevalence and impact of back pain have led
to an expanding array of tests and treatments, including
injections, surgical procedures, implantable devices,
and medications. Each is valuable for some patients, but
use may be expanding beyond scientifically validated
indications, driven by professional concern, patient
advocacy, marketing, and the media.”
3. Although approximately 25% of US adults reported
back pain during the past 3 months, this percentage has
not changed for decades.
4. Expanded testing and treatment for back pain have
not improved outcomes, but have increased complications,
including deaths.
5. “Chronic back pain is among the most common
patient complaints.”
6. There are increases in Medicare expenditures for
back pain diagnostics and treatments, as follows:
a. A 629% increase for epidural
steroid injections
b. A 423% increase in expenditures
for opioids for back pain
c. A 307% increase in the number of lumbar magnetic
resonance images
d. A 231% increase in facet joint
injections
e. A 220% increase in spinal fusion
surgery rates
7. These increases have not improved in patient
outcomes or disability rates.
8. Manufacturers aggressively promote new drugs and
devices for the treatment of back pain, yet there is
evidence of misleading advertising, kickbacks to
physicians, and major investments by surgeons in the
products they are promoting.
9. The use of lumbar magnetic resonance imaging (MRI)
has increased dramatically, and spinal surgery rates are
highest where imaging rates are highest.
10. Approximately 33–66% of spinal computed
tomography (CT) imaging and MRI may be inappropriate.
11. “Many factors probably underlie the growth of
imaging, including patient demand, the compelling nature
of visual evidence, fear of lawsuits, and financial
incentives.”
12. “One problem with inappropriate imaging is that it
may result in findings that are irrelevant but
alarming.”
13. “Positive findings, such as herniated disks, are
common in asymptomatic people.”
14. Positive imaging findings result in more surgery
and higher costs than those receiving plain X-rays, but
the clinical outcomes are no better, including
subsequent pain, function, quality of life, or overall
improvement.
15. Prescription opioid use is steadily increasing,
especially for musculoskeletal conditions. Emergency
department reports of opioid overdose parallel the
numbers of prescriptions. Deaths related to prescription
opioids are greater than the combined total involving
cocaine and heroin.
16. Cancer patients tend not to take opioids for long
periods of time because they die. In contrast, patients
taking opioids for back pain can do so for decades. More
than half of the prescriptions for opioids are for back
pain and, consequently, they constitute a major portion
of those with opioid consumption complications.
17. The benefit of opioids drugs in clinical practice
for the long-term management of chronic low back pain is
questionable.
18. Ironically, “Opioid use may paradoxically
increase sensitivity to pain.”
19. Chronic use of opioid drugs may also cause
hypogonadism, reduced testosterone levels, diminished
libido, and erectile dysfunction.
20. “Epidural corticosteroid injections may offer
temporary relief of sciatica, but both European and
American guidelines, based on systematic reviews
conclude they do not reduce the rate of subsequent
surgery.”
21. “Facet joint injections with corticosteroids seem
no more effective than saline injections.”
22. “For patients with axial back pain without sciatica,
there is no evidence of benefit from spinal injections.”
23. Spine fusion surgery is limited when treating
degenerative discs with back pain with no sciatica, yet
they have increased 220% from 1990 to 2001 in the United
States.
24. “Higher spine surgery rates are sometimes
associated with worse outcomes.”
25. New and improved fusion techniques and devices,
such as implants, increase the risk of nerve injury,
blood loss, overall complications, operative time, and
repeat surgery, but do not result in improved disability
or reoperation rates.
26. Increases in the rates of imaging, opioid
prescriptions, injections, and fusion surgery might be
justified if there were substantial improvements in
patient outcomes; unfortunately, they are not. In fact,
statistics indicate that disability from musculoskeletal
disorders is rising, not falling.
27. “Prescribing yet more imaging, opioids,
injections, and operations is not likely to improve
outcomes for patients with chronic back pain.”
28. “There are no “magic bullets” for chronic back
pain, and expecting a cure from a drug, injection, or
operation is generally wishful thinking.”
29. “Chronic back pain, like diabetes or asthma, is a
condition we can treat but rarely cure,” and its
management may “benefit from sustained commitment from
health care providers; involvement of patients as
partners in their care; education in self-care
strategies; coordination of care; and involvement of
community resources to promote exercise, provide social
support, and facilitate a return to work.”
COMMENT FROM DAN MURPHY
In the 10 years that I have been doing my Article
Reviews, we have seen a number of studies that show that
spinal adjusting is highly effective, safe, cost
effective, and results in long-termed stable outcomes in
the treatment of chronic low back pain.
Dr. Daniel J. Murphy D.C., D.A.B.C.O. graduated magna
cum laude from Western States Chiropractic College in
1978. He received Diplomat status in Chiropractic
Orthopedics in 1986. Since 1982, Dr. Murphy has served
part-time as undergraduate faculty at Life Chiropractic
College West, currently teaching classes to seniors in
the management of spinal disorders. He has taught more
than 2000 postgraduate continuing education seminars.
Dr. Murphy is a contributing author to both editions of
the book Motor Vehicle Collision Injuries and to the
book Pediatric Chiropractic. Hundreds of detailed
Article Reviews, pertinent to chiropractors and their
patients, are available at Dr. Murphy’s web page,
www.danmurphydc.com
