Shift in back pain guidelines favors non-medication therapies

When the American College of Physicians issued new guidelines for treating lower back pain last month it represented a big shift: instead of recommending prescription medications as the first line of treatment, as it had for years, the new recommendations favored non-invasive treatments such as exercise and heat therapy.

The previous guidelines, issued in 2007, recommended acetaminophen (Tylenol) and other non-steroidal anti-inflammatory pain killer medications (NSAIDs) as first line therapy. The new guidelines removed these from first line therapy, and replaced them with non-pharmacological strategies. These medications can help, in particular NSAIDs; acetaminophen is less helpful). NSAIDs, however, have a risk of toxicity, especially for older patients or patients with heart, kidney, or liver disease or stomach ulcers.

Dr. John Mafi, an assistant professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA, welcomed the new guidelines. Mafi’s research has found that the use of imaging, opioid medications and physician referrals for more intensive treatment such as surgery or injections constitute unnecessary “low value” care that ultimately have no effect on the patient given that lower back pain by and large resolves itself in a few days or weeks.

Q: What do you think of these new guidelines?
The most radical shift with the guidelines is removing medications from first-line therapy and replacing them with non-pharmacological approaches. The non-medication oriented treatments have much lower risk of harm than medications and they are just as, if not more effective, than most medications. Of course, the most effective treatment of low back pain is time, as the majority of patients' symptoms resolve within a few weeks.

Q: What are the key differences in the new guidelines that patients need to know?
Some of the recent changes include using heat packs for acute back pain, which can modestly improve symptoms. Also, we’ve learned that acetaminophen (Tylenol) is ineffective for treating acute low back pain. But I would have also liked to have seen a bit more evidence on how physicians can help patients prevent low back pain in the future.

Q: How and why are clinical guidelines for back pain treatment evolving?
Generally, they are moving away from medications and more towards non-medication-based therapies. The challenge to this is that although these alternatives are less costly and less harmful, they take more effort on the patient’s part, and access to these kinds of services is often not guaranteed.

Q: What has been UCLA’s involvement in researching back pain treatment?
We’ve launched an intiative called the Back Pain Quality Improvement (BPQI) program aimed at providing standardized care for back pain across the UCLA Health system. It was launched by Our very own Dr. Kenrik Duru, associate professor of medicine in the division of general internal medicine and health services research. he BPQI program is consistent with the new guidelines, promoting the idea that, in the absence of red flag signs or symptoms, patients don't need back imaging or invasive procedures for six or eight weeks, since many will improve on their own.

Q: Haven’t experts been recommending more conservative, non-drug treatment for a while now? Has this advice been slow to catch on?
Absolutely. There are lots of reasons for this. Part of it is financial incentives that reward more care instead of better care. Another is that doctors are worried about malpractice, which sometimes results in a tendency to over treat. Also, patients may have difficulty accessing these alternative services, such as physical therapy, that have long waits or may not be covered by insurance.And i think people come to expect that coming to the doctor will enable a quick fix. Unfortunately, back pain, much like the common cold, does not have a cure or quick fix, and the only thing that makes it go away is time. You can use some ibuprofen and gentle exercises to help, but these things are not as sexy as a fancy MRI or a powerful painkiller.

Q: Do patients who have previously been treated with drugs for back pain still have an expectation of receiving prescription therapy?
Patient expectations is certainly a part of it, but not the entire story. Some patients come to the doctor expecting to get a powerful painkiller Or an MRI for the back pain, whereas others simply want to be examined and reassured by a physician. They need to know that in the vast majority of patients, back pain will resolve on its own over time, and no amount of MRIs, CT scans, specialty referrals, or opioids will alter that course; in many cases, it can make things worse. These new guidelines are introducing different, alternative therapies that have strong evidence of help. It’s time we start getting serious about using them.

Q: What’s the best thing to do when back pain flairs up or when you injure your back?
The best thing to do is actually NOT bed rest. This can make things worse by making the muscles too stiff. Keep moving as much you can tolerate. Heat packs can help. If medications are necessary, then over the counter anti-inflammatory medications such as ibuprofen can help calm some of the inflamed low back muscles.

Q: When should you see a doctor for it?
Among the main reasons to see a doctor for low back pain are when there are clues that something more serious is going on, which is rare, or when there is the presence of what we call “red flags.” These include if you have a fever with the back pain, or a history of cancer, or if you can’t walk or have weakness of the legs, or if you had a history of trauma, such as falling down and hitting your back on something, where we’d be concerned for fracture.

Q: What are the treatments for chronic back pain that just won’t go away?
The most successful treatments for low back pain involve physical therapy, which focus on core strengthening and stretching (the core represents the abdominal muscles, low back muscles, and hip muscles). Although these effects are slow-going and modest, they do work over time. Of note, a healthy and strong core is the best way to prevent future occurrence of back pain.