The misery of low back pain often drives people to the doctor to seek relief. But doctors are doing a pretty miserable job of treating back pain, a study finds.
Physicians are increasingly prescribing expensive scans, narcotic painkillers and other treatments that don't help in most cases, and can make things a lot worse. Since 1 in 10 of all primary care visits are for low back pain, this is no small matter.
What does help? Some ibuprofen or other over-the-counter painkiller, and maybe some physical therapy. That's the evidence-based protocol. With that regimen, most people's back pain goes away within three months.
But when researchers at Beth Israel Deaconess Medical Center in Boston looked at records of 23,918 doctor visits for simple back pain between 1999 and 2010, they found that doctors have actually been getting worse at prescribing scientifically based treatments.
Doctors were recommending NSAID pain relievers and acetaminophen less often. Instead, they were increasingly prescribing prescription opioids like OxyContin, with use rising from 19 percent of cases to 29 percent. Over-the-counter painkiller use declined from 37 percent to 25 percent. Other studies have found that opioids help only slightly with acute back pain and are worthless for treating chronic back pain.
"That's a big public health issue," says Dr. John Mafi, chief medical resident and a fellow at Beth Israel Deaconess. Mafi was the lead author of the study, which was published online inJAMA Internal Medicine. In the 1990s doctors were criticized for ignoring patients' pain, Mafi says. Some of that criticism was valid, but doctors have overreacted. "What magic bullet better than a very powerful pain medication?"
About 43 percent of patients taking opioids for chronic back pain also had other substance abuse disorders, the researchers found. In 2008, almost 15,000 people died from overdoses of prescription opioids, and abuse has surged among women. Opioids may be necessary in some cases, Mafi says, but "they're certainly not first-line."
Doctors were also quick to whip out the prescription pad and call for CT and MRI scans for people with lower back pain, the study found. The number of people getting scans rose from 7 to 11 percent. Though those scans won't hurt the patient, in most cases they don't find anything wrong. And they are expensive, costing $1,000 or more.
Patients are partly to blame for the rush to scan, Mafi says. "Patients are expecting very comprehensive evaluations," he tells Shots. "There's a sentiment perhaps if my doctor ordered an MRI for my back pain they really listened to me. It's almost validating."
And in an era when doctors are rated online by patients, "doctors have an incentive to make patients happy," Mafi says.
Financial incentives for doctors may also be a factor. This study didn't examine why doctors aren't following clinical guidelines for treating back pain, but other studies have found that when doctors own imaging equipment, they are more likely to use it.
Doctors should be cut a little slack, a journal commentary accompanying this study says, because guidelines have been conflicted on back pain treatment until recently, and it takes 17 years, on average, for new treatment standards to be widely adopted. But creating checklist-type guidelines for doctors would help speed that process, the commentary says. So would requiring patients to pay more of the cost of expensive imaging, and providing payment incentives for doctors who do the right thing.
"For the majority of new-onset back pain [cases], it gets better within three months," Mafi says. "Unfortunately, we don't have fancy treatments that cure it." Time, some ibuprofen and gentle exercise aren't sexy. But they most often do the trick.
http://www.npr.org/blogs/health/2013/07/30/206910829/doctors-increasingly-ignore-evidence-in-treating-back-pain
Living With Pain : Neurology Now
A few months after being diagnosed with multiple sclerosis (MS) at age 17, Jon Hood of Phoenix, AZ, wandered through his home gathering medications—in an attempt to kill himself to escape the physical pain he was experiencing as a result of the disease. He swallowed a pile of pills with a glass of water. Hours later, he woke up disoriented, confused, and suffering from severe stomach cramps. "My mom heard me vomiting and took me to the hospital," says Hood.
He had begun feeling pain in his limbs at age 11. At 13, leg cramps kept him up all night. By 17, Hood had lost his vision, developed a limp, and could no longer play sports.
He went to a string of doctors, but none were able to pinpoint the cause of his symptoms. Many thought he was making them up. Although physical pain is becoming increasingly recognized as a symptom of MS, many people—including doctors—are unaware that it can be caused by the disease. Some research suggests that more than half of MS patients experience pain at some point during the course of the disease, and that nearly half experience chronic pain. MS has been associated with trigeminal (facial) pain, painful spasms, burning or shooting pain, and back pain.
Hood was finally diagnosed with MS following a series of imaging exams and lab tests that spanned a few weeks.
"The day I attempted suicide, I was with a group of friends at a gas station. I offered to run in and get some sodas. My friend said, 'Stay here; I'll run in real quick,'" says Hood, now 24. "I suddenly felt like I would always be treated differently." The statement reinforced his sense of hopelessness at the hands of an incurable and painful disease.
Hood's despair isn't unique. Reports show that 50 percent of chronic pain patients consider suicide to escape the unrelenting agony of their pain. A study published in Psychosomatic Medicine in 2006 found that relative to the general population, risk of death by suicide appears to be at least doubled in chronic pain patients.
Despite these sobering statistics, there's reason for hope. Beyond the bevy of pharmaceutical options available to target pain and accompanying depression, a variety of self-help tools are available. First, however, the cause of the pain must be identified by a neurologist, as different pain conditions require different treatments.
More ...
http://journals.lww.com/neurologynow/Fulltext/2013/09020/Living_With_Pain.28.aspx
He had begun feeling pain in his limbs at age 11. At 13, leg cramps kept him up all night. By 17, Hood had lost his vision, developed a limp, and could no longer play sports.
He went to a string of doctors, but none were able to pinpoint the cause of his symptoms. Many thought he was making them up. Although physical pain is becoming increasingly recognized as a symptom of MS, many people—including doctors—are unaware that it can be caused by the disease. Some research suggests that more than half of MS patients experience pain at some point during the course of the disease, and that nearly half experience chronic pain. MS has been associated with trigeminal (facial) pain, painful spasms, burning or shooting pain, and back pain.
Hood was finally diagnosed with MS following a series of imaging exams and lab tests that spanned a few weeks.
"The day I attempted suicide, I was with a group of friends at a gas station. I offered to run in and get some sodas. My friend said, 'Stay here; I'll run in real quick,'" says Hood, now 24. "I suddenly felt like I would always be treated differently." The statement reinforced his sense of hopelessness at the hands of an incurable and painful disease.
Hood's despair isn't unique. Reports show that 50 percent of chronic pain patients consider suicide to escape the unrelenting agony of their pain. A study published in Psychosomatic Medicine in 2006 found that relative to the general population, risk of death by suicide appears to be at least doubled in chronic pain patients.
Despite these sobering statistics, there's reason for hope. Beyond the bevy of pharmaceutical options available to target pain and accompanying depression, a variety of self-help tools are available. First, however, the cause of the pain must be identified by a neurologist, as different pain conditions require different treatments.
More ...
http://journals.lww.com/neurologynow/Fulltext/2013/09020/Living_With_Pain.28.aspx
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