A large majority of individuals with chronic low back pain seek care from more than one provider and receive a number of tests and treatments. These tests and treatments often do not reflect the best evidence for effective treatment of this chronic and disabling condition. Some treatments, such as use of therapeutic exercise, appear to under-utilized, while other treatments, such as utilization of muscle relaxants, advanced imaging studies, and physical modalities such as traction, TENS units, and corsets, appear to be substantially over-utilized. Consistent with other literature we found very high utilization of narcotics.4
Utilization of narcotics has increased substantially in recent years, possibly in response to efforts to make pain the “fifth vital sign” and concern regarding under-treatment of pain.12
However, consistent with systematic reviews, we found that patients on narcotics had poor physical functioning and there was significant evidence of depression with poor SF-12 mental functioning scores.13
Patients on narcotics were also more likely to have a positive depression screen, relative to those not on narcotics. While some of the findings from our respondents could be due to confounding by indication (worse functioning patients are more likely to be placed on narcotics by their providers), our findings reinforce the need for appropriately sized placebo-controlled trials of narcotics for chronic pain. Certainly these chronically ill patients do not seem to be substantially benefiting from their medications, and they are at risk for significant side effects.
The burden of un- or under-treated depression in this population is substantial. Depression rates are known to be increased in chronic pain patients and treatment with medication or cognitive-behavioral therapy can lead to substantial improvement in depressive symptoms, although not necessarily in level of physical functioning.14 15
We recommend greater efforts towards case-finding and treatment of depression in the chronic back pain population.
The strengths of this study are the ability to generalize the sample to a defined population with demographics similar to the rest of the US, and the lack of restrictions by payment source or type of care sought. The second strength is the specific definition of back pain: respondents had to identify the problem as sufficiently severe that they could not perform their usual activities of daily living and lasting greater than 3 months in duration- providing information on the clinical syndrome associated with the majority of spine disability and social cost.16
Our measures of functional status, care utilization and depressive symptoms were based on standard measures. Our study does have several limitations. We could not link care received with the identity of the provider who recommended that care; we found in pretesting that patients could not reliably identify which of their often multiple care providers prescribed specific tests, medications or treatments. As a cross sectional survey we cannot track the individuals over time to determine the course of their impairment, although other literature has demonstrated that chronic back pain, once established, is persistent.17
The measures of effect in the systematic reviews we examined were almost always assessed as an average effect; evidence is generally lacking in the constituent studies in subset analyses by age, gender, comorbidity, or other clinical criteria. Even when there is no overall benefit from a treatment, some individual patients may benefit, but current evidence generally cannot guide us toward what those patient subsets are.
The reasons for the marked disparities between care provided and best evidence care are likely multiple. Under use of treatments such as exercise instruction may serve as a marker for care that is poorly reimbursed and/or provided by individuals other than physicians. Exercise may also have relatively low acceptance among patients with high expectations that use of advanced technology will be an answer to their chronic back pain. However, in recent years exercise programs such as cardiac rehabilitation have gained somewhat greater acceptance through more structured programs and improved insurance reimbursement, with now 30% of eligible patients participating.18
Less than half of back pain patients received any exercise prescription and only a small number were in a formal program. Detailed examination of the reasons for lack of dissemination of such structured programs for chronic back pain is needed. Reasons could include poor reimbursement, lack of trained providers, provider and patient knowledge, and acceptability.
Other over-utilized tests and treatments may be subject to the allure of technology (MRIs, CT scanning), and treatments that address short term symptom relief without a sufficient focus on long-term functioning (narcotics, muscle relaxants and electro-stimulation, among others). Treatment for depression may be under-utilized due to lack of recognition by health care providers. Published guidelines are now available but past experience has demonstrated that simply publishing guidelines will not substantially change care patterns, and adherence to guidelines is often poor.19 20
Untreated depression makes other components of treatment of chronic back pain more difficult; depression and back pain are risk factors for each other.21
High rates of utilization of CT and MR, narcotics, muscle relaxants and under-use of more effective test and treatments remain. Concerted efforts by professional groups, insurers and health policy makers are needed to substantially change treatment patterns, which currently result in poor distribution of health care resources for this common and disabling illness. Reallocation of resources and reimbursement away from ineffective or potentially harmful treatments to more effective treatments has the potential to substantially ameliorate this public health crisis.