Doctors who treat back pain are prescribing more narcotic painkillers, making more referrals to specialists and ordering too many unnecessary diagnostic tests, according to a new report published in JAMA Internal Medicine. Researchers and patient advocates say the trend is not only increasing the cost of healthcare, but in some cases harming patients.
“Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines,” said lead author John Mafi, MD, of Harvard Medical School.
Mafi and his colleagues studied nearly 24,000 visits by patients who saw their doctors for back pain between 1999 and 2010. During that period, they found that physicians were increasingly less likely to follow established clinical guidelines for treating back pain, which is one of the most common reasons patients visit a doctor.
“Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID (non-steroidal anti-inflammatory drugs) or acetaminophen use,” Mafi said.
Researchers found that NSAID or acetaminophen use per office visit decreased from nearly 37% in 1999 to less than 25% in 2010. During the same period, the prescribing of more powerful opioid painkillers rose from 19% to 29%.
“Although we lack adequate data to make firm recommendations on narcotic medications, which may be indicated in certain circumstances, such increases in narcotic prescriptions may be contributing to a current crisis in public health: the rapid increase in narcotic overdose deaths,” Mafi wrote.
The study also found that while physical therapy referrals remained unchanged at about 20%, referrals to other physicians increased from nearly 7% to 14%.
Doctors were also more likely to order magnetic resonance images (MRIs) or cat scans for their patients. The use of those advanced imaging tests increased from about 7% to 11%.
Mafi wrote that many of the tests were “inappropriate” and said “the significant increase in spine operations seen during the last decade is almost certainly related to the overuse of imaging.”
The trend towards more testing and more referrals is disturbing to Dawn Gonzalez, a patient advocate for the Arachnoiditis Society for Awareness and Prevention (ASAP), whose spine was severely injured by epidural steroid injections (ESI) for back pain.
“There no longer is any kind of rest, ice, or seeing if your body can heal on its own anymore. You are immediately sent to a specialist, for MORE tests, invasive procedures, and absolutely no regard for the human body as a whole anymore,” Gonzalez wrote in an email to National Pain Report.
“In the case of back pain, you are immediately referred to pain management and given ESI’s, or sent to a neurosurgeon to see what can be operated on. These procedures have serious risks and are being used as a first line of treatment. They are damaging and disabling people for life with ESI’s and their horrible effects, or leading to a life of repeat surgeries with never ending pain,” Gonzalez said.
“It is disgraceful and sickening. Doctors are no longer allowed to do their job anymore. It’s all about the ‘referral game’ and bouncing people around to be maimed by invasive procedures.”
In a commentary on the study also published in JAMA Internal Medicine, one physician suggested that making diagnostic tests more expensive would be one way to stop their overuse.
“More appropriate economic incentives are needed for patients and physicians, such as higher patient out-of-pocket insurance copayments for expensive imaging and linking of payments for clinicians to improved outcomes for populations of patients with back pain,” said Donald Carey Jr., MD, of New York University Langone Medical Center.
“The first step in addressing a problem is to admit that you have it, and in that regard the article by Mafi et al forces us to admit that development of clinical guidelines alone will not solve our problem in managing back pain,” said Casey, adding that a “checklist” needs to be developed for doctors to properly diagnose and treat patients for back pain.