Study: Many Doctors Don’t Follow Guidelines for Treating Back Pain

Study: Many Doctors Don’t Follow Guidelines for Treating Back Pain

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.

Back PainMafi 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.

Authored by: Pat Anson, Editor

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John Quintner

@ Stephen. I cannot share your belief in a “universal healing force” that can only be released by a group of divinely inspired human beings wielding stainless steel needles.

@John. If you don’t mind, the phrase “ancient concepts of vitalism and spiritualism” is not completely valid” I prefer universal force or God given. “May the Force be with you” … if it’s not you are just scattered bits of stuff or dust. One would be naive if they deny this awesome power.

The only part humans play in this natural power as it relates to the human body and healing is to ignite, activate and set it in motion. The stainless steel fine filament tool is like a “key” to unlock the Force which can then be fueled and nourish until the wound has completely healed. A scar will still be present but it is an inactive or quiet scar.

A logical follow up question is “What stalls, stops or blocks this natural healing Force?”

John Quintner

@ Stephen. Yours is certainly a novel twist to the ancient concepts of vitalism and spiritualism - The Vis Medicatrix Naturae of Hippocrates being administered via a “fine, thin, filamentous, stainless steel probe.” A miraculous tool? I must remain skeptical about such miracles.

@Gonzales, “heal on it’s own!” That’s what is missing in modern medicine, natural healing. We need to find a way to access this natural God given healing power.

What if we had a way to turn on natural healing and keep it going as needed? Imagine if someone could wave a magic wand over a painful area to ignite a healing force. The same force that heals a cut, bruises, broken bone or a dog bite.

We already have tools to perform some surgical procedures. A surgeon’s scalpel is used to punch an opening into an abscess so the infection could drain out and allow for natural healing. In medicine, the treatment of choice for an abscess is Incision and Drainage or “I & D.” NO medications needed in most cases.

We also treat infected surface wounds or ulcers is with scalpel debridement. A physician would take a scalpel to scrape off all the dead tissues to reach healthy bleeding viable flesh. This viable flesh has a good blood supply, that would nourish itself and generate fresh tissues. The physician would have to keep the wound open, keep it clean and maybe use some medicine. The addition of medicine would “help” the healing along to fight infection, not to be used without the scalpel.

But a scalpel is a clumsy tool that would cause a lot of collateral damage and the ¼ inch blade could easily cut through a blood vessel or nerve causing paralysis or a lot of bleeding.

Hmmm what could we use to perform such a vital surgery and not do harm? A fine, thin, filamentous stainless steel probe!!! That would be a miraculous tool!

John Quintner

@ Devin. In my opinion, chasing and treating phantoms (“peripheral pain generators”) happens to be one of the main driving factors that has got us into such a mess.

We do need to allow those doctors with diagnostic skill the time to identify the causes and perpetuating factors for chronic pain, so that they can be properly treated. This is going to take major changes to the system, requiring education for 3rd party payers, legal resources and medical resources. If the peripheral pain generators are identified and treated, we could save a lot of money in the long term. Devin

John Quintner

@ Kay. The question then becomes how do we all get off “conveyor belt” medicine? One way is to educate people in pain so that they come to understand that “one size does not fit all” and that drugs and invasive interventions for spinal pain are not on their own the answer.

A major cultural shift is needed before either of these messages has a chance of bearing fruit. Changing our way of thinking about chronic pain will also be a requirement for success. If what it takes is for people in pain to drive these changes, then someone has to start the ball rolling. To borrow a metaphor, the tide of change is now rolling in.

Dr’s seem to be busy with referrals just to get you out the door. Once referred to a specialist they no longer regard you as their problem & most specialist’s seem to be knife happy, suggesting ops that are not necessary (but are very expensive) & in most cases these ops do more harm than good. Money seems to be the driving factor, most people with “back pain” are really not treated as entities, their diagnosis is universal. Everyone is classed to have the same problems & the treatment is the same for all. The blame can then be shifted to any of the people involved, right down to a junior nurse who doesn’t do much more than bring you a drink. Change is not expected in the near future, back pain sufferer’s are the nuisance patients & will continue to be seen as such until “chronic pain” is really recognised as a reality, not just “something in your head”…..

Dawn Marie G

Please, please check into Arachnoiditis if you have balance issues, headaches, increased pain, bowel or bladder issues, the feeling of water dropping down your legs, or bugs crawling on or under your skin after an epidural, surgery, trauma, or infection. These are all signs of Adhesive Arachnoiditis. Chronic Spinal Meningitis brought on mainly by invasive procedures in your back, or anywhere in your spine.

Shana C

Referrals to specialists for back pain led me to a terrible year with Cushing’s Syndrome as the facet block injections led to the shutdown of my adrenal gland. It’s been a very hard year of recovery, and my back is worse than ever. I went to a “top” specialist after that and was told to build up to 30 minutes 2x a day on an exercise bike and lose some weight; object: surgery. I now cannot move without yelling out in pain. Yes, the bike went back. I refuse to take painkillers. I’m on my way to a scooter, I guess. I’ve tried so hard to get help. Tests, tests, meds, bad advice. I’m pretty downhearted.

Tonya Morrow

I, myself, have suffered a severe back injury. I had surgery, August if last year. Since this surgery, I have had severe nerve damage and tend to fall a lot. I regret the choice of going through with the surgery. I have had the injections in my spine, one of the worst choices I had ever made. I now have cysts growing off of my spinal cord. Which was never there, prior to the injections. They are also doing SI injections, saying its the space between the hip and the spine, that is causing me pain. I lost total use of my right leg for DAYS, after these injections. My injury is due to a horse back riding accident. I have obvious trauma to my spine. And they keep brushing it off, saying my pain is something else. I see a pain management specialist now. Have been for three months. They do their best to keep me comfortable. My quality of life, has changed to a extreme since surgery. I am unable to walk, without falling, I cannot sit for extended periods, I cannot stand for extended periods. This surgeon caused me more harm, then well being. The pain management doctor specifically stated, they messed up in my surgery. It is a choice I regret and now I will have to live with the results of my choice for the rest of my life. PLEASE RECONSIDER, before you allow them to operate. Get a second and third opinion. Once they do the surgery, the damage is done. I am a 39 year old young lady, with small children, that has lost her quality of life due to this choice. I am disappointed in the medical professionals, that I entrusted my body to. With the promise that they was going to make me better.

The alternate problem is that doctors see an obvious problem, but tell the patient that it can’t be the problem, it’s a normal variant. I am a victim of that game. It took me 7 years to find a doctor that could actually accurately diagnose and treat my back pain. I am now pain free after a relatively simple procedure and have my life back. Something that many people suffering with back pain will never have, and something I wasn’t sure I was going to have either.

Christina R

Doctors are getting nervous to do anything for patients intill they have everything on paper in fear of the DEA. Doctors want MRIs updated every two years not that anything going to be better. The DEA is making it ridiclious to afford medications and allowing pharmacies to raise prices and not except insurance. This is why the government has no place in the health care world. They are driving the cost up by controlling how much medication is made.Pain patients are being treated like criminals and over charged on top of being in pain. Im already going threw hell I dont need more pain in my pocket book because of it.

John Quintner

@ Susan. In my opinion Dr John Sarno and his followers have a huge problem to overcome - the theory upon which they practice (Tension Myositis Syndrome) lacks scientific credibility. Does that really matter? You bet it does!

Dawn Marie G

Thank you, John. Sadly. It’s very very true. There are so many of us out here with Adhesive Arachnoiditis and other conditions and injuries from being rushed into surgical procedures.


Dear Gayle,

Please search Dr. John Sarno and read his books. Many people have been totally freed from their pain using his techniques. I am one of them so I know this is the real deal.


For 6 yrs a commun. Hospital and staff refused to believe my pain after a simple whiplash injury I thought then went to Cleveland Clinic where they used conventional treatment physical therapy Exedra they finally did an MRI and found in their words that my cervical disc looked like a dog took a bite out of the discs they did aC 4-5 disc ectomy &fusion. I had no relief even worse pain for the last 30 for years I have other lumbar herniated discs, a thoracic syrnx. I refuse to have any more surgeries and I am in terrible pain always . I have fibromyalgia DDD& DJD and of course daily migraines from the cervical area and of course depression from all this pain my doctor is getting nervous about you giving me narcotic pain medicine however I use it very judiciously and I only go to her for my pain medicine I have tried everything in the book including physical therapy acupuncture rekki movement therapy water therapy and everything elseI am desperate for someone to convince my conservative

John Quintner

Our society expects doctors to provide answers quickly and this could be another important factor that is driving the escalating number of referrals for spinal imaging and specialist opinion. I agree with everything that Dawn Gonzalez has written in her email.