Samson, Kurt

ARTICLE IN BRIEF

New guidelines urge non-pharmaceutical approaches first for managing and treating low back pain.

Physicians should exhaust all other treatment options before prescribing opioid medications for non-radicular low back pain, the American College of Physicians (ACP) said in an updated clinical treatment guideline released February 13 in the Annals of Internal Medicine.

Instead, clinicians should advise patients with acute, subacute, or chronic low back pain to remain as active as possible, and use superficial heat, massage, acupuncture, spinal manipulation, or physical therapy, according to the review. For the first time, the guidelines also found supportive data for mindfulness-based stress reduction interventions.

If these do not resolve pain, the ACP said nonsteroidal anti-inflammatory drugs (NSAIDs) may serve as first-line therapy, while tramadol and fluoxetine can be used as second-line treatment.

There is little evidence that methyl-prednisolone injections or a five-day course of prednisolone provide any greater benefit than placebo for acute pain, nor does acetaminophen.

The vast majority of patients with acute or subacute back pain get better with time and improve rapidly in the first month. However, up to one third of them report persistent back pain of at least moderate intensity one year after an acute episode, ACP President Nitin S. Damle, MD, told Neurology Today.

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” he said. “Because of this, physicians should avoid ordering unnecessary tests or prescribing costly and potentially harmful drugs, especially narcotics, for these patients.”

Dr. Damle said clinicians should select therapies that have the least harm and lowest costs because there were no clear comparative advantages for most treatments when compared with one another.

The ACP issued its last back pain treatment guideline in 2007. At that time, the college recommended acetaminophen or NSAIDs. The earlier guideline also said that opioids or tramadol could be an option when used judiciously for acute or chronic low back pain that is severe and disabling and “that is not controlled, or is unlikely to be controlled, with acetaminophen and NSAIDs.”

An emerging body of evidence points to coordinated, multidisciplinary rehabilitation for chronic back pain focused on teaching patients how to better cope with their pain through cognitive-behavioral therapy, meditation, and other mindfulness techniques.

Research showed that ultrasound, transcutaneous electrical nerve stimulation, and Kinesio taping had no effect on pain or function when compared with control treatments, while electromyography biofeedback and cognitive-behavioral therapy both had a moderate effect on pain, but none on function. Neither tricyclic antidepressants (TCAs) nor selective serotonin reuptake inhibitors (SSRIs) provided pain or functional relief compared with placebo.

The ACP noted that the guidelines may not apply to all patients or clinical situations, and are not intended to override clinicians’ judgment.

“Physicians should consider opioids as a last option, and only when nonpharmacological therapies have failed,” said Dr. Damie, adding that it is important in such cases for physicians to carefully screen patients for past problems with alcohol or other drugs.

“Screening by physicians has been a problem, so we need to do a better job of educating not only them but patients too about the risks versus benefits of opioids. No doctor should be writing prescription for 60 or 90 pills at a time,” he told Neurology Today.

THE OPIOID DILEMMA

The shift away from opioids reflects mounting concerns over the current epidemic of narcotics dependency and addiction, and associated overdoses and deaths.

Many professional medical societies, including the American Academy of Neurology, have issued position statements or guidelines advising physicians to only use opioid medications when absolutely needed. (See sidebar, “The AAN Position on Opioids.”)

The American College of Occupational and Environmental Medicine practice guidelines recommend that opioid medications only be used on a limited basis and for not more than two weeks. In a 2015 study of more than two million opioid prescriptions written for Medicaid beneficiaries, 51.7 percent were for back pain and were written for more than 30 days, considerably longer than recommended by the ACP guidelines.

Richard A. Deyo, MD, the Kaiser Permanente Professor of Evidence-Based Family Medicine at Oregon Health and Science University, in Portland, helped provide research in two background evidence reviews used in drafting the guideline, which was also partially based on data from a 2106 report issued by the Agency for Healthcare Research and Quality at the Department of Health and Human Services.

He noted there is a growing consensus among multiple professional societies to reduce the use of opioids because they are of limited benefit when weighed against the potential risks if used for long periods. However, he also said this leaves some patients in a bind.

“Patients want relief by any means. They want a pill, but patients need to understand that drugs can only provide a small benefit — there is no silver bullet,” he told Neurology Today. “This leaves it to physicians to offer alternatives, but many are not very familiar with these options and there are few networks of providers of alternative approaches.”

Gary S. Gronseth, MD, FAAN, professor and vice chair of neurology at the University of Kansas Medical Center in Kansas City, also voiced concern. “The pendulum is definitely swinging, but I am a little concerned that it might swing too far; we tend to swing to extremes when it comes to such issues,” he told Neurology Today.

“With careful screening, using NSAIDs in acute situations might be appropriate even though pain scores are only slightly better. The evidence for chronic pain though is that they just do not help.”

Regardless, he said they should never be prescribed for over one month.

Steven Atlas, MD, associate professor of medicine at Harvard Medical School and director of practice-based research and quality improvement at Massachusetts General Hospital, told Neurology Today that the shift away from drugs toward physical therapies represents a very big change.

With acetaminophen no longer recommended, clinicians are left with NSAIDs as the first-line choice, but many patients cannot tolerate them or they are contraindicated. If these are not an option for these patients, muscle relaxers are a second-line treatment, but these too are not well tolerated by many individuals because of sedation which can limit their ability to work or operate vehicles, he noted.

Although the guidelines recommend different nonpharmaceutical options, these are not always available for many patients, and where they are, many insurers will not cover them, he noted. “There is also the time factor,” he said. “For patients it is much easier to take a pill than to see a chiropractor three times a week or a physical therapist. These recommendations are reasonable, but we need more ways for physicians to implement them.”

One way would be to establish risk-stratification procedures, something that was not addressed by the ACP guideline, he said. “Doctors are not very good at choosing from the available options because there are a slew of choices and all of them are about equal in terms of research to date.”