Guideline recommendations are not only frequently being ignored, but the number of physicians not using them is growing.
Back pain is one of the main reasons why patients seek care from physicians. Fortunately for the overwhelming majority of patients who suffer from this problem, its presence does not indicate the presence of a serious medical condition.
Most clinical practice guidelines recommend that in the absence of “red flags” indicating the possible presence of a severe underlying disease, such as cancer or infection, treatment be limited to acetaminophen or NSAIDs and physical therapy; in contrast, referral to other physiciansfor additional treatment or work-up and the use of opioid analgesics be avoided. If imaging studies are thought to be indicated, they should be plain x-ray films and not CT scans or MRI scans.1,2
However, a new study shows that not only are the recommendations of these guidelines frequently ignored but there is a growing trend of physicians doing so.3
Using data from 2 national health surveys, the study examined the following for patients with back and neck pain3:
• The use of imaging techniques.
• Referrals to other physicians.
• Prescriptions for opioid analgesics, benzodiazepines, muscle relaxants, and “neuropathic agents.”
• Recommendations for the use of acetaminophen or NSAIDs.
• Referrals for physical therapy.
In particular, the study sought to determine whether changes occurred in clinical practice as the result of the introduction of practice guidelines.
Patients whose pain was accompanied by red flags or whose pain was thought to be related to trauma or some other identified comorbid disease were excluded.
The study found that from 1999 -2000 to 2009-2010, the recommendations for NSAIDs and acetaminophen declined from 36.9% to 24.5% of visits; prescriptions for opioids during this period increased from 19.3% to 29.1% of visits. The use of muscle relaxants and benzodiazepines increased from 19.6% to 23.7% and of neuropathic agents from 3.4% to 7.9% of visits.
During this same period, referrals to physical therapy remained unchanged at about 20%; referrals to other physicians more than doubled, going from 6.8% to 14%. Finally, the use of MRI or CT scans increased from 7.2% to 11.3%; the use of plain x-ray films remained flat at about 17%.
An accompanying editorial4 offered these possible explanations for why the back pain guidelines often are not being followed:
• Increasing numbers of imaging centers making CT and MRI scans more widely available.
• Reduced time primary physicians have with patients.
• Difficulty in having patients understand the guideline recommendations.
• Patients’ demands for quick resolution of their problems.
• A belief among many patients that specialists know the most about a problem.
• Malpractice concerns among physicians that they might be “missing something,” resulting in more testing.
• Price insensitivity regarding the cost of services.
All of these have validity, but I believe there are several additional important reasons.
There is a tendency for many patients to believe that the more tests they undergo and the more invasive the treatments, the more seriously their pain is being taken by physicians. Based on my own experience, patients often believe that unless tests are performed and invasive treatments are provided, their pain is being dismissed as not being “real” and that this indicates they are imagining the pain or are viewed as having a mental illness.
Also, it is far easier and takes much less time to give patients what they believe they need and want than it is to provide them with the correct course of care. Why spend time for which you won’t be reimbursed talking to patients about their pain and explaining to them why tests are not needed and why conservative treatments are indicated when it is much easier to order tests or refer to a specialist?
Referrals to physical therapy may be similarly interpreted as the pain being dismissed. In addition, this modality takes time and patients must put in effort for it to be effective. Why bother with this when advertisements for physicians offering instant relief of back pain are ubiquitous?
Although concerns about malpractice suits may be an issue, I have to admit that the reason for much of the unnecessary testing and treatments I have seen over the course of my career is that there is money to be made by providing them.
With regard to why opioids may be prescribed despite limited evidence that they are even as effective as, much less more effective than, acetaminophen and NSAIDs in most cases of back pain, several factors may be playing a role.
First, many patients feel they wasted a visit to the doctor if the treatment recommendation is for an over-the-counter medication that they could have bought without the time and cost of a visit.
Also, a widespread belief held by many patients and many health care professionals is that opioids are the optimal analgesics in every case. Patients who do not receive prescriptions for these agents may feel that they aren’t they receiving optimal treatment and that their doctors are not prescribing them because they fear being sanctioned by state or federal medical authorities or they believe patients are going to abuse them. Thus patients may believe that their doctors are denying them opioids and, therefore, optimal care because they are viewing them as potential if not actual drug abusers or because they wish to protect their medical licenses.
The increase in the number of opioid prescriptions, which has been noted by other studies, contradicts the widespread belief that doctors are too frightened now to prescribe these medications even to patients for whom they are indicated.
Finally, and I believe most important, is an issue that makes pain management different from most other areas of medicine.
Physicians may be not even be aware of the guidelines much less know what is in them. This is primarily the result of the inadequate education most physicians receive in medical school and postgraduate training. It also reflects the fact that the education most physicians do receive focuses primarily on managing pain secondary to other medical illnesses. During medical school, clinical education on back pain may be limited to what is learned on anesthesiology rotations where the focus often is on performing procedures.
I don’t have any easy solutions for these problems. Even the one issue physicians have the most control over-improved education of their present and future colleagues on pain management-has been difficult to resolve much less the others that require instituting major changes in how patients understand their pain and how health care is paid for in this country.
I wish I could be optimistic that things eventually will improve, but I don’t see anything that will have this result any time in the near future. I’ve been involved in the development of a number of clinical practice guidelines on pain management over the past 20 years, including several issued by the Federal government and other initiatives to improve physicians’ knowledge and education in this field. Unfortunately, none of these efforts appears to have had much of an impact on how we diagnosis and treat patients with pain.
1. Chou R, Huffman LH; American Pain Society; American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.
2. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009:34:1078-1093.
3. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013 Jul 29. doi: 10.1001/jamainternmed.2013.8992. [Epub ahead of print]
4. Casey DE. Why don’t physicians (and patients) consistently follow clinical practice guidelines? Comment on “Worsening Trends in the Management and Treatment of Back Pain.” JAMA Intern Med. 2013 Jul 29. doi: 10.1001/jamainternmed.2013.7672. [Epub ahead of print]