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A Surplus of Treatment Options, Few of Them Good

by Leslie Berger

Published: 30/08/2007

In brief:
  • Back pain is one of the most widespread medical complaints, but a specific cause is rarely identified.
  • Concerns about substance abuse and side effects limit the usefulness of many painkillers.
  • Antidepressants, anticonvulsants and other drugs are increasingly prescribed to ease patients' back pain.
  • Despite the popularity of spinal injections, there is no strong evidence that they provide benefit beyond short-term relief of back pain.
  • Surgery for back pain has met with mixed results. Many experts now favor more conservative treatments like exercise and physical therapy.

Back pain is one of the most common medical complaints, so it’s no surprise that treatments for it have multiplied over the years. That ought to be good news; instead, many patients find that sudden back pain opens the door to a world of medical controversy. Virtually every pharmaceutical or surgical remedy has been challenged in recent years, and for all the money sufferers spend on doctor visits, hospital stays, procedures and drugs, studies clearly show that most people with back pain heal the old-fashioned way: on their own, slowly, without significant intervention.

“Low back pain represents so many different diseases that there really hasn’t been a breakthrough treatment,” said Dr. Russell K. Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York. “It’s good for the public to know how little we know.”

The mystery begins with the first visit to a doctor’s office. The exact cause of back pain is never found in 85 percent of patients, according to Dr. Dennis C. Turk, professor of anesthesiology and pain research at the University of Washington and a past president of the American Pain Society. Even sophisticated magnetic resonance imaging seldom sheds light (indeed), in many studies the scans have picked up spinal abnormalities in many people who have never reported back pain.

Regardless of cause, an ailing back hurts. So what’s a sufferer to do? Pop a pill? Submit to the scalpel? Wait and see?

These days, most heavy-duty pain relievers come with a hefty set of warnings. Narcotics like OxyContin, used regularly by more than eight million Americans, can work wonders, but doctors remain deeply divided over when to prescribe them. On the one hand, these painkillers can be highly addictive; on the other, serious pain is too often untreated in this society, with its Puritan roots, and many patients with back problems suffer for weeks.

Alternatives to the narcotics have proved problematic, too. Rofecoxib (Vioxx) and valdecoxib (Bextra), both nonsteroidal anti-inflammatory drugs, were pulled off the market after it was discovered they raised the risk of heart attacks. Even over-the-counter mainstays like ibuprofen and aspirin can cause gastrointestinal bleeding or organ damage at high doses.

Spinal injections of steroids and anesthetics increased by nearly a third during the 1990s, but several scientific reviews found scant evidence that any provided more than short-term relief. With options diminishing, many physicians have begun prescribing off-label painkillers such as pregabalin (Lyrica) and antidepressants like duloxetine (Cymbalta) to their patients with chronic back pain.

While the quest for a safe and effective pain pill continues, Americans undergo more than 300,000 spinal fusion surgeries a year, at an average cost of $59,000 each, according to the National Center for Health Statistics. Almost as many undergo laminectomies or discectomies, aimed at removing damaged vertebrae and disks. Back surgery can be life-altering, eliminating pain and disability. It can also have serious consequences.

One study found that 11.6 percent of patients in the 78 spinal surgeries developed infections and other serious complications. Perhaps more disturbing, more than half of those surgeries were performed to correct complications from a previous surgery.

Newer surgical procedures have met with mixed results. Implants of medication pumps and stimulators into the spine, for example — a promising area of growing research — have been greeted as godsends by some patients. For others, the devices have led only to infections and bleeding, or have required repair. The jury is also still out on kyphoplasty, a newer outpatient procedure for patients whose vertebrae fracture because of osteoporosis. The doctor inserts a needle into the spine and inflates a balloon, then injects a cement literally gluing the bones together. The procedure works only for a subset of patients.

With all the uncertainties surrounding medications and surgery, it’s little wonder that many physicians have fallen back on noninvasive, traditional approaches to easing the pain, like exercise or counseling. This year the Accreditation Council for Graduate Medical Education, which oversees doctors’ training programs, began requiring that residents who want to become pain specialists study not only anesthesiology but also psychology, neurology and rehabilitative medicine.

Indeed, many back pain specialists are now evaluating their patients daily exercise habits and emotional stresses. The new standards are a small step, but one reflective of the growing realization that pain, in all its forms, must be approached more holistically. But realization now dawning on physicians has not yet been felt by insurers. Health plans pay for surgery, drugs and spinal injections, but rarely for long-term physical therapy, psychotherapy - or joining a gym.

Noted Dr. Portenoy, “Training people to do the right thing doesn’t necessarily work in the real world if you’re only reimbursed for interventions.”

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