Back Pain Eludes Perfect Solutions

 By LESLIE BERGER

Published: May 13, 2008

BACK pain is one of the most common physical complaints, so it’s no surprise that treatments for it have multiplied over the years. That ought to be good; instead, many patients find that sudden back pain opens the door to a world of medical confusion.

“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 doctor’s visit. The exact cause of back pain is never found in 85 percent of patients, said 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 magnetic resonance imaging seldom sheds light; in many studies the scans have picked up spinal abnormalities in many people who have never reported back pain.

So what’s a sufferer to do?

Narcotic pain relievers like OxyContin, used regularly by more than eight million Americans, can help, but doctors remain deeply divided over when to prescribe them. The painkillers can also be highly addictive and lead to mood changes.

“I think we are an overmedicated society, and I would not recommend narcotics for everyday back pain except for in most rare of circumstances,” said Dr. James N. Weinstein, editor of the medical journal Spine and chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Alternatives to narcotics have proved problematic, too. Two anti-inflammatory drugs, Vioxx and Bextra, were taken off the market after being linked to heart attacks. And 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 these provided more than short-term relief. Some doctors have begun prescribing drugs like Lyrica, an anticonvulsant, and Cymbalta, an antidepressant, to treat chronic back pain. But the data on antidepressants is also mixed. A study last fall in The Annals of Internal Medicine found that antidepressants help back sufferers, but this year a review by the respected Cochrane Collaboration, a nonprofit organization for health information, concluded there was no evidence that antidepressants offered relief.

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 diskectomies to remove damaged vertebrae and disks.

For some, back surgery can be life-changing, eliminating pain and disability. But for others, it can have serious consequences. One study found that 11.6 percent of patients in the 78 spinal surgeries that were analyzed developed infections and other complications.

Newer procedures, like implants of medication pumps and stimulators, have received mixed reviews, too. The jury is still out on kyphoplasty, an outpatient procedure for patients with vertebrae fracture from osteoporosis. The doctor inserts a needle into the spine and inflates a balloon, then injects a cement, gluing the bones together. The procedure works only for some patients.

With such uncertainties, it is little wonder that many doctors have fallen back on more traditional approaches to easing the pain, like exercise or counseling. This year, the Accreditation Council for Graduate Medical Education began requiring that medical residents who want to become pain specialists study not only anesthesiology but also psychology, neurology and rehabilitative medicine.

The reality is that most people with back pain heal on their own, slowly, without major intervention. “The best treatment for straightforward back pain without a specific diagnosis is reactivating yourself to what you normally do as fast as possible,” Dr. Weinstein, the Spine editor, said.

Americans Spend More to Treat Spine Woes

 TARA PARKER-POPE

Published: February 13, 2008

Americans are spending more money than ever to treat spine problems, but their backs are not getting any better.

Those are the findings of a report in The Journal of the American Medical Association, which found that spending on spine treatments in the United States totaled nearly $86 billion in 2005, a rise of 65 percent from 1997, after adjusting for inflation. Even so, the proportion of people with impaired function because of spine problems increased during the period, even after controlling for an aging population.

“You’d think if you’re putting a lot of money into a problem, you’d see some improvements in health status,” said Brook I. Martin, research scientist at the Department of Orthopedics and Sports Medicine at the University of Washington and lead author on the study, published Wednesday. “We’re putting a lot of money into this problem, and it’s a big investment in health care expenditures, but we’re not seeing health status commensurate with those investments.”

The report is the latest to suggest that the nation is losing its battle against back pain, and that many popular treatments may be ineffective or overused. Researchers have produced conflicting data about the effectiveness of spinal surgery for back pain, although one major clinical trial, known by the acronym Sport, showed that spinal surgery patients did better than patients receiving more conservative care, which included medications or physical therapy. However, some doctors have questioned whether surgeries, injections and narcotic pain medications are being used appropriately.

“I think the truth is we have perhaps oversold what we have to offer,” said Dr. Richard A. Deyo, a physician at the Oregon Health and Science University in Portland and a co-author of the report. “All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients. But I think in each of those situations we’ve begun using those tests or treatments more widely than science would really support.”

To study spending trends on spinal care, the researchers examined annual household survey data from the Agency for Healthcare Research and Quality, which was collected from about 23,000 people a year from 1997 to 2005. It includes pharmacy and medical record data, and was used to estimate national spending and treatment practices.

The researchers found that people with spine problems spent about $6,096 each on medical care in 2005, compared with $3,516 in medical spending by those without spine problems.

The biggest surge in spending has been for drugs. In 2005, Americans spent an estimated $20 billion on drug treatments for back and neck problems, an increase of 171 percent from 1997. The biggest jump was for narcotic pain relievers, like OxyContin and other drugs, which increased more than 400 percent.

Outpatient treatment for back and neck problems increased 74 percent to about $31 billion during the period, while spending related to emergency room visits grew by 46 percent to $2.6 billion. Spending for surgical procedures and other inpatient costs grew by 25 percent to about $24 billion.

Despite the growth in treatment of back problems, the data show that the percentage of people with serious spine problems has not declined; it appears to have increased.

Based on the sample, the researchers estimated that in 1997, about 21 percent of the adult population suffered from back or neck problems that limited their function. By 2005, that number grew to about 26 percent, after adjusting the numbers for an aging population.

It is not clear why more people appear to be suffering from back and neck pain. It could be because of rising obesity rates, researchers suggested. Or excessive treatment of back problems could lead to more problems.

“I do worry there is a combination of side effects and unnecessary treatments and labeling people as being fragile when they’re really not,” Dr. Deyo said. “The combination of those kinds of things may actually be in some cases doing more harm than good.”