New acute low back pain guideline steers clinicians away from routine imaging and opioids

Imaging and opioids should not be first-line treatment for most adults with acute low back pain, according to a new clinical practice guideline published in Pain Medicine.

The guideline was developed by a partnership between the Pacific Northwest Evidence-Based Practice Center at Oregon Health & Science University and Aggregate Analytics Inc. and the American Academy of Pain Medicine.

“Clinicians practicing in primary care, urgent care, emergency department, or other outpatient settings are likely to encounter patients with acute lower back pain,” the panel, including corresponding author Andrea C. Skelly, Ph.D., M.P.H., write in the study. “While most patients improve over days to weeks, symptoms of acute lower back pain can contribute to short-term diminished quality of life and functional deficits.”

Why routine imaging is not recommended for acute low back pain

Low back pain is the leading cause of disability in the United States and worldwide, the authors noted, yet more than 85% of patients with an acute episode have no specific underlying disease or spinal abnormality. Serious causes such as cancer, infection or fracture account for only 5% to 10% of presentations in primary care.

Three trials found routine early imaging did not improve pain, function or quality of life compared with usual care. The panel issued a strong recommendation against routine imaging in patients without signs, symptoms or risk factors for serious spine pathology, while noting that imaging remains appropriate for red-flag presentations or for symptoms that persist beyond 4 to 6 weeks or progress. Routine imaging adds cost and may lead to unnecessary injections or surgery, the authors wrote.

Self-care first, then non-steroidal anti-inflammatory medications

The guideline’s starting point is self-management. Clinicians should explain how an episode typically unfolds, assure patients that staying active will not cause harm and encourage them to continue lighter daily activities. Heat and brief use of nonprescription NSAIDs are also options for patients who can take them safely. The panel did not endorse acetaminophen for routine use because a large placebo-controlled study found it ineffective but considered it a fallback for patients who cannot use NSAIDs.

Patients whose pain has not eased or has gotten worse after 1 to 2 weeks should be offered at least one additional therapy, such as muscle relaxants, physical therapy and acupuncture. Carisoprodol and benzodiazepines were discouraged, and the panel found nothing to support antidepressants or gabapentinoids in this setting.

Opioids not recommended as initial treatment for acute low back pain

Opioids performed no better than placebo over the short term in five trials and produced more side effects. In the panel’s view, most patients with acute low back pain do not need them, though a brief course of a short-acting opioid may be appropriate for people with severe, disabling pain or those unable to use other drugs. The authors also cited a review showing that 6% of low-risk patients given opioids for acute musculoskeletal injuries moved on to long-term opioid use, a share that climbed to 27% among higher-risk patients.

What the guideline means for payers and coverage

U.S. spending on low back and neck pain reached about $134.5 billion in 2016, more than for any of the 154 conditions examined in a JAMA analysis. The guideline recognizes that insurance coverage, out-of-pocket costs and appointment wait times can limit access to nonpharmacologic therapies. In line with the SUPPORT Act, the authors stressed that the recommendations should not serve as grounds for restricting or denying coverage of legitimately prescribed medications.