Despite Practice Guidelines for Back Pain, Prescriptions for Narcotics Rise While Those for NSAIDs Fall

Medical practice guidelines are voluntary. Sometimes, this leads to clearly dysfunctional outcomes.

This interview with the author of a new article in JAMA Internal Medicine underscores the conclusions reached in the 2010 study by Bishop and colleagues at the National Spine Center in Canada, published in Spine Journal, which found management of low by pain by primary care medical physicians (PCPs) to be highly “guideline-discordant” with regard to medications. (Bishop’s article also found that for low back pain, guideline-based care that includes spinal manipulation by chiropractors is significantly more effective than usual care by PCPs).

The new JAMA Internal Medicine article’s lead author is John N. Mafi, MD, chief medical resident and fellow in general medicine at Beth Israel Deaconess Medical Center in Boston:

We saw a decline in use of NSAIDs that was discordant with the guidelines. The guidelines recommend it as a first-line treatment. What we are seeing instead is a rise in narcotic prescriptions. The guidelines are cautious about narcotics and say to be cautious and recommend them only as second- or third-line therapies.

There is also discordance between the guidelines and physician use of imaging. In patients with new-onset back pain, ordering an MRI or CT scan is not indicated in most cases. Finally, we saw a rise in referrals to specialists, though primary care clinicians are usually able to manage patients with routine cases of back pain themselves with minimal treatment.

news@JAMA: What do you think is driving physicians to pursue these more aggressive treatment approaches?

Dr Mafi: We are a society that demands instant solutions, but back pain doesn’t play by these rules. It takes time, and unfortunately, the fancier treatments haven’t been shown to decrease patient’s pain or increase their quality of life. That’s why we have to rely on the less-is-more approach.

news@JAMA: What do you think is driving the shift from NSAIDs to narcotics?

Dr Mafi: It is in part patient expectations and a sentiment that emerged in the 1990s physicians weren’t paying enough attention to patient pain. The Joint Commission made pain the fifth vital sign. In response, there has been an overcorrection and now narcotics are reached for first. Since that time, there has been a 300% increase in narcotic prescriptions and rise in narcotic overdoses and deaths. In 2008 almost 15000 people died—more than for cocaine and heroin overdoses combined. There are huge public health implications.

References:

1. Mafi JN, McCarthy EP, Davis RB, Landon BE. WOrsening trends in the management and treatment of back pain. JAMA Internal Medicine. 2013 (epub before print).

2. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal. 2010;10(12):1055-1064.

Southern (and Some Northern) States Choose to Leave Millions of Their Citizens Uninsured

This intransigence will bring with it a great deal of unnecessary suffering, death and, not so incidentally, economic hardship in its wake. Will they change their minds eventually? Only if their own citizens force them to.

From the Institute of Southern Studies:

But in Rome, 27 percent of adults under 65 are uninsured, a rate that holds true across the state. Last year, the city’s two hospitals report spending more than $80 million delivering uncompensated care, often in the emergency room, where costs run high. Taxpayers and those with health insurance will end up paying for that care through government subsidies and higher premiums, industry experts say.

Rome’s dilemma is exactly the situation that the Patient Protection and Affordable Care Act, also known as “Obamacare,” was designed to fix — but that fix isn’t coming to Georgia.

The Patient Protection and Affordable Care Act provides for expansion of insurance coverage for low-income and middle-class adults, with the goal of reducing the $41 billion spent covering uninsured care each year.

A key provision, set to kick in on Jan. 1, 2014, offers states federal funding to expand Medicaid coverage to all adults making up to 133 percent of the poverty line, or $25,975 for a family of three. In Georgia, over half of that group is uninsured.

But in the Deep South and Florida, Republican governors and state legislatures have turned down the funding, citing cost concerns and philosophical opposition to the safety net insurance program, which was signed into law on July 30, 1965. In Louisiana, Mississippi, Alabama, Georgia, South Carolina and Florida, the move will exclude 2.7 million low-income residents from Medicaid eligibility, according to the Urban Institute.

“In Georgia, these people are the working poor,” said Dr. Leonard Reeves, a family physician in Rome who volunteers at the city’s privately-funded free clinic. “I had an uninsured patient in his late 30s who worked every day of his life, and one day he finally came in when he felt he couldn’t go on any more.”

Dr. Reeves diagnosed the man, who was married and worked part-time as a forklift operator, with diabetes, but it was too late for insulin. After years without basic treatment, his kidneys had failed, and he needed weekly dialysis treatments to stay alive.

“He’s now on disability,” said Dr. Reeves. “If he’d had that insurance, he’d still be paying into the tax rolls instead of taking from them. There’s an old saying — ‘An ounce of prevention is worth a pound of cure.’ And that’s exactly what we’re talking about here.”