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February 22, 2017

Opioids should be 'last resort' in lower back pain treatment, ACP says

Daily Briefing

    Physicians should recommend alternative therapies to treat lower back pain before turning to medication, according to new guidelines from the American College of Physicians

    The guidelines mark a shift from previous ACP recommendations, which touted medication as a first-line therapy for back pain, according to the New York Times. The guidelines come amid growing opioid misuse in the United States, which has led many physicians to reevaluate their opioid prescribing habits, the Times reports.

    Updated guidelines

    ACP's updated guidelines are based on a review of more than 150 studies that examined lower back pain treatments.

    ACP in the guidelines strongly discouraged the use of prescription opioid painkillers to treat back pain, even in the case of chronic back pain—pain that lasts at least 12 weeks. ACP also recommended that patients try alternative therapies—like exercise, acupuncture, massage therapy, meditation, or yoga—before taking anti-inflammatories or muscle relaxants. The group said such alternative therapies can work as well as or better than drugs but do not have side effects.

    If alternative therapies do not help, ACP in the guidelines suggested that patients then consider anti-inflammatory drugs like ibuprofen or naproxen. If those treatments also do not help, ACP then suggested patients receive medication intended to treat nerve pain or prescription opioids, though it stressed that such treatments should be used as a last resort. ACP President Nitin Damle said, "Only in rare circumstances should opioids be given and then only at the lowest dose possible and for the shortest period of time."


    Back experts say the medical industry and insurance companies can pose barriers to the alternative treatments ACP is now recommending. For instance, Rick Deyo, a spine researcher and professor at the Oregon Health and Science University and a co-author of the new guidelines, said health insurance companies often do not cover alternative treatments for back pain, which he said can be costly.

    Steven Atlas—an associate professor at Harvard Medical School and a primary care physician, who wrote an editorial accompanying the new guidelines—said it can be difficult for physicians to prescribe alternative treatments because there is not a simple way to refer patients for such care. He explained, "It is much easier" for patients "to get a shot than to get a mind-body or cognitive behavioral therapy."

    Your chances of long-term opioid use could hinge on who you see in the ED, study finds

    However, Atlas in his editorial concluded that the new guidelines represent a needed a change. "We are moving away from simple fixes like a pill to a more complex view that involves a lot of lifestyle changes," he wrote (Neighmond, "Shots," NPR, 2/20; Belluz, Vox, 2/14; Kolata, New York Times, 2/13).

    How hospitals can reduce opioid prescriptions—and cut millions in costs

    As legislators grapple with the opioid epidemic, hospitals are also rethinking their prescription practices. We polled over 200 acute care pharmacy leaders to understand how they are making formulary decisions, and what's the impact on reducing opioid prescriptions and related complications.

    Read the research brief to learn more about our analysis of more than 400 organizations to investigate the impact of multi-modal pain regimens, and how your organization may be able to save over $1 million by reducing opioid use during surgery.

    Download the brief

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