Shift to non-painkiller lower back pain approach

Medicare needs to keep up with changes to best practice for treating low back pain, one researcher warns

Recent changes to major international guidelines for the management of lower back pain mean that GPs are now unlikely to recommend pain medicines which were previously first line treatment, says Dr Adrian Traeger.

Dr Traeger, a researcher from the Musculoskeletal Health Group at the University of Sydney’s School of Public Health, says the new guidelines – the UK National Institute for Health and Care Excellence clinical guideline for low-back pain and sciatica, and a clinical practice guideline from the American College of Physicians – encourage a shift in thinking about the primary care management of low-back pain.

Dr Traeger is the lead author of a University of Sydney review to investigate the current approach and changes to diagnosis and management of lower back pain, published in the Canadian Medical Association Journal.

The changed guidelines are a response to an escalating prescription opioid crisis, and an “overwhelming” amount of research showing most pain medicines have little to no effect compared to placebo for people with lower back pain, he says.

Instead of pain medicines, GPs might suggest non-medicinal approaches including yoga, mindfulness and various types of physiotherapy and psychological therapies.

“Until now, the recommended approach to help LBP in general practice was to prescribe simple pain medicines such as paracetamol or anti-inflammatories,” says Dr Traeger.

“These new guidelines suggest avoiding pain medicines initially and discouraging other invasive treatments such as injections and surgery. The recent changes to these guidelines are important and represent a substantial change in thinking on how best to manage LBP – the previous recommendations were in place for decades.

“If you have an uncomplicated case of recent-onset LBP, your doctor may now simply provide advice on how to remain active and non-drug methods for pain relief such as heat and massage, and arrange to see you in two weeks to make sure the pain has settled.

“If your pain started a long time ago, they might suggest treatments such as yoga, exercise or mindfulness as treatment. Other effective options could include spinal manipulation, acupuncture, or multi-disciplinary rehabilitation programs.

“These revisions to major international guidelines should see changes to practice worldwide.”

However Dr Traeger is concerned that without support from Medicare the suggested reforms could place additional financial strain on those suffering from low back pain.

“There will be challenges to providing this type of care. It’s currently much easier and cheaper to provide a prescription for an opioid pain medicine (which is not a long-term solution to chronic pain and carries a risk of substantial harm) than a course of treatment with a physiotherapist or psychologist.

“Health systems in most industrialised countries, including Australian Medicare, are simply not set up to fund the care that is considered the most appropriate for low back pain right now.

“Without policy changes, it will be difficult for GPs to follow current best practice. However, if Medicare were to make simple changes to improve affordability of alternatives to pain medicines, not only would it make a GPs job easier, it could result a major impact on the lives of many living with low back pain, including those who rely on opioids.”

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  1. Debbie Rigby

    The imperative for pharmacists, especially in light of codeine upscheduling, is to have these conversations with patients/customers. Repeated messages about not relying on analgesics will help change consumer expectations for low back pain (“pill for every ill”) towards “motion is the lotion”

    • Jarrod McMaugh

      Very important for pharmacists to have these discussions with their local GPs as well. We need to get out of the cycle of referring a patient for chronic pain, and having them return with a prescription for stronger opioids.

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