Many older patients with new episodes of low back pain receive care inconsistent with current guidelines, including high use of opioids and advanced imaging tests, according to a study published in Medical Care.
Results of the study showed that opioids were prescribed to nearly one-third of older adults with new and persistent low back pain — in most cases without trying guideline-recommended pain medications or physical therapy.
“This study raises concerns about excessive use of potentially harmful treatments for the common problem of lower back pain in older adults, with underuse of evidence-based, guideline-recommended treatments,” said Dan Pham Ly, MD, Harvard University, Boston, Massachusetts.
The study used Medicare claims data on more than 162,000 older adults with new low back pain from 2011 through 2014. About 70% of patients were women with an average age of 77 years. None had received previous opioid treatment. The analysis included information on multiple visits for back pain over the course of a year, providing data on the timing and sequence of care.
Just over half (54%) of the patients in the study made only 1 healthcare visit for low back pain, which is consistent with evidence that many new episodes of low back pain are self-limiting. As stated in the current American College of Physicians guidelines, most patients with low back pain “improve over time regardless of treatment.”
Advanced imaging studies with CT or MRI were used in about 15% of patients overall, and 29% of those were patients with ≥2 visits for their pain. In about half of cases, CT or MRI scans were performed within 6 weeks, which is contrary to an American Academy of Family Physicians statement that most patients don’t need advanced imaging studies for initial evaluation of low back pain.
Opioids were prescribed to about one-fourth of patients overall, including one-third of those with ≥2 visits for low back pain. In contrast, guidelines suggest that other pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), should be tried before opioids.
Physical therapy was prescribed to only 11% of patients overall and 17% of those with ≥2 visits. Evidence suggests that early use of physical therapy can avoid the use of opioids in patients with low back pain.
Most patients treated with opioids had not received a prescription NSAID or physical therapy. Chronic opioid use developed in about 1% of patients overall, and nearly 2% of those with ≥2 visits.
“Many patients who develop new low back pain receive guideline non-concordant care such as early advanced imaging and opioids before other modalities like physical therapy and prescription NSAIDs,” the authors concluded.
Dr. Ly calls for future studies examining barriers to guideline-recommended treatments for low back pain in older adults, particularly physical therapy and NSAIDS. He also pointed out that pain management can be challenging in older adults, highlighting the need for studies to compare the safety and effectiveness of medication options.