HealthDay News — Pain management strategies for back pain commonly used in the United States are often discordant with current guidelines, researchers have found.

Although the use of first-line therapy for back pain waned from 1999 to 2010, opioid prescriptions and use of nonguideline treatment rose, John N. Mafi, MD, from Harvard Medical School in Boston, and colleagues reported in JAMA Internal Medicine.

The researchers examined nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to characterize back pain treatments from 1999 through 2010. 

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They specifically examined the use of guideline discordant indicators, such as imaging, narcotics and referrals to physicians, and guideline concordant indicators, such as nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen use and referrals to physical therapy. A total of 23,918 outpatient visits for spine problems were assessed, representing about 440 million visits.

NSAID or acetaminophen use significantly decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010, the researchers found. During the same time period, narcotic use increased significantly from 19.3% to 29.1%, and physician referrals increased significantly from 6.8% to 14.0%. There was no change in physical therapy referrals, which remained steady at about 20%. 

The number of radiographs ordered also remained unchanged at about 17%, but computed tomograms and magnetic resonance imaging increased significantly from 7.2% to 11.3%.

Patients who were black, Hispanic, another race or female were significantly less likely than white and male patients to receive narcotic treatment. 

“Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care,” the researchers wrote. “Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.”

Standardizing low back pain management through checklist-based algorithms, creating more appropriate economic incentives for patients and physicians to follow such guidelines, and promoting a common framework for evaluating back pain were among solutions Donald Casey Jr., MD, of the New York University Langone Medical Center, suggested in an accompanying editorial.

Study limitations included incomplete data on symptom duration, missing data on treatment patterns and lack of data on comorbidities prior to 2005. 


  1. Mafi JN et al. JAMA Intern Med. 2013; doi:10.1001/jamainternmed.2013.8992.
  2. Casey DE. JAMA Internal Med 2013; doi: 10.1001/jamainternmed.2013.7672.