Introduction

Primary care providers soon recognize that management of low back pain is common and complex. Low back pain is one of the most common reasons for physician visits in the United States and about one-fourth of all US adults report low back pain in the last three months. Furthermore, acute low back pain complaints oftentimes become chronic ones. Fortunately, our understanding of the physiology of pain and its treatment has increased dramatically in recent years. For example:

• We now know that the use of opioids for chronic non-cancer back pain is counterproductive.
• We know that advanced imaging of patients without dangerous “red flag” symptoms and signs is counterproductive.
• We know that keeping a patient with low back pain active is essential.

Many tools have recently been developed to assist providers as they approach their patients with back pain. The goal of this clinical update is to help introduce members of health care teams to these resources.

SPACE: The final frontier

Opioids show no benefit over non-opioids for function or pain

1. Randomized controlled trial comparing opioid vs. non-opioid medication therapy in chronic low back pain and hip/knee osteoarthritis
2. Primary outcome was pain-related function, main secondary outcome was pain intensity
3. At 12 months there was no difference between the two groups for either outcome
4. The opioid group had significantly more side effects
5. For Chronic Pain, opioids offered no benefit over non-opioid medications for function or pain intensity and had significantly more side effects

The significance of this study is that for chronic pain, opioids didn’t provide any benefit over non-opioid in terms of function or pain intensity and carry significant risks. All decisions in medicine involve balancing risk and benefit. The SPACE trial showed that when it comes to opioids and chronic low back and degenerative hip and knee pain, there is no benefit, only risk.

Key points to remember

1. Opioids are not a first line treatment
2. Routine imaging is rarely helpful for most back pain
3. Keep your patients active!
4. Improved function is the goal

References and Resources

1. Opioids are not a first line treatment
   • Diagnosis and Treatment of low back pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society http://annals.org/aim/fullarticle/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from Ann Intern Med. 2007;147(7):478-491 (Step by step recommendations for work-up and treatment of low back pain)
   • Noninvasive Treatments for Acute, Subacute, and Chronic Back Pain: A Clinical Practice Guideline from the American College of Physicians http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice Ann Intern Med. 2017;166(7):514-530 (Implementing a selective approach to low back imaging would provide better care to patients, improve outcomes, and reduce costs)
     
   • Editorial: Management of Low Back Pain: Getting from Evidence-Based Recommendations to High-Value Care: http://annals.org/aim/fullarticle/2604103/management-low-back-pain-getting-from-evidence-based-recommendations-high Ann Intern Med. 2017;166(7):533-534. (Editorial comment on the 2 articles above)
   • SPACE TRIAL: Effect of Opioid vs. Non-opioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip and Knee Osteoarthritis Pain, The SPACE Randomized Clinical Trial JAMA 2018; 319: 872-882 https://jamanetwork.com/journals/jama/article-abstract/2673971 (Opioids are no better for chronic low back pain than non-opioid approaches)
     
   • Oregon HERC (Health Evidence Review Commission) Guideline Note 60: “Opioids for conditions of the back and spine” http://www.oregon.gov/oha/HPA/CSI-HERC/SearchablePLdocuments/Prioritized-List-GN-060.docx (Guidelines regarding the use of opioids for back pain with Oregon Health Plan patients).
2. Routine imaging is rarely helpful for most back pain
   • Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians Ann Inter Med 2011; 154: 181-189 http://annals.org/aim/fullarticle/746774/diagnostic-imaging-low-back-pain-advice-high-value-health-care (Addresses implementing a selective approach to low back imaging)
   • Oregon HERC Guideline Note D4: “Advanced Imaging for Low Back Pain”. http://www.oregon.gov/oha/HPA/CSI-HERC/SearchablePLdocuments/Prioritized-List-GN-D004.docx (Guidelines regarding recommendations for Initial Diagnostic Work-up and Potentially Serious Conditions-so called “Red Flags”)
3. Keep your patients active!
   • Providence Persistent Pain Program. https://oregon.providence.org/our-services/p/providence-persistent-pain/persistent-pain-toolkit/ (A Toolkit designed to help both health care professionals and patients and their families with resources for understanding and quieting pain)
   • Oregon HERC Guideline Note 56: “Non-Interventional treatments for the back and spine”. http://www.oregon.gov/oha/HPA/CSI-HERC/SearchablePLdocuments/Prioritized-List-GN-056.docx (Tools to stratify patients into “Risk levels” for poor functional prognosis based on psychosocial indicators. Use of PT, OT, DC, Acupuncture, Cognitive Behavioral Therapy, yoga, massage, supervised exercise therapy).
4. Improved function is the goal