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Integrative Care for Low Back Pain: Implementing Evidence-Based, Non-Opioid Treatments

July 2016

Contributed by Florin Orza, M.D., and Roni Evans, D.C., Ph.D.

There has been increasing recognition that pain, especially when chronic, is a complex disease that jeopardizes public health and productivity.1 The prevalence of pain in the United States is significant, with persistent pain affecting more Americans than diabetes, heart disease, and cancer combined. Results from the 2012 National Health Interview Survey found over half of the U.S. population experienced pain in the previous three months, and nearly 1 in 10 individuals had pain daily.2 Almost 20% had pain that is classified as more severe, which is associated with greater healthcare utilization and disability. Low back pain (LBP) is the most reported form of pain, with over 80% of adults experiencing it at some point in their lives. While most patients with acute LBP recover, a small percentage of cases become chronic. It is these persistent cases, however, that account for the lion’s share of the associated burdens and costs.3

LBP and pain management overall are gaining increased attention as concerns mount regarding the rise of opioid use in the United States. With an estimated 1 in 5 noncancer pain sufferers receiving an opioid prescription despite extensive evidence of the medication’s potential harms, there has been a pivotal shift in the management of the most commonly presenting pain conditions.4 Most notable is the Centers for Disease Control and Prevention’s recent recommendation of nonopioid pharmacologic and nonpharmacologic approaches to pain management.4

Complementary healthcare, used by one-third of U.S. adults, is a common means of treating pain.2 Developed outside of mainstream medicine, these approaches are also sometimes called “alternative”; however, most individuals use such treatments in conjunction with conventional medicine. The most common are natural products, which include dietary supplements other than vitamins and minerals, and are used by nearly 20% of U.S. adults. Other common complementary approaches are deep breathing (11% of population); movement exercises like yoga, Tai Chi, or Qigong (10%); chiropractic or osteopathic manipulation (8%); and meditation (8%). Pain is the most common health condition for which individuals use complementary therapies. Once thought to be inconsistent with conventional medical care, these approaches are gaining acceptance in medical settings, and there is a growing interest in how to best blend conventional and complementary approaches. This is especially true for the burdensome and costly LBP conditions, for which the body of research investigating the mechanisms, benefits, and risks of complementary therapies continues to grow.

roni-evans
— Roni Evans, D.C., Ph.D

Pharmacologic and Nonpharmacologic Care and Injections for Low Back Pain

According to the recently released Agency for Healthcare Research and Quality (AHRQ) review, research supports several conventional and complementary treatments for relieving symptoms of LBP.5 These include NSAIDs, skeletal-muscle relaxants, and opioids (buprenorphine patch), which were associated with small effects for acute LBP, and NSAIDs, tramadol duloxetine, and benzodiazepines for chronic LBP. The evidence for the effectiveness of pharmacologic approaches for radiculopathy is still very limited. While pharmacologic therapies have been shown to be associated with an increased risk of adverse events versus that found with placebo, serious harms were rare in clinical trials.

The AHRQ review also found several nonpharmacological therapies to be effective for improving LBP pain or function, with no evidence of serious harms.5 These include more conventional approaches like exercise, psychological therapies, multidisciplinary rehabilitation, and low-level laser therapy, as well as complementary self-management approaches, such as yoga and Tai Chi. Provider-based complementary treatments such as acupuncture, spinal manipulation, and massage also demonstrated benefit. Little difference in effectiveness was found among different exercise, massage, spinal manipulation, or acupuncture techniques or among different types of psychological therapies. Of interest is new and emerging research on mindfulness meditation that demonstrates its effectiveness in addressing LBP.6 While there is still little high-quality research evidence on nonpharmacologic approaches for radiculopathy, one randomized clinical trial conducted by University of Minnesota faculty found spinal manipulation beneficial when added to home exercise and advice.7 Overall, research on the range of nonpharmacologic treatments, including complementary approaches, is promising. This bodes well for LBP patients, who can now benefit from a greater range of options through integrative care.

The 2015 AHRQ Technology Assessment provides the best available research (through 2014) regarding the effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for LBP conditions.8 Epidural corticosteroid injections for radiculopathy have been shown to provide immediate, albeit small, improvements in pain and possibly function; however, these benefits are typically not sustained over the long term nor do they appear to prevent need for surgery. No differences in effectiveness were found based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for facet joint pain. The evidence was insufficient to evaluate effectiveness of sacroiliac joint corticosteroid injections.

OrzaFlorin 2016-5-9 Bio
— Florin Orza, M.D.

An Integrative Approach to Low Back Pain Management

The Institute of Medicine has called for a cultural transformation in pain prevention, diagnosis, and management, recommending greater collaboration between different clinical disciplines.1 The University of Minnesota’s new Clinic for Comprehensive Pain Management (CCPM) takes such an approach, offering state-of-the art, comprehensive, and integrative care to managing pain. From its onset, the CCPM has aimed to diminish the reliance on opioids and focuses on providing patient-centered, evidence-informed care that includes a range of conventional and complementary nonpharmacologic, nonopioid pharmacologic, and injection approaches.

Psychological comorbidities (e.g., depression, anxiety) and maladaptive approaches for living and managing pain (e.g., fear avoidance, catastrophizing) are associated with pain chronicity. CCPM clinicians work to address not only the biological aspects of patients’ pain but also their psychological and social needs.

CCPM clinicians educate patients on the benefits and risks of therapeutic options so patients can make informed choices aligned with their preferences. Emphasis is placed on empowering individuals to better care for themselves. This is accomplished by using conventional and complementary provider-based therapies to provide symptom relief and facilitate patient engagement in longer-term self-management approaches. Preference is given to procedures for which there is reasonable research evidence. However, commonly practiced approaches for which evidence is lacking or just emerging may be recommended, particularly when no other evidence-based alternatives are available and a patient’s quality of life is severely impacted.

Thus, a person with uncomplicated LBP may receive a short course of nonopioid pharmacologic treatment like NSAIDS or muscle relaxants, coupled with recommendations for acupuncture, massage therapy, spinal manipulation, or physical therapy and advice to stay active. For patients with more persistent and disabling LBP accompanied by radiculopathy secondary to a confirmed disc herniation, epidural steroid injections may be recommended for symptom relief.

Supervised rehabilitation and possibly psychological support or training in mindfulness meditation might also be suggested to facilitate long-term self-care. In all cases, the potential benefits, risks, and costs need to be considered and monitored alongside patients’ values and preferences.

The National Center for Complementary and Integrative Health (https://nccih.nih.gov) serves as a useful resource for those wishing to learn more about these increasingly popular forms of pain management.

Pain Research at the University of Minnesota

The new Integrative Care for Pain Research Group at University of Minnesota rigorously examines the potential of the full range of pharmacologic, nonpharmacologic, and injection therapies for LBP and other painful conditions. This research group includes scientists and clinicians from conventional and complementary healthcare backgrounds who share a common vision for delivering safe-and-effective patient-centered care. Members of the group are investigating manipulation, exercise, and self-management treatments for LBP in adolescents and adults. Other research-group studies funded by the National Institutes of Health examine the optimal dose of spinal manipulation, as well as its cost-effectiveness. Several other studies are under development to further examine how best to combine conventional and complementary approaches and to examine the mechanisms by which these treatments work. This includes identifying which therapies might be best for which patients based on promising biomarkers like genetic profiles, brain functional connectivity, among others.

Article appears in MetroDoctors. 2016;18(4):11-13. MetroDoctors is the journal of the Twin Cities Medical Society.

References

  1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.
  2. Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J of Pain. 2015;16(8):769-780.
  3. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010;303(13):1295-1302.
  4. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016. MMWR Recomm Rep 2016;65(1):1-49.
  5. Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
  6. Morone NE, Greco CM, Moore CG, et al. A mind-body program for older adults with chronic low back pain: A randomized clinical trial. JAMA Internal Medicine. 2016;176(3):329-337.
  7. Bronfort G, Hondras MA, Schulz CA, et al. Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: A trial with adaptive allocation. Ann Intern Med 2014;161(6):381-391.
  8. Chou R, Hashimoto R, Friedly J, et al. Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
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