American College of Physicians Clinical Practice Guidelines for Non-Invasive Treatments for Acute, Subacute, and Chronic Low Back PainBy OSCAR DE LEON-CASASOLA, MD Feb 21, 2017
These guidelines were published on Annals.org on February 14, 2017 (Ann Intern Med. doi:10.7326/M16-2367) to provide clinical recommendations on non-invasive treatment of acute, subacute, and chronic low-back pain. The major change in the guidelines is that they are NOT recommending pharmacological therapies as the first-line treatment. Instead, for patients with chronic low back pain, they promote the use of “exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.” This is a puzzling recommendation because they label the available data as low-quality evidence and because getting insurance approval for many of these therapies in chronic pain patients has been difficult, if not impossible. Thus, it will be interesting to eventually know the number of patients who actually received this form of therapy and the long-term success rate associated with it.
For patients with chronic low back pain who have not responded to the aforementioned approach, they recommend the use of non-steroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, and tramadol or duloxetine as second-line therapy. However, they reported that moderate-quality evidence showed that NSAIDs were associated with small to moderate improvement in pain when compared with placebo and that there was low-quality evidence suggesting that this alternative could result in low to none functional improvement with no differences among the different agents. They also noted that there were no data on COX-2 inhibitors. Moreover, the authors described that moderate-quality evidence showed that more adverse effects occurred with NSAIDs than placebo. This is in line with the strong FDA language on the chronic use of NSAIDs published on July, 2015, where they warned that “heart attack or stroke risk can increase as early as the first weeks of NSAID use, and the risk may increase with longer NSAID use. The risk appears to be greater at higher doses” and it is part of the black box warning in the package insert of all NSAIDs.
The authors also reported that “moderate-quality evidence showed that strong opioids (tapentadol, morphine, hydromorphone, and oxymorphone) were associated with a small short-term improvement in pain scores (about 1 point on a pain scale of 0 to 10) and function compared with placebo” with no differences in pain relief between short-acting and long-acting opioids. Interestingly, they found moderate-quality of evidence showing that tramadol achieved moderate short-term pain relief and a small improvement in function compared with placebo (see below). Moreover, they found that duloxetine was associated with a small improvement in pain intensity and function compared with placebo.
So... what can we conclude? In doing the analysis, the authors are just “recycling” the available data WITHOUT a much needed inclusion of what we know in 2017:
- We should stop using the term low back pain as a diagnosis and be more specific. Is it osteoarthritis of the facet joints, myofascial pain of the longissimus thoracis or iliocostalis lumborum muscles, intervertebral disc degeneration, etc.? Thus, a differential diagnosis is needed. This is because each of this conditions respond differently to the suggested therapeutic approaches. (e.g., opioids for myofascial pain – see Cohen SP, et al. Anesthesiology 2004;101:495-526)
- Isn’t it time for our colleagues outside of pain management to embrace the concept of multimodal therapy? Pain is not generated by one single neurotransmitter and a receptor. A multitude of receptors and neurotransmitters are involved in the process, justifying the use of multimodal therapy.
- Peripheral and central sensitization. There is ample evidence that chronic pain may lead to the development of peripheral and central sensitization. It has been demonstrated in osteoarthritis (Lancet 2005;365 and Pain 2009;146:253) and in myofascial pain (Manual Therapy 2010;15:135) — two conditions that may be the source of pain in patients with chronic low back pain. The development of a centralization phenomenon explains the need for multimodal therapy and the lack of efficacy of difference monotherapeutic approaches.
- It is truly puzzling to see in this type of guidelines, which are supposed to help clinicians in primary care, the recommendation to use NSAIDs as first line agents in light of
- The small to moderate improvement in pain when compared with placebo and the low to none functional improvement with all of these agents.
- The well recognized high risk for thromboembolic phenomenon associated with these agents that make the use of these agents both not practical and risky.
It is also noteworthy that a commentary on these guidelines were published in the New York Times on February 13, 2017. Although the author provided a good summary, it is stated that “the guidelines also said that steroid injections were not helpful.” Although the author was specifically referring to intramuscular steroid injections, this statement could be confusing to patients who are being considered for an epidural steroid injection (ESI) as they are usually referred to as steroid injections. The authors of the guidelines specifically stated on page 2, in the Guideline Focus and Target Population section that “this guideline does not address topical pharmacological therapies or epidural injection therapies.” I am highlighting this issue because patients may question the usefulness of an ESI based on this report.
Dr. de Leon-Casasola is the president of the ASRA Board of Directors. He is also the Senior Vice-Chair and Professor of Anesthesiology (Tenure Track), Department of Anesthesiology, and Professor of Medicine at the University at Buffalo, School of Medicine and Biomedical Sciences and Chief of the Division of Pain Medicine and Professor of Oncology at Roswell Park Cancer Institute, both in Buffalo, NY.