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Opioids should be a last resort for chronic back pain, medical group says

Patients with chronic back pain should try therapies such as tai chi, yoga, acupuncture, and mindful meditation before being prescribed opioid painkilling drugs, according to new guidelines from the nation's largest specialty physicians group.

Monday's release from the American College of Physicians is the latest in a continuing deluge of recommendations that seek to reframe how patients and doctors think about the prescription drugs blamed for fueling a national addiction crisis.

Still, the message hasn't gotten to many of its intended targets.

"I think most patients want medications as a fast fix," said Anita Gupta, vice chair of Drexel University College of Medicine's division of pain medicine. "What patients understand is often far from what the evidence tells us to do."

Gupta, who was not involved with the new guidelines, said her practice at Hahnemann University Hospital gets patients' family and friends involved in care, and often includes psychotherapy, because pain can cause isolation and depression.

The recommendations from the Philadelphia-based physicians organization, published  in the Annals of Internal Medicine, are based on reviews of more than 150 studies. They find a bit more evidence to support practices like yoga for pain control. Most acute lower back pain eventually will go away on its own, the guidelines note, though multidisciplinary approaches work best to aid the healing process.

The surgeon general last year estimated that opioids are responsible for 78 overdose deaths a day. They should be an option only in patients who have failed multiple other treatments "and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits," the new guidelines say.

But health insurance is more likely to cover pills than tai chai.

"There is still a disconnect between what is paid for in health care and what the evidence is showing is helpful," said Michael Ashburn, director of pain medicine for the University of Pennsylvania Health System.

The most effective pain treatment is interdisciplinary integrative medicine, Ashburn said. The common thread among mindfulness meditation, tai chi, and other mind-body practices is that "people learn to take care of themselves and their bodies," and that "leads to better outcomes than most medications we have to offer."

Surgery once was held up as a favored option for back pain, he pointed out,  until research started showing that in many cases, it is ineffective and can even make things worse.

The guidelines released Monday made three sets of recommendations:

  1. For pain lasting up to 12 weeks, nondrug treatments are preferred, with the strongest evidence for applying heat. There is also evidence for  massage, acupuncture, and spinal manipulation. Evidence does support nonsteroidal anti-inflammatory drugs (NSAIDs, such as aspirin and ibuprofen) and muscle relaxants.

  2. Chronic lower back pain (more than 12 weeks) should initially be treated with practices like exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. There is also evidence for practices ranging from tai chi and yoga to biofeedback and cognitive behavioral therapy.

  3. Chronic back pain that did not respond to nondrug treatments should first be treated with NSAIDs. Tramadol (a short-acting opioid) or duloxetine (an antidepressant) would be second-line treatments. Other opioids should be a last resort.

"For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another," Nitin S. Damle, president of the American College of Physicians, said in a statement.