Frequently Asked Questions About Back Pain Treatment

What do national guidelines recommend for reasonable treatment for chronic back pain?

For people who do not see improvement with self-care options, several national and international guidelines recommend up to eight to 10 sessions of individual or group exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation over a period of 12 weeks.

For people who have not found success through the above treatments or have high disability or psychological distress, physicians are recommended to consider referral for a combined physical and psychological treatment that includes approximately 100 hours over eight weeks. The UI Spine Rehabilitation Program includes approximately 80 hours of professional contact involving the physician, psychologist, and physical therapists over two weeks.

Do these pain rehabilitation programs really work?

Yes–if you can make positive behavior changes. Researchers have clearly revealed that chronic pain programs offer the most successful and cost-effective treatment for people with chronic pain. They even including spine fusion surgery when compiling data for their research.

These findings have also been confirmed by the American Pain Society and the American College of Physicians and have been an integral part of their clinical practice guidelines. There is also strong evidence that a graded activity program using a behavioral approach is more effective than usual care in getting patients back to work.

This is part of the reason we do not recommend opioid medications in place of our spine rehabilitation program, which has a long track record of success and includes virtually no risk of harmful side effects.

If a patient continues to have severe pain after a physical therapy and psychology program, would surgery then be helpful?

No–that’s another common misunderstanding. Some people think that their pain isn’t bad enough to need surgery now. What the surgeons are looking for is any extension of pain into the leg or a substantial change in the quality of a person’s pain. They are not likely to operate on you just because the intensity of back pain has increased because of the concept of central sensitization.

“Intense pain is not necessarily an indication for surgery,” says Dr. Richard Deyo, professor at Oregon Health Sciences University. In cases of radiculopathy, ankle/toe weakness, or ankle/toe pain, surgery can be effective. Surgery for axial back pain generally is not successful in eliminating pain.

People typically overestimate the potential benefits of fusion surgery for generative disc disease. Less than half of patients surveyed had good outcomes as defined as having only rare pain, slight limitation of function, and only occasional use of pain medications. In another study of patients who underwent spinal fusion:

  • 64 percent were still off work more than one year after surgery
  • Only 6 percent had gone back to work
  • 20 percent had complications from surgery
  • There was a 27 percent reoperation rate
  • 90 percent were still taking opioid medications

What are national guidelines recommending for medications to use for chronic back pain?

The American Pain Society and the American College of Physicians recommend acetaminophen or nonsteroidal anti-inflammatory medications. Second line treatments for chronic back pain include tricyclic antidepressants. The following chart is used by many of our spine specialists at the UI Health Care.

Medication Class Common Examples (Brand Names) Advantages Disadvantages Cost
Analgesic Acetaminophen (Tylenol) Effective in osteoarthritis and chronic pain; analgesic of choice for patients with renal disease; option for children Potential for hepatic toxicity with long-term use; minimal anti-inflammatory effect $
Non-steroidal anti-inflammatory drugs (NSAIDs) Ibuprofen (Advil), Naproxen (Aleve), Diclofenac, Nabumetone, Etodolac Effective in a variety of pain, inflammatory conditions Risk of gastrointestinal bleeding; CV toxicity $
Tricyclic antidepressants (TCAs) Amitriptyline, Desipramine, Nortriptyline Effective for associated sleep disturbances Do not stop quickly; sedation; dry mouth; adjust dose in elderly $
Anticonvulsants Gabapentin (Neurontin) Effective for neuropathic pain; large dosing range allows flexibility in dose adjustments Sedation; balance or gait problems; use low dose in renal dysfunction $
Neuropathic pain agent Pregabalin (Lyrica) Effective for neuropathic pain, fibromyalgia Weeks before full effect, do not stop quickly; sometimes poorly tolerated $$$
Selective serotonin reuptake inhibitors (SSRIs) Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Venlafaxine (Effexor) Effective for fibromyalgia and chronic musculoskeletal pain, and associated mood disorders Do not stop quickly; Weeks before full effect achieved; sexual dysfunction; suicidal ideation possible $
Mixed mechanisms Tramadol (Ultram) Effective for neuropathic pain (also can be beneficial for hyperalgesia and allodynia) Avoid use with other serotonergic agents (SSRIs, TCAs); caution in elderly $

Will you prescribe opioid medications for me?

No–opioid pain medications for the control of chronic back pain have been controversial. Over 9 million adults in the United States (3 percent of the adult population) receive long-term opioid therapy and another 5 million abuse them for chronic, non-cancer pain even though this form of treatment is not supported by research. A recent summary from the National Institutes of Health conference noted, “Despite what is commonly done in current clinical practice, there appear to be few data to support the long-term use of opioids for chronic pain management.”

The American Pain Society and the American Academy of Pain Medicine are concerned about harms of opiate medications including drug abuse, addiction, and diversion. Of the patients taking opioid medications, only about a quarter of the patients had their pain decrease by one third. Only one in six people actually improved their ability to function or return to work to do more activities. Higher dosages were not associated with any increase in clinical improvement. Serious opioid overdoses occur among stably insured patients on long-term opioid therapy for chronic pain.

Did you know that over 16,000 people die every year due to use of opioid medications? These deaths are not from people abusing or being addicted to pain medication. These are good, hard-working people who take their medications as directed by their physicians. Unfortunately, opioid medications can depress a person’s respiration at night and can be deadly when mixed with consumption of alcohol or other sedating medications.

Researchers have indicated that observational studies suggest that long-term opioid use, when compared to non-use, is associated with increased risk of:

  • Abuse and dependence
  • Overdose
  • Fractures
  • Myocardial infarction
  • Markers of sexual dysfunction

At the same conference they also noted, “The United Sates has a dysfunctional health-care delivery system that promotes clinicians prescribing the easier rather than the best approach to addressing pain.” In another study of a large claims database nearly 50 percent of patients with low back pain were prescribed opioids but only 8 percent received psychological therapies, 19 percent received exercise therapies, and 12 percent received physical therapy.

For all the above reasons, UI Health Care does not recommend the use of opioid medications. There are many reasons we feel this way:

  • Opioids do not decrease chronic pain well
  • What short-term effectiveness opiods have eventually wears off
  • There are serious, long-term, harmful effects including:
    • Addiction
    • Osteoporosis
    • Immune suppression
    • Sexual dysfunction
    • Increased pain

Our most successful patients have been able to wean themselves off their opioid medications over several weeks. If you are currently taking an opioid medication, contact your prescribing physician for instructions how to start this process. Many of our patients say that they feel far better when they are not taking opioids. Fear about experiencing increased pain can lead to increased use of even more powerful pain medications and long-term disruption of hormonal function. You are the best person to decide when to stop this cycle.

It is not easy to discuss these difficult issues. We understand it’s not easy for all of our patients to understand these complex issues, especially when they have been dealing with chronic pain for so long. These are our best recommendations, and we would give the same information to everyone, even a spouse, family member, friend, or neighbor.

There is more cost to surgery than recovery or physical side effects

Spine fusion operations are expensive, twice as many of these surgeries are done by American surgeons as are done in European countries, and up to five times more in the U.S. than done in England. There are no epidemiological studies that indicate the spines of human beings living in the U.S. are the much weaker than the spines of human beings living in European countries. The New England Health Care Institute estimates the U.S. could save $1 billion a year by eliminating unnecessary back surgeries.

At UI Health Care we are also concerned about:

  • The excessive use of opioid medication
  • Unnecessary advanced imaging and testing (MRIs and EMGs)
  • Overuse of pain injections for low back pain
  • The potential for overuse of lumbar fusion surgery

We firmly believe that the patient knows best about what care he or she wishes to undergo. Our job is to help you learn about your medical condition, the risks, benefits, and likelihood of success. Studies indicate that when informed patients share in the responsibility of making their treatment decisions, they are more likely to choose conservative (non-surgical) treatment options.

It is also comforting to know that scientific research studies from multiple reliable sources indicate exercise with cognitive behavioral treatment or lumbar fusion surgery share similar long-term functional results. Spine fusion surgery for back pain is not the only way to get better.