Painful truth about managing back pain

OPINION: This month the prestigious New England Journal of Medicine published a paper reporting that epidural glucocorticoid (or ''steroid'') injections are no more effective than a sham, or placebo treatment for a back condition called lumbar spinal stenosis.

This trial is not the first to question the use of steroid injections for back pain. Research conclusively shows that, regardless of the type of back pain you have, the area of the back that is injected, or the route of administration, steroid injections are ineffective for back conditions.

The United States Food and Drug Administration has a very clear position on this: “The effectiveness and safety of epidural administration of corticosteroids have not been established, and FDA has not approved corticosteroids for this use”.

The lack of efficacy of steroid injections is especially relevant to Australia as the number of steroid injections for back conditions funded by Medicare has more than doubled in the 10 years to 2011, with more than 31,500 provided in 2011 and more than 35,000 in 2012.

It is also of interest because this is the same treatment that harmed a great number of patients in 2012 in the US due to fungal contamination when the steroid was being prepared. Unfortunately 749 people developed a fungal infection and 61 died.

But doctors are not just injecting steroids into backs. They are injecting substances such as dextrose, botulinum toxin, methylene blue, stem cells, and blood extracts (platelet rich plasma). What all these treatments have in common is that they are either known to be ineffective or that there is insufficient evidence to judge if they do more good than harm.

It's not just injections, and it's not just doctors: across the board there are opportunities to improve how back pain is managed. But for that to happen we need greater recognition that we have a major problem.

Australia is meant to be the clever country but we ignore one of our most burdensome health conditions. Back pain has never been a health or research priority, despite the fact that 25 per cent of Australians suffer from it. It is the most common health condition forcing older Australians out of the workforce.

Over the next 12 months we will spend $4.8 billion on health care for back pain. 

So where has it all gone wrong? Part of the problem is a lack of investment in back pain research, but an equally important part of the problem is sufferers often receive the wrong care.

Given the current budget climate perhaps one way to get back pain noticed would be to point to the enormous waste we allow by ignoring back pain. Spinal injections are just one example of many.

Each year in Australia Medicare pays out $220 million on imaging (such as X-rays and CT and MRI scans) for back pain; which is astonishing because treatment guidelines for low back pain explicitly discourage imaging in most circumstances.

Spine-fusion surgery for back pain carries far greater cost and potential risks, and also lacks a firm evidence base.

Add to these the money paid on spine injections and the failure of health-care providers to manage back pain according to evidence-based guidelines, and we can see that our efforts in managing back pain are, at best, misdirected. At worst, they are harmful and expensive.

We feel that changes need to be made to the distribution of public funding for ineffective treatments by linking funding to effectiveness and net benefit, not demand.

One suggestion to solve this problem is to withdraw public funding for ineffective treatments.

We believe, however, that leaving this to Medicare to solve is not ideal; the health professions are arguably in the best position to guide reform in this area.

In the US there is an initiative called 'Choosing Wisely' where the professional associations take the lead and advise both patients and clinicians on low value health care options. For example,  the American Society of Anesthesiologists instruct members to “avoid imaging studies (MRI, CT or X-rays) for acute low back pain without specific indications”.

With $4.8 billion being spent each year on back pain in Australia, and health outcomes getting worse, now seems a very good time to choose wisely.

Professor Chris Maher is Director of the Musculoskeletal Division at The George Institute for Global Health.

Professor Ian Harris is Professor of Orthopaedic Surgery at UNSW.

Professor Rachelle Buchbinder is Director of the Monash Department of Clinical Epidemiology.

This opinion piece was first published in the Sydney Morning Herald.