On February 14, 2017, the American College of Physicians (ACP) released a clinical practice guideline recommending physicians prescribe massage therapy and other non-opioid interventions for back pain before opioid drugs. This recommendation represents a significant shift in the United States medical community’s guidelines toward massage therapy and pharmaceuticals.
According to the Penn State Department of Orthopaedic Surgery, more than 80% of people will feel lower back pain at some point in their lives. Physicians often find it difficult to identify the causes of this condition, which may include a vast array of injuries and diseases such as:
- Muscle strain
- Ligament damage
- Ruptured or bulging discs
Because of the difficulty of identifying and treating the root cause of lower back pain, painkillers are a common treatment for managing the pain. However, the most effective painkillers—called opioids—carry major risks, including overdose and addiction. According to the Centers for Disease Control and Prevention, sales of prescription opioid drugs quadrupled from 1999 to 2014, and nearly 20% of people treated for non-cancer related pain are prescribed opioids.
What Are Opioids?
Opioids exist naturally in your body as endorphins and transmit messages between your nerve cells (and in your digestive system). Opioid pain medications bind to cells’ opiate receptors, blocking pain signals headed to the brain. In strong concentrations, these chemicals can cause euphoria, confusion, sleepiness, nausea, constipation, and respiratory problems.
Because opioids affect the brain areas involving pain, pleasure, and reward, people may become addicted to the drugs, especially after recreational use. Patients prescribed painkillers can also become addicted to these chemicals. They may continue taking opiates after the pain subsides, ingest more than the recommended dosages, and purchase these drugs illegally when their prescriptions run out. Some people addicted to prescription painkillers eventually switch from prescription opioid drugs to heroin or other opioids such as codeine or morphine.
New Treatment Guidelines from the American College of Physicians
To understand the new ACP treatment recommendations, you need to know the three terms doctors use to define lower back pain—not how bad it hurts, but how long it lasts:
- Acute: Pain lasting less than 4 weeks
- Subacute: Pain lasting 4-12 weeks
- Chronic: Pain lasting more than 12 weeks
Duration plays a major role in treatment decisions, because many lower back pain episodes may go away on their own. In a few days or weeks, your body may heal itself, making further treatment unnecessary.
To curb the rising number of opioid prescriptions for lower back pain, the ACP offers three suggestions:
- Patients with acute and subacute lower back pain that may go away on its own should try massage therapy, acupuncture, heat, and spinal manipulation. People who prefer the pharmaceutical approach can try anti-inflammatory drugs and spinal muscle relaxants.
- Patients with chronic back pain should first seek out non-pharmaceutical activities like yoga and tai chi and mental interventions such as cognitive behavioral therapy.
- Patients with chronic back pain that does not improve after first trying non-pharmaceutical treatments should only consider using opioid pain medication after trying out non-steroidal or anti-inflammatory drugs and discussing the risks with their doctors.
Nitin S. Damle, MD, MS, MACP, former president and current board member of the American College of Physicians still cautions against opioid treatment.
“Physicians should consider opioids as a last option for treatment and only in patients with chronic low back pain who have failed other therapies,” Damle said. “[Opioids] are associated with substantial harms, including the risk of addiction or accidental overdose.”
- American College of Physicians. (2017, February). Summaries for patients: noninvasive treatments for acute, subacute, and chronic low back pain. Annals of internal medicine. doi:7326/P17-9032
- Centers for Disease Control and Prevention. (2016, December 20). Prescribing data. Retrieved from https://www.cdc.gov/drugoverdose/data/prescribing.html
- Mayo Clinic Staff. (2015, June). Back pain: causes. Retrieved from http://www.mayoclinic.org/diseases-conditions/back-pain/basics/causes/con-20020797
- National Institutes of Health. (2016, August). Misuse of prescription drugs: which classes of prescription drugs are commonly misused? Retrieved from https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/which-classes-prescription-drugs-are-commonly-misused
- com. (n.d.). Opiate vs. opioid – what’s the difference? Retrieved from http://opium.com/derivatives/opiate-vs-opioid-whats-difference/
- Patrick, N., Emanski. W., & Knab, M. (2016). Acute and chronic low back pain. Medical clinics of North America, 100(1), 169-81. doi: 10.1016/j.mcna.2015.08.015.
- Qaseem, A., Wilt, T., McLean, R., & Forciea, M. (2017, February). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Annals of internal medicine. doi: 10.7326/M16-2367