How to treat lower back pain

Lower back pain is one of the most common health problems around the world and healthcare professionals are continuously reviewing how best to treat it. Putting aside the individual for a moment, millions of productive hours are lost in the workplace and, with the loss of earnings that represents, there are serious implications for national economies as many find their ability to work restricted or completely finished. This puts pressure on national agencies to set best practice standards to keep the majority of adults in productive work. Although the UK often gets a bad press for its National Health Service (NHS), one of the more successful features of the service is the National Institute for Health and Clinical Excellence (NICE). This agency is responsible for co-ordinating national healthcare planning and directing individual agencies through clinical guidelines. It reviews all the available scientific information to decide which treatments are sufficiently cost-effective to be adopted across the whole of the NHS. The idea is to ensure that everyone gets the same quality of treatment no matter where they live. More importantly, the evidence-based approach is designed to produce better patient outcomes. NICE has just published its guidelines for the treatment of lower back pain. It treats the issue as multidisciplinary, i.e. one that should be approached using a variety of different forms of treatment supplied by different groups of health professionals. The basic assumption is that patients benefit from maintaining mobility, i.e. everyone should remain physically active. So the key recommendation is for therapists to design home-based exercise programs which run in conjunction with spinal manipulation and massage sessions at clinics and hospitals. The conclusion is that intensive exercise is the best treatment, particularly if combined with cognitive behavioral therapy to teach coping strategies and reduce depression. The evidence shows that patients who have a good understanding of their condition manage the pain more effectively and make better lives for themselves. No injections or investigations using X-rays or MRI scans are considered cost-effective. This does not deny the use of drugs to support the exercise programs. Indeed, nursing staff are considered vital in helping patients understand how to manage the more common side effects to using medication like tramadol. Constipation can make back pain more severe so learning how to prevent the side effects from worsening the underlying problem is necessary. The focus is therefore on front-line nursing staff and therapists rather than doctors and surgeons. The aim is to show patients that back pain is not a life-threatening condition and that, within the new physical limitations, they should get on with their lives as normally as possible. Although tramadol and, where appropriate, more powerful pain killers can be prescribed, their use should be kept to a minimum. Curiously, this contrasts sharply with the doctor-led approach in the US where expensive diagnostic testing and surgery are commonly used even though there is no reliable evidence that this approach is better value to the patients. Doctors in the US are powerful and protect their status and role in delivering health care. The only common feature between the two systems is the reliance on tramadol as the first-response for pain relief. No matter where you live, doctors agree tramadol is the best.

New research finds limits to the effectiveness of opioids

Once formed, habits are difficult to break. It always just seems easier to go on as you have before. This can become a serious problem when science gets in the way of the habits. If you look at the world of adverts in print and the media, you will see opioids recommended as the sure-fire drugs to use as painkillers, no matter what the pain. It carries on in the venerable tradition of the slogan, “Beecham’s Pills cure all ills”. The idea of a panacea — one pill to rule them all, as The Dark Lord of Mordor might have said - has been around since the beginning of time. This is fair game for the marketers to use when talking to the public, but the same thinking has entered the training manuals for the medical profession. Sit in lectures for student doctors and you will hear the same story that opioids are the first line of defense when it comes to moderate to severe pain. Once you have the source of the prescriptions in on the group think, the habit is almost impossible to break. The monitoring and review process put in place after a drug is released into the market is designed to catch any unexpected side effects. If evidence of problems emerges, the FDA can require the manufacturer to change the warnings on the label or, in the worst cases, withdraw the drug from the market. But this monitoring process is not designed to catch the drugs that are ineffective. If no-one has an adverse reaction when taking it, no report is filed with the FDA. It’s safe so who cares whether it works. All this brings us to the Cochrane Collaboration. This is a non-profit group where researchers sift through and analyze existing published medical research to see whether there are any consistent patterns - what might not be apparent in one clinical trial involving two hundred participants might be identified when you compile the results from fifteen different trials, each involving two hundred participants. Two recently published Cochrane Reports have concluded that opioids should not be routinely prescribed to patients even with severe pain from hip and knee osteoarthritis. In both Reports, the independent conclusions were that the adverse side effects outweighed the benefits and that tramadol, as the leading opioid, was no more effective than the strongest NSAIDs. The first Report consolidated the results from ten trials involving a total of just over 2,250 participants and concluded that there was little pain relief and minimal improvement in mobility. With higher dosages, one in twelve participants experienced adverse side effects. The second Report consolidated the results from eleven trials involving 1,020 participants and found little difference between the effectiveness of tramadol and the placebo. This leads to a somewhat controversial conclusion. That doctors should not routinely prescribe opioids for the treatment of hip and knee osteoarthritis. There should be a careful discussion of treatment options including weight loss, physical therapy and exercise, and a detailed explanation of all the adverse side effects to be expected. This new research does not change the general acceptance of tramadol as an effective painkiller. All it does is confirm that there is no such thing as one pill to cure all ills.