Overtreating chronic back pain: time to back off?
Open accessAbstract
Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.
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The most common treatments for CBP include injections or surgery, which often show no substantial improvements and limited efficacy.
“However, the most common treatments include injections or surgery, which often show no substantial improvements and limited efficacy [8].”
From EFFects of Exposure and Cognitive behavioral Therapy for chronic BACK pain (“EFFECT-BACK”): study protocol for a randomized controlled trial (2024) · cites this paper as [8]
The Spinal injections section says their efficacy is limited, and the Spine surgery section says fusion has limited benefit for back pain from degenerative discs without sciatica. The paper also questions whether increased use of these treatments has improved outcomes. It does not establish that injections and surgery are the most common treatments for chronic back pain, and it acknowledges that they benefit some patients. (LLM, conf=0.87)
Experimental — accuracy not yet measuredDespite rising intervention rates, functional disability from chronic low back pain has worsened in recent decades, and symptom prevalence and expenditures have also increased.
“Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades.”
From Report of the NIH Task Force on research standards for chronic low back pain. (2014) · cites this paper as [37]
The current approach to care requires patients to judge when an undesired event is problematic and what action to take in the face of that event.
“Specifically, the current approach to care requires patients to judge when an undesired event is problematic and what is the preferred action to take in the face of that event [30,31,32].”
Sample size was calculated a priori with G*Power, expecting moderate between-group differences, with 80% power, alpha 0.05, Cohen's d of 0.5, yielding 50 participants needed per condition.
“Sample size was calculated a priori with the statistical software G*Power [49] considering previous studies on complications of pain treatments [30,50].”
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- Authors
- Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I.
- Affiliations
- Oregon Health & Science University (US)
- ORCID
- Turner, J. A.
- Venue
- The Journal of the American Board of Family Medicine
- Published
- 2009-01-01
- Volume
- 22
- Issue
- 1
- Pages
- 62-68
- ISSN
- 1557-2625 (ISSN-L)
- 1558-7118
- PMC
- PMC2729142
- OpenAlex
- W2117092285
- Cited by
- 796
- References
- 91
- Citations by year
- 2026: 26 · 2025: 36 · 2024: 24 · 2023: 36 · 2022: 40 · 2021: 44 · 2020: 51 · 2019: 39 · 2018: 51 · 2017: 51 · 2016: 51 · 2015: 50 · 2014: 46 · 2013: 76 · 2012: 67
- FWCI
- 5.99
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of the American Board of Family Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- University of Washington
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (5 P60-AR48093, 5K23AR48979, K23AR048979, P60AR048093)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
- Health Sciences › Medicine › Pathology and Forensic Medicine › Spine and Intervertebral Disc Pathology
- Keywords
- chronic back pain, overtreatment, epidural steroid injection, opioid use, spinal fusion, Medicare spending, treatment efficacy and safety, pain mechanisms, post-marketing surveillance, chronic disease management
- MeSH terms
- Analgesics, Opioid, Chronic Disease, Patient Care, Humans, Spinal Injuries, Time Factors, Low Back Pain
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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