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Doctors finally admit drugs can’t fix most cases of back pain

The American College of Physicians now recommends heat therapy and yoga ahead of pain meds for low back pain.

New guidelines suggest medicines as the last line of treatment for low back pain.
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America’s doctors have finally admitted it: Their pharmaceutical tools to treat one of patients’ most common ailments don’t work.

Lower back pain is one of the most frequent reasons people visit the doctor. Yet doctors are finding drugs should actually often be the last line of treatment for it.

A new guideline out Tuesday from the American College of Physicians suggests doctors recommend exercise and treatments like heat wraps, yoga, and mindfulness meditation to their patients before turning to medications like opioids or even over-the-counter painkillers. That marks a big departure from previous guidelines, Roger Chou, a professor at Oregon Health and Science University, told Vox.

Exercise or alternative therapies, the ACP noted, can work as well as or better than medications, but don’t come with the side effects. The doctors group also strongly discourages opioids, since research suggests these drugs are only modestly effective for back pain and carry serious risks, including overdose and addiction.

Back pain sufferers should take the new suggestions with grain of salt, though: The effectiveness of some of these alternatives may be limited, since a lot of the evidence backing them isn’t great.

Lower back pain is incredibly common — yet doctors don’t really know what causes it

Doctors talk about back pain in a few different ways, but the kind most people suffer from is what they call "nonspecific low back pain."

To be clear, this kind of low back pain has no detectable cause — like a tumor, pinched nerves, osteoporosis, or a fracture. And it can be acute (lasting up to four weeks), subacute (lasting between four and 12 weeks), or chronic (lasting 12 or more weeks). But rarely is it a sign of a more serious medical problem.

It’s also very prevalent. Low back pain is one of the top reasons people go to see their doctors in the US, and the leading reason for missing work anywhere in the world.

Obesity, being overweight, smoking, depression, and anxiety have all been linked with lower back pain. But the cause is usually more complicated. "Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role, but psychological and social factors also play a big role," said Chou, who wrote a big evidence review that helped inform the new ACP guideline.

For example, in patients who have nearly identical results from an imaging test like an MRI, those who are depressed or unsatisfied with their jobs tend to have worse back pain than people who aren’t, Chou said. Partly for this reason, doctors don't generally recommend doing MRIs for acute episodes of low back pain, since they can lead to overtreatment — like surgery — that also won't improve health outcomes.

There’s a range of treatments that can alleviate pain, but no silver bullet

There's little you can do to prevent back pain, beyond what you should be doing for your body anyway: getting a reasonable amount of exercise, maintaining a healthy weight, and avoiding injury. And there’s a range of treatments that can only sort of help, and no magic pill or cure that works for everybody.

For acute or subacute low back pain — cases that last for less than 12 weeks — the ACP recommends considering heat therapy as a first line of defense. Massage, acupuncture, and spinal manipulation by a chiropractor can help, but the evidence isn’t as strong for these alternatives.

For chronic back pain, exercise, rehabilitation therapy, acupuncture, and mindfulness-based stress reduction have the best evidence for effectiveness. After that, yoga, tai chi, motor control exercises, low-level laser therapy, cognitive behavioral therapy, and spinal manipulation can help — but the data backing these treatments is also not that strong.

If these alternative therapies don’t help, the guideline suggests asking your doctor about ibuprofen or muscle relaxants (acetaminophen is increasingly seen as unhelpful). Opioids should only be considered as a very last resort, because the serious side effects, like accidental overdose and addiction, don't usually outweigh the minimal benefits.

Again, none of these are particularly outstanding solutions — not even chiropractic treatment.

So Chou summed it up this way: Exercise should generally be the first-line therapy for chronic low back pain. “[Passive] therapies like spinal manipulation and acupuncture … should be used in conjunction with more 'active' therapies like [exercise, psychological therapies, yoga, mindfulness based stress reduction],” he added.

This may be a frustratingly vague answer, but maybe it's also liberating: With no magic pill, consider heat therapy and exercises first, and then maybe move on to other interventions, like massage, and find the ones you like. And do it soon.

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