From ACP: Another Unscientific & Biased Guideline

New clinical guideline issued for treating low back pain – Medical News Today – 2/14/17

The American College of Physicians (ACP) have published their clinical practice guideline for treating nonradicular low back pain in the journal Annals of Internal Medicine. Nonradicular pain refers to pain that does not irradiate from, and is not caused by, damage to the spinal nerve root.

approximately 31 million U.S. individuals experience low back pain at one point during their lives

The condition accounts for a large proportion of all doctor visits in the U.S., and almost 25 percent of the entire adult population in the U.S. has experienced at least one day of low back pain in the past 3 months. 

An evidence-based guideline for clinical practice

This claim is simply not true.

The treatments they suggest are NOT solidly evidence-based.They are based on just a few barely significant results of a few small poor-quality studies that they dredged up.

The guideline is based on a review of randomized controlled trials and observational studies conducted on noninvasive drug and non-drug treatments for low back pain.

The ACP have reached their conclusions through a meticulous reviewing process that consists of several stages: a systematic review of the evidence available; a deliberation based on the evidence; a summary of the recommendations; grading the quality of the evidence; and issuing the recommendations.

These are all just empty words when no large well-designed studies ever supported such “alternative” treatments.

The studis show low-quality evidence for 5-10% improvement on the pain rating scale, which is barely noticeable.

Here, it is played up as though such non-opioid therapies greatly eased pain, but the studies only show tiny gains – and then with low confidence.

Opioids should be ‘last option’ for treatment

Clinical trials reviewed in the guidelines show that acetaminophen does not reduce pain when compared with a placebo.

Systemic steroids were also shown to be ineffective in treating acute or subacute low back pain.

However, the evidence supporting this was deemed “low-quality” by the ACP.

The committee recommends that patients with chronic low back pain start by undergoing non-drug therapy and exercising, as well as engaging in multidisciplinary rehabilitation, acupuncture, mindfulness-based therapies for stress reduction, tai chi, and yoga.

Other practices recommended by the ACP in the initial stages of chronic low back pain include

MCE (an activity that focuses on the “activation of the deep and global trunk muscles”) and progressive muscle relaxation, including the use of electromyography biofeedback.

Biofeedback-assisted relaxation uses electronic devices to measure body functions, thus helping the patient gain control of muscle tension and relaxation.

From personal experience, I know health insurance does not pay for biofeedback, which I think is one of the few modalities that would be useful for pain.

Note the lack of evidence – these are just recommendations with the slimmest scientific basis.

The ACP also recommend low-level laser therapy and spinal manipulation, as well as cognitive behavioral and operant therapy.

As the next clinical step for patients with chronic low back pain who did not respond well to nonpharmacological therapy, the ACP recommend nonsteroidal anti-inflammatory drugs, followed by drugs such as tramadol or duloxetine as second-line therapy

They are apparently unaware of the horrible withdrawal syndrome from Cymbalta/duloxetine, which the drug company is being sued about.

The committee notes that physicians should only consider prescribing opioids for patients who did not respond adequately to these previous treatments.

Isn’t this the way things are currently done anyway? Even patients themselves want to try all possible alternatives before settling on opioid therapy.

The committee recommends that physicians should consult the patients and present to them the associated risks and potential benefits of opioid treatment.

Finally, the physicians should only prescribe opioids if the possible benefits clearly outweigh the risks.

Is there any other reason a legitimate doctor would prescribe opioids to someone in pain?

All these guidelines seem to assume that doctors wrote opioid prescriptions as the first treatment for chronic pain, but I haven’t heard of a single case like that except in “pill mills”.

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