Reducing harms in the management of low back pain

A multifaceted intervention targeting emergency department clinicians in NSW and supporting guideline-endorsed care of patients with low back pain has reduced the use of opioids by 12.3%.

Some of the key messages in the intervention were that most patients with low back pain do not require lumbar imaging, simple analgesics should be the first medicines used, and patients should be managed as outpatients.

The intervention included clinician education sessions delivered by rheumatologists and physiotherapists, resources including posters and patient handouts, provision of non-opioid pain management including heat wraps, a fast referral track to outpatients, and a real-time audit and feedback.

The study, published in BMJ Quality & Safety, compared outcomes in 1,392 patients presenting at EDs where the intervention had occurred and 3,222 patients at EDs during the control phase of usual care.

The intervention resulted in a non-significant reduction in the primary outcome of lumbar imaging (OR 0.77, p=0.290) but a significant reduction in a secondary outcome of any opioid use (OR 0.57, p=0.006).

There was no clear evidence of any impact on other healthcare utilisation outcomes such as referral for advanced lumbar imaging, prescription of strong opioid medicines or non-opioid pain medicines, hospital admission, length of stay, re-presentations within 48 hours or specialist consultations.

The intervention improved the accuracy of clinicians’ knowledge about back pain and its management.

Patients reported outcomes of pain intensity, physical function, quality of life, or satisfaction with care were not adversely affected by the intervention and the lower use of opioids.

The study’s success in reducing ED use of opioid medicines might be explained by the provision of evidence-based alternatives such as non-opioid analgesics and access to heat wrap therapy – making it easier for clinicians to change their prescribing behaviour.

“The audit and feedback showed a reduction in opioid prescription almost immediately, and this positive reinforcement may have contributed to the ongoing reduction in prescriptions,” the study said.

However the researchers said that reducing imaging rates was obviously more complicated.

“Although the training emphasised the value of clinical assessment, rather than routine imaging in screening for serious spinal pathologies, there is evidence that patients’ expectations, clinicians’ concern for missing a serious pathology, fear of litigation, belief of minimal harm and time constraints contribute to overuse of lumbar imaging,” they said.

Similarly, reasons for hospital admission were multifactorial and could not always be addressed in the ED due to factors such as competing clinical demands.

They concluded the study at least showed promise in addressing one aspect of the opioid crisis.

Lead author Dr Gustavo Machado, from Sydney’s Institute for Musculoskeletal Health, said thousands of Australians were unnecessarily being prescribed opioids which could can cause addiction, overdose and even death.

“Patients turn up at emergency departments often in incredible pain and discomfort and receive a highly addictive painkiller. It’s meant to be just a short-term fix but in reality, a month later a third of patients are still taking these pills.”

“Emergency departments are incredibly busy places and there is a huge pressure on clinicians to treat people as quickly as possible. Unfortunately, there is no easy fix for acute back pain but providing opioids has a lot of downsides,” he said.

“Our trial has demonstrated that there is a safer way to treat acute back pain that can easily be adopted by hospitals across the country. With back pain often being a leading reason people visit emergency departments, this new strategy could result in millions of scripts being handed out each year and help tackle the global opioid epidemic.”

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