To the Editor: We appreciate the article by Earwood, et al., on acute low back pain.1 However, we want to highlight and prioritize a care gap where family physicians could make a huge difference. For management of malignancy, Table 1 only recommends oncology referral. No medications are suggested. In contrast, management recommendations for the other etiologies of acute low back pain include medications in addition to referrals. Why do we think that is?
The American Society of Clinical Oncology names some of the potential issues; in this case, we want to name one: stigma.2 The Centers for Disease Control and Prevention's guidelines for opioid prescriptions specifically state that their recommendations do not apply to cancer-related pain.3 After weighing potential harms, the American Society of Clinical Oncology makes a strong recommendation that opioids should be offered for moderate to severe cancer pain, starting with low doses of immediate-release formulations and titrating as needed.2
Therefore, we recommend the authors add “consider low-dose opioids” and “consider palliative care referral” to the Management Recommendations for malignancy in Table 1. Waiting for an opioid pain medication until a patient is able to see an oncologist, sometimes weeks or months after diagnosis, unnecessarily delays care. Patients on a cancer journey already face fear of the unknown, high medical bills, and many more struggles, on top of physical pain. An additional evidence-based recommendation is early palliative care involvement.4 These additions will help empower family physicians to use opioids when indicated, and evidence shows that the benefits outweigh the risks. Although we acknowledge the importance of judicious and evidence-based use of opioids, stigma does not justify withholding appropriate cancer care.5
In Reply: We appreciate your appropriate recommendation to consider low-dose opioid medications in patients presenting with cancer-related acute low back pain. However, there are a few caveats to this recommendation. First, we still recommend oncology referral if a patient has a known history of cancer. If another physician is managing this patient's pain, we recommend that physician be informed of the likelihood of metastatic disease as the etiology of this new back pain and need for additional pain control, and should continue pain management if no unreasonable delay in care is anticipated. Second, if this is likely cancer initially identified during the evaluation for acute low back pain, low-dose opioid therapy should be considered. However, diagnosis and full staging of the cancer, including oncology evaluation if practical, is recommended.
Finally, although we agree with early palliative care in patients with advanced cancer, the meta-analysis referenced by Drs. Fan and Chui recommends consideration of palliative care within 8 weeks of diagnosis.4 In my reading of this article, the authors did not appear to be recommending palliative care before oncologic evaluation or disease staging. Although imaging is suggestive, it is not diagnostic. From a practical standpoint, a clinician is unlikely to recommend palliative care to a patient at the time of initial presentation of acute low back pain. For those patients with established advanced cancer who have new-onset cancer-related acute low back pain and have not already been referred for palliative care, we agree with considering that referral.
