To the Editor:

We enjoyed reading Dr. Earwood and colleagues' excellent and thorough article regarding acute low back pain.¹ The cost of treating low back pain in the United States is $134.5 billion annually and increasing.² Despite rising costs and increasing awareness, patients continue to receive care that is inconsistent with clinical guidelines, including an overreliance on passive modalities.²

We worry that the article overstates the evidence supporting routine use of acupuncture, dry needling, trigger point injections, and transcutaneous electrical nerve stimulation—all of which increase initial cost and have inconsistent supporting evidence.^2–4 Best evidence and guidelines for acute nonspecific low back pain recommend reassurance, advice to stay active and resume normal activities, and education on self-management and seeking care only when needed.^3,4 If pain or functional disability persists, then passive modalities such as those mentioned above may be considered. However, much of their benefit may derive from the placebo effect and is unlikely to change the natural history of low back pain.⁵

We also applaud the authors' reference to the OPAL (opioid analgesia for acute low back pain and neck pain) trial that demonstrated a lack of improvement in low back pain with an opioid prescription.⁶ However, this trial has limitations when informing opioid recommendations. The OPAL trial treated patients with up to 12 weeks of pain, including those outside of typically defined “acute” periods; used a sustained-release oxycodone-naloxone formulation as opposed to an immediate-release opioid; and measured outcomes starting at 2 weeks instead of immediately after administration, when pain relief is needed most and opioids are likely to show an effect. Thus, although it is an important addition to low back pain research, the OPAL trial may not have actually addressed whether immediate-release opioids are effective at improving acute low back pain. In patients with contraindications to other medications (eg, nonsteroidal anti-inflammatory drugs), a short course of opioids for severe acute low back pain at the lowest effective dose is reasonable and consistent with guideline recommendations.^3,4

The views expressed in this publication are those of the authors and do not necessarily  reflect the official policy or position of the Department of the Navy, the Department of War, or the US government.

In Reply:

We appreciate your comments. We are also concerned about the increasing cost of lower back pain in the United States. The vast majority of the cost estimate you quote ($134.5 billion annually) is from the management and disability of chronic lower back pain, not acute.¹ The guideline on management of acute lower back pain has largely remained unchanged for decades. Despite that, you correctly identify that costs are increasing. In 2019, low back pain in general was in the top 10 leading causes of disability-adjusted life-years worldwide in all age categories, a 46.9% increase since 1990.² As physicians, we tend to blame nonadherence to guideline-directed therapy for this increasing cost, which has some merit. Sadly, this lament has not stemmed the increase.

In an era of decreasing patient trust in the health care system and physicians, reassurance is not enough. There is a link between trust in the physician and health outcomes.³ Additionally, there are comorbid conditions that increase a patient's likelihood of developing chronic lower back pain (eg, smoking, obesity, mood disorders, sedentary lifestyle, certain occupations).⁴ Management of acute lower back pain in isolation is efficient in clinic but is likely missing the mark.

In addition to managing comorbid conditions, using modalities that have evidence of reducing acute lower back pain and are unlikely to harm the patient is a reasonable approach. Similarly, avoiding modalities with evidence of harm or no evidence of improvement is a reasonable approach. There is a large body of evidence of harm from use of opioids in treatment of chronic lower back pain. Similarly, there is evidence that opioid use for acute lower back pain leads to chronic opioid use.^5,6 Although there are situations where opioid use should be considered for acute lower back pain, it deserves a healthy reconsideration if other modalities can be used with a reasonable expectation of success.