Change in VA/DoD Guidelines for Low Back Pain Surprising Even for Authors

By Annette M. Boyle

WASHINGTON—If VA clinicians are surprised by the significant changes in the updated recommendations recently issued by the VA and DoD for the diagnosis and management of low back pain, they are not alone. The evidence review even shocked many members of the work group that wrote the new clinical practice guidelines.

Sanjog Pangarkar, MD

“It was surprising for me how little evidence there was for techniques used diagnostically and therapeutically,” pointed out Sanjog Pangarkar, MD, director of the inpatient and interventional pain service at the West Los Angeles VAMC. For instance, Pangarkar said, “we didn’t find robust evidence that epidural injections provide a benefit. It didn’t seem as clean-cut as it’s practiced today.”

Friedhelm Sandbrink, MD

Friedhelm Sandbrink, MD, chief of the pain management program at the Washington, DC, VAMC, and deputy national director of pain management for the VHA went further. While “very commonly used in practice, steroid injections for acute exacerbation in the emergency department have no supporting evidence. It’s associated with potential harm and a lack of evidence of benefit, so we made a strong recommendation against it.”

More generally, the “literature review provided limited evidence of the effectiveness of pain medication,” Sandbrink told U.S. Medicine. “Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for chronic or acute low back pain and we made a weak recommendation for duloxetine. For temporary use, a muscle relaxant may be helpful, but that’s it really.”

The recommended list is even shorter than Sandbrink’s comments might indicate, with the absence of one ubiquitous NSAID. “It surprised me that the review of acetaminophen showed that there may be more side effects or problems than benefits. We made a strong recommendation against its use in low back pain,” said Daniel Kang, MD, an orthopedic spine surgeon at Madigan Army Medical Center in Tacoma, WA.

The most-notable change in the guidelines for pharmacological treatment, however, came in the clear warning against the use of opioids for low back pain. “The number one recommendation in the guidelines for chronic pain issued in February was against long-term opioid therapy,” Sandbrink emphasized. “That was instrumental for the low back pain recommendation against initiating long-term opioid therapy and our referral back to the clinical practice guidelines for opioid therapy, which emphasize an individualized approach and recognizes the challenges in opioid dosage reduction for those already on long-term opioid therapy.”

With the evidence review supporting few of the treatments frequently used to manage one of the most common presentations at clinics, what do the guidelines recommend?

“For physicians seeing patients in the DoD, readiness is a priority. Our young patients might be referred to spine surgeons, but they are likely to respond to things that clinical providers may not have thought about. We found a lot can be treated with nonoperative options,” Kang told U.S. Medicine.

“Not all pain is addressed through medication, therapies or surgery,” echoed Pangarkar. “Our patients use acupuncture, yoga, tai chi and other techniques to manage their pain and we wanted to understand if there is value in those integrative therapies.”

The work group found mixed results in the literature. “There was a surprising lack of evidence for many integrative therapies,” said Adam Bevevino, MD, chief of spine surgery service at the William Beaumont Army Medical Center in El Paso, TX.

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