Primary Care

FEBRUARY 8, 2018

In Chronic LBP, Outcomes Unchanged

By Provider Specialty

Boston—Outcomes are equivalent in patients with low back pain whether they
saw pain management specialists or transitioned from specialists to their
primary care doctors, according to researchers.

A recent prospective, randomized clinical trial enrolled 60 subjects with

nonstructural, nonspecific chronic low back pain (LBP) and randomly assigned
them to one of two treatment groups of 30. One group was treated by pain
management physicians and the other was treated by each individual patient’s
own primary care physician (PCP). Both groups were treated at three-month
intervals over a six-month period.
The study, presented at the 2017 annual meeting of the American Society of
Anesthesiologists (abstract A4021), considered whether back pain patients
who transition from pain management specialists to their PCPs do at least as
well as patients whose chronic back pain continues to be cared for by pain
management specialists.

The rationale for the study was that pain specialists are scarce—roughly 4,000
to 5,000 in the United States, said study co-author Mario Moric, MS, a
biostatistician at Rush University Medical Center, in Chicago. They tend to be
overbooked, and costs are higher for the patient and the medical system, he
said.

Additionally, and more importantly, the investigators’ working hypothesis held

that because the PCP knows the patient, including any medical issues, and
given that the physician can spend more time with the patient than a specialist
can, treatment is likely to be at least equivalent, Mr. Moric said.

For example, the PCP might be better able to determine whether a cognitive-
behavioral therapist or a physical therapist would be of further help to the
patient, Mr. Moric told Pain Medicine News. Presumably, the PCP also would
be better positioned to help the patient transition to lower doses of an opioid if
the patient so desired.

The trial found that outcomes supported the study hypothesis. At the follow-up
evaluation, the difference between the two LBP patient groups was not
statistically significant. Patients cared for by pain management professionals
had an average Brief Pain Inventory pain severity score of 6.0 versus 5.4 in the
PCP-treated group, which was statistically equivalent (P=0.0291). The overall
change in pain in the groups from first visit to follow-up also was equivalent
(P=0.0092). Pain in both groups at follow-up was equivalent to pain at the first
visit.

In view of these findings, Lynn R. Webster, MD, vice president of scientific

affairs at PRA Health Sciences, in Salt Lake City, past president of the
American Academy of Pain Medicine and a Pain Medicine News editorial
advisory board member, noted that the cohort is a subset of people with back
pain and do not have a clearly identifiable pathology of back pain. “These are
people not likely to benefit from interventions that a pain specialist could
offer,” he said.
“Pharmacotherapy and complementary therapy would likely be the primary
therapeutic options, and if the PCP has pain management training, they should
be able to provide the same level of care as a pain specialist,” Dr. Webster
said.

One notable problem the investigators encountered in conducting the study

was that recruiting patients for the PCP arm was difficult because many of
them did not want to prescribe opioids, contrary to the protocol.

—David C. Holzman