What causes acute low back pain to become chronic? That's the question explored in a new study¹ suggesting acute LBP patients shouldn't be going to primary care medical doctors for their pain. Here's why.

The study evaluated the care provided to 5,233 patients with acute LBP in 77 primary care practices. Among the potential factors leading to chronicity, the authors considered "nonconcordant" care, or care not consistent with established guidelines. Surprisingly, almost half (48 percent) of patients received at least one form of nonconcordant care.

The authors note: "[N]onconcordant care can lead to direct and indirect harm, given that it has been linked with medicalization and unnecessary health care utilization."

Nonconcordant care as provided to study participants was divided into three categories: pharmacologic, diagnostic and medical subspecialty referral. Almost 50 percent of patients received at least one form of nonconcordant care within the first 21 days– many for non-guideline-recommended medications such as opioids.

Patients were stratified based upon their likelihood of transitioning to chronic LBP: low, medium or high risk. Overall, about a third (32 percent unadjusted) transitioned from acute to chronic: approximately one fifth of low-risk patients, a third of medium-risk patients and almost half of high-risk patients.

A patient whose primary care medical doctor provided two or more forms of nonconcordant care was more likely to transition to chronic than a patient stratified in the medium-risk category. The nonconcordant actions of the MD effectively moved the patient from low risk (one in five chance of becoming chronic) to medium risk (one in three chance) or almost high risk (even chance). Overall, exposure to one, two or three forms of nonconcordant care increased the odds of transitioning to chronicity incrementally.

The above is not lost on health payers, who enjoy the ability to analyze large data to better understand what works. That's why we've seen recent guidelines for low back and other musculoskeletal pain recommend acupuncture and other forms of conservative care first.

Reference

1. Stevans JM, et al. Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Netw Open, 2021;4(2):e2037371.

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