I welcome the new recommendations by the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists (ANZCA), as published on 14 February 2018 by Choosing Wisely Australia. These recommendations address the growing concerns over the prescription of pain medicines and spinal fusion surgery for lower back pain. Recent studies have demonstrated that an overwhelming amount of research reveals most pain medicines had little to no effect compared to placebos in treating lower back pain. GPs are now unlikely to recommend pain medicines in response to changes in major international guidelines for the management of lower back pain.
The five recommendations by ANZCA are:
1. Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic non-cancer pain.
2. Do not continue opioid prescription for chronic non-cancer pain without ongoing demonstration of functional benefit, periodic attempts at dose reduce and screening for long-term harms.
3. Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain.
4. Do not prescribe benzodiazepines for low back pain.
5. Do not refer axial lower lumbar back pain for spinal fusion surgery.
The highly respected American College of Physicians (ACP) low back pain guidelines recommend clinicians and patients should select nonpharmacological approaches for low back pain, several of which are commonly utilised by chiropractors. For example, for acute and subacute low back pain these recommendations include superficial heat, massage and spinal manipulation among other options where pharmacological treatment is not desired. For chronic low back pain, the guidelines recommend a range of nonpharmacological treatments including exercise therapies, rehabilitation and spinal manipulation.