The Price of Back Pain

After what seemed like a minor fall, Bruce Wilson began having back pain. That was 25 years ago. Since then the former manufacturing executive, now 60, has had seven operations—at a cost to insurance companies of $278,000. Yet Wilson's back still hurts, and he spends hundreds of dollars a month on pain relievers and other medications.

Now a surgery vet, Wilson has some hard-won advice for other sufferers: "I'd tell young people with back problems that they should try the nonsurgical avenues first." When doctors recommend an operation, says the Seattle resident, "we're all too quick to agree. As a society, we all want instant gratification or instant relief."

Despite a growing array of sophisticated drugs, diagnostics, physical therapies, and surgical techniques, the millions of Americans battling back pain may not be any closer to getting that quick relief than they were 20 years ago. Several recent studies indicate that even with the latest in high-tech medical intervention, effective treatments for back problems remain elusive. And in any case, the price tag is staggering.

In 2005 Americans spent $85.9 billion looking for relief from back and neck pain through surgery, doctor's visits, X-rays, MRI scans and medications, up from $52.1 billion in 1997, according to a study in the Feb. 13 issue of the Journal of the American Medical Association (JAMA). That money hasn't helped reduce the number of sufferers; in 2005, 15 percent of U.S. adults reported back problems—up from 12 percent in 1997.

Not only are more people seeking treatment for back pain, but the price of treatment per person is also up. In the JAMA study, researchers at the University of Washington and Oregon Health & Science University compared national data from 3,179 adult patients who reported spine problems in 1997 to 3,187 who reported them in 2005—and found that inflation-adjusted annual medical costs increased from $4,695 per person to $6,096.

Spinal patient costs were also significantly higher than for nonspinal patients. "People with back problems cost 76 percent more on average than people without back problems each year," says study co-author Brook Martin, a research scientist at the University of Washington.

"We seem to be doing more and more," says Dr. Rick Deyo, co-author of the JAMA report and Kaiser Permanente professor of evidence-based family medicine at Oregon Health & Science University. "[But] there's no evidence that people are getting more pain relief." In fact, they self-reported more work limitations and poorer functioning in 2005 than in 1997, he says. "This suggests to me that we're overtreating a lot of people, and we're providing a lot of services that may not be very beneficial."

High-tech imaging tests, for example, are a major money drain when it comes to treating back pain. "Patients want [imaging] and think that it will discover the answer for why they're having pain that can be fixed," says Deyo. "Doctors want it because they're afraid they'll be sued if they don't do it."

The tests are useful once a patient is committed to surgery, but before that "patients may want to think twice before they ask for them," says Deyo. "In part, we're just guilty of trying to keep hitting things with the same hammer over and over again and not taking a step back and rethinking the problem and considering whether an exercise program, more physical therapy, may be beneficial."

An ever-larger arsenal of prescription medicines is another huge factor in the cost of treatment. In the JAMA cost analysis study, expenditures for pain medicines increased about 423 percent from 1997 to 2005. During the same period the average bill for each pharmacy visit for a spine-related medication rose from $25 to $58.

The rise is due to more prescriptions being written—and to greater use of newer brand-name medications instead of generics. But Deyo believes that many patients can get "quite effective" pain relief with simple and cheap over-the-counter pain relievers such as ibuprofen and naproxen instead of expensive prescription drugs. And they can try a low-tech heating pad, too.

Having an operation to fix a back problem is costly both financially and in recovery time. But the jury is still out as to whether some of these procedures are worth it. According to a 2006 study published in JAMA, herniated disk patients who did not opt for surgery fared nearly as well after a two-year period as those who went under the knife.

Researchers said the differences in outcome between the two approaches were "small and not statistically significant." Deyo, a co-author of the 2006 report, said that risk-averse patients who prefer to avoid surgery would probably get better anyway, and risk takers who prefer surgery would probably get better faster and spend more money. It's largely "a matter of personal preference, which way you go," says Deyo.

The price tag for these procedures is hefty. Each year about 300,000 Americans have surgery for herniated disks—with hospital, anesthesia and surgery costs running around $10,000 per operation. The bill for a spinal fusion procedure is even higher, at about $60,000 per procedure for hospitalization costs in 2005. (That's more than double what it was in 2000.)

Nonetheless, Deyo isn't advocating an end to surgery and other treatments. "It's a matter of being more judicious about what we do, not stopping what we do," he says. "We all have a bias for action. Both doctors and patients hate the idea of just wait and see, or try something that doesn't seem very dramatic." But it's often the best bet.

"It's not so clear that a lot of the things we're doing are helping that much," says Deyo. "Most of the time you can take care of it yourself. It will get better. The odds are in your favor. Time is in your favor."

Aside from allowing time to heal, the best treatments may be the least dramatic: exercise more and lose weight. "They're harder to do than getting an injection or an operation or taking a pain pill," says Deyo. "People want something more than that, and lifestyle change is hard for all of us." But it's worth trying. "The take-home message is that some of these basics that we tend to ignore or overlook are probably the most important things," says Deyo.

This is not to say that all the expenditures on back pain treatments are for naught. The percentage of the population seeking treatment for back pain increased from 20.7 percent in 1997 to 24 percent in 2005—which may mean better access to treatment rather than a greater incidence of back pain, or ineffective treatments, says Dr. Alan Hilibrand, a professor of orthopedic surgery at Jefferson Medical College and a spokesman for the American Academy of Orthopaedic Surgeons. "Hopefully, people are having better access to the care they need."

Educating doctors about alternative treatments—even when a patient may be clamoring for high-tech intervention—may be another key to reducing costs and relieving pain. "They [patients] can't order drugs and tests for themselves. Somebody has to be offering them," says Dr. Michael Haak, a spine specialist and orthopedic surgeon at Northwestern University's Feinberg School of Medicine. "You need to encourage [doctors and patients] to be aware of all the alternatives."

Deyo is all too aware of those alternatives, both professionally and privately. He has had back problems himself. "I don't know how I got mine, like most people," he says. Now 58, he started feeling the pain in his mid-40s (and still occasionally gets twinges). He knew better than to demand MRIs and surgery. Instead he took ibuprofen and let it heal on its own. "Most people will have recurrences of back pain," he says. "Most of the time it's something you can take care of yourself, and you'll get better eventually."