Chronic Low Back Pain Treatments Must Be Weighed Against Risk, Cost, and Limited Benefit

Chronic low back pain remains one of the most common and burdensome pain conditions worldwide, affecting an estimated 619 million people globally in 2020, with cases projected to increase to 843 million by 2050.¹ Although many patients seek long-term relief through medications, injections, procedures, or implantable devices, growing evidence suggests that some high-risk interventions may provide limited benefit while exposing patients to substantial harm, cost, and treatment burden.^1-3

In an interview with Pharmacy Times, Caitlin Jones, PhD, postdoctoral research associate at the Institute for Musculoskeletal Health, said health care professionals should reevaluate chronic low back pain treatments that carry high risk but offer little evidence of meaningful improvement.

“The treatments that most urgently need reevaluation are high-risk interventions, including invasive procedures such as surgeries and implants, as well as certain high-risk medications,” Jones explained. “These treatments can carry substantial risks while providing relatively little benefit.”

Jones said this is especially concerning when patients assume significant risk in pursuit of relief but are unlikely to experience a clinically meaningful benefit.

“High-quality randomized controlled trials have shown that many of these interventions offer either no benefit or only minimal benefit. Patients may therefore be taking on considerable risk with little chance of experiencing a meaningful improvement, which raises ethical concerns,” she said.

Spinal Cord Stimulators Raise Concerns About Evidence and Marketing

Jones identified spinal cord stimulators as a key example of a high-risk, low-reward intervention that warrants closer scrutiny. Spinal cord stimulation involves implantation of a device that delivers electrical impulses to the spinal cord, and it has been used for persistent low back pain; however, a 2023 Cochrane review determined that spinal cord stimulation probably does not improve back or leg pain, function, or quality of life compared with placebo at 6 months. The same review concluded that current evidence does not support use of spinal cord stimulation to manage low back pain outside of a clinical trial.³

“Clinicians and pharmacists need to understand that high-quality, blinded randomized controlled trials have shown that spinal cord stimulators are not effective at reducing pain,” she said. “The increase in their use is being driven, in part, by hype and effective marketing that can masquerade as science.”

Jones said that patient-facing messaging can present spinal cord stimulation as minimally invasive or as a safer alternative to long-term opioid therapy, but emphasized that these descriptions may not fully reflect the nature of the procedure or its risks. “The procedure involves placing an electrical lead between the vertebrae to deliver electrical impulses to the spinal cord. That lead is powered by a battery implanted in the buttock. I would not describe that as minimally invasive.”

Potential harms associated with spinal cord stimulation include infection, lead migration, neurologic injury, and repeat surgery. In the Cochrane review, 1 placebo-controlled study that followed patients for 12 months showed that approximately 18% experienced adverse events (AEs) and 8% required revision surgery. Another study found that 31% of patients receiving spinal cord stimulation required revision surgery at 24 months.³

“I understand why someone living with chronic low back pain—particularly someone who has tried many treatments without finding relief—may be willing to accept some risk in the hope of regaining part of their quality of life,” Jones said. “However, the way these devices are advertised to patients is often not transparent about the evidence demonstrating that they do not work better than placebo, the seriousness of the potential harms, or the likelihood that additional surgery may be required to correct complications.”

Opioids May Offer Small Benefits While Risks Accumulate

Long-term opioid therapy is another area where Jones said clinicians should carefully assess whether treatment benefits outweigh potential harms. A systematic review and meta-analysis published in JAMA revealed that opioids were associated with statistically significant but small improvements in pain and physical functioning among patients with chronic noncancer pain, while also increasing the risk of AEs such as vomiting.⁴ In that analysis, opioid use was associated with a pain reduction of 0.69 cm on a 10-cm scale compared with placebo, a difference below the 1-cm minimally important difference threshold.⁴

“For chronic low back pain, opioids provide very small benefits over placebo,” Jones said. “On average, the difference is approximately 1 point on a 10-point pain scale, which is around the threshold at which people may be able to detect a difference.”

The CDC’s 2022 opioid prescribing guideline emphasizes individualized, patient-centered pain care and warns that the guideline should not be used as an inflexible standard or to justify abrupt discontinuation of opioids in patients already receiving therapy.⁵

Jones echoed this point, particularly for patients who have developed physiological dependence. “The risks associated with opioids are particularly well understood. Physiological dependence can develop, the pain-relieving effects may diminish over time, and patients may need progressively higher doses. Higher doses can lead to more AEs, such as constipation and dizziness, as well as increased risks of serious outcomes, including addiction, overdose, and death.”

Jones emphasized that physiological dependence is not the same as addiction. Patients who miss a dose, reduce a dose, or attempt to stop opioids may experience withdrawal symptoms that can be mistaken for worsening pain.

“Patients can misinterpret those symptoms as evidence that the medication was effectively treating their condition, thinking, ‘The opioid must have been working because I felt terrible when I stopped taking it,’” she said. “However, what they are experiencing may be opioid withdrawal, and it can be difficult to distinguish withdrawal symptoms from the underlying pain condition.”

For pharmacists, this distinction is critical when counseling patients on opioid safety, identifying AEs, and supporting tapering plans. Jones said any opioid reduction should be gradual, medically supervised, and patient-centered.

“Patients who want to reduce their opioid use should do so slowly, under careful medical supervision, and with as much support as possible,” Jones emphasized. “Tapering must also be consensual. Considerable harm has been caused by withholding or discontinuing opioids without the patient’s agreement.”

Pharmacists Can Help Identify When Treatment Burden Outweighs Benefit

While pharmacists may not directly manage implantable devices or perform procedures, they can play an important role in helping patients evaluate the medication-related and overall burden of chronic pain treatment. This includes asking about pain, AEs, cost, function, and quality of life.

“The most important information often comes from the patient,” Jones said. “Clinicians should ask how the patient’s pain is changing, what AEs they are experiencing, how bothersome those effects are, how much the treatment costs, whether they can continue to afford it, and how their symptoms have changed over time.”

Jones said patient preference remains central. A patient may decide that certain AEs are tolerable if the treatment provides meaningful relief. However, when benefits are minimal, uncertain, or driven more by expectation than evidence, clinicians have a responsibility to help patients understand the tradeoffs.

“The patient’s perspective on their overall quality of life is also essential. A person may be experiencing AEs but still believe that the relief they receive makes those effects worthwhile. That is a personal decision,” she emphasized.

The WHO guideline for nonsurgical management of chronic primary low back pain emphasizes evidence-based, primary and community care approaches and identifies pharmacists among the health workers who may use these recommendations in practice.² For pharmacists, this creates an opportunity to support safer chronic pain care through medication review, counseling, AE monitoring, opioid risk mitigation, and referral to appropriate nonpharmacological or multidisciplinary care when needed.

System Incentives May Push Patients Toward Lower-Value Care

Jones said patients may also be harmed when health system incentives make lower-value treatments easier to access than safer, multidisciplinary approaches. She noted that in Australia, medications, surgeries, and injections may be available at low cost through the public system, whereas services such as physiotherapy or psychological care may involve out-of-pocket expenses.

“When patients are conscious of cost—and most [of them] are—they may be funneled toward medications and surgeries that cost them less out-of-pocket, but provide lower value because their benefits are smaller and their risks are greater,” Jones said.

Guidelines are intended to help health care professionals interpret evidence and make individualized treatment decisions, but Jones said they may be outdated, unavailable, influenced by conflicts of interest, or difficult to apply in practice.

“Despite good intentions, harm can occur because clinicians and patients do not always have access to trustworthy, digestible, and up-to-date summaries of the evidence needed to guide treatment decisions,” Jones said.

Jones said improving chronic low back pain care will require reducing marketing influence and restructuring systems so that high-value, lower-risk treatments are easier for patients to access.

“I would restructure the system so that high-value, low-risk treatments, including allied health and multidisciplinary interventions, were also the most affordable and accessible choices,” Jones said. “At present, the incentives are often backward, and patients may be nudged toward less effective treatments, including certain medications and surgeries.”

For pharmacists, the broader takeaway is that chronic low back pain treatment should not be evaluated solely by whether a patient is receiving an intervention, but whether that intervention provides enough meaningful benefit to justify its risks, costs, and long-term consequences. As patients navigate complex pain care decisions, pharmacists can help reinforce realistic expectations, monitor medication-related harms, and support evidence-based conversations about safer, higher-value approaches.

REFERENCES

1. GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(6):e316-e329. doi:10.1016/S2665-9913(23)00098-X

2. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: World Health Organization; 2023. Accessed July 17, 2026. https://www.ncbi.nlm.nih.gov/books/NBK599212/

3. Traeger AC, Gilbert SE, Harris IA, Maher CG. Spinal cord stimulation for low back pain. Cochrane Database Syst Rev. 2023;3(3):CD014789. doi:10.1002/14651858.CD014789.pub2

4. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: A systematic review and meta-analysis. JAMA. 2018;320(23):2448-2460. doi:10.1001/jama.2018.18472

5. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1