Understanding Evidence

What does the evidence show for conventional treatments?

TL;DR — What the Evidence Shows

We look at conventional treatments with the same scrutiny as acupuncture. Many common treatments for chronic back and neck pain have limited long-term evidence and real risks.

Physical therapy and exercise have the strongest evidence and the lowest risk. NSAIDs (pain drugs like ibuprofen) help short-term but can harm the stomach and heart. Opioids have no evidence for chronic pain beyond 16 weeks. Surgery for general low back pain shows poor average results in clinical trials.

Physical therapy and exercise

Moderate Certainty for chronic LBP and neck pain

Exercise and physical therapy have the strongest evidence and lowest risk among all treatments for chronic musculoskeletal pain. Multiple systematic reviews support their use for chronic low back and neck pain.

Limitation: effect sizes are moderate and patient adherence is a significant factor. Supervised exercise shows stronger evidence than home exercise programs alone.

Hayden JA et al. "Exercise therapy for treatment of non-specific low back pain." Cochrane Database Syst Rev. CD000335. (Updated 2021.)

Cognitive Behavioral Therapy (CBT)

Moderate Certainty for chronic pain with psychological components

CBT addresses the central sensitization and psychosocial components of chronic pain that physical interventions cannot reach. Moderate evidence supports its use as part of a multimodal approach, particularly for patients with significant pain catastrophizing or depression.

CBT is not a denial that pain is "real" — it is a recognition that chronic pain becomes a CNS phenomenon partly independent of tissue damage, and that cognitive and behavioral factors modulate pain experience.

Williams ACC et al. "Psychological therapies for the management of chronic pain (excluding headache) in adults." Cochrane Database Syst Rev. 2020;CD007407.

NSAIDs (ibuprofen, naproxen, diclofenac)

High Certainty for short-term pain relief

NSAIDs are effective for short-term pain reduction in both back and neck pain. The evidence base for short-term use is strong. The evidence for long-term chronic pain management (beyond 4–6 weeks of continuous use) is substantially weaker.

Risk profile

GI bleeding: estimated 5,000–16,500 GI deaths per year in the US attributable to NSAID use
Cardiovascular: increased risk of myocardial infarction and stroke; COX-2 inhibitors (celecoxib) increase CV risk while reducing GI risk
No safe option for patients with both CV and GI risk — no NSAID avoids both categories simultaneously
Kidney injury: increased risk with chronic use, particularly in patients with existing renal compromise

Bhala N et al. "Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs." Lancet. 2013;382(9894):769–779. PMID 23726390.

Opioids (oxycodone, hydrocodone, morphine, tramadol)

Low Certainty for chronic non-cancer pain; not supported beyond 16 weeks

There are no randomized controlled trials demonstrating opioid efficacy for chronic non-cancer pain beyond 16 weeks. This is a genuine absence of evidence — not evidence of absence — but it means long-term opioid use for chronic back pain lacks an evidence foundation.

The SPACE trial (2018) found opioids were not superior to non-opioid medications for chronic back and hip/knee pain over 12 months.

Risk profile

Addiction: estimated 8–12% of patients prescribed opioids for chronic pain develop opioid use disorder
Overdose deaths: 42,245 opioid-related overdose deaths in the US in 2016 (CDC); approximately 806,000 total 1999–2023
Physical dependence develops with regular use; discontinuation requires medical supervision
Opioid-induced hyperalgesia: paradoxical increase in pain sensitivity with long-term opioid use

Krebs EE et al. "Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial." JAMA. 2018;319(9):872–882. PMID 29509867.

Epidural steroid injections

Moderate Certainty for radicular pain (sciatica); short-term only

Epidural steroid injections have moderate evidence for short-term relief of radicular pain (pain radiating down the leg from nerve compression). The evidence for non-specific low back pain without radiculopathy is much weaker.

A key finding: adding corticosteroid to local anesthetic in epidural injections is no better than local anesthetic alone in RCT evidence, suggesting the steroid component may not be the active ingredient. Short-term relief from both may reflect the anesthetic and volume effect rather than the steroid.

Friedly JL et al. "A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis." N Engl J Med. 2014;371(1):11–21. PMID 24988555.

Spinal surgery (fusion for non-specific low back pain)

Low Certainty for non-specific LBP; stronger evidence for specific structural indications

For non-specific low back pain (the large majority of chronic LBP cases), spinal fusion surgery shows a non-significant 4.13-point difference on the Oswestry Disability Index versus no surgery in RCT evidence. This does not meet a clinically meaningful threshold.

Concerning pattern: regional variation

Spinal surgery rates vary up to 14-fold across US regions. This variation is not explained by patient characteristics or disease burden — it reflects non-clinical factors including local surgical culture and financial incentives. High variation is a reliable signal that decision-making is not driven purely by clinical evidence.

Surgery is appropriate for specific structural indications: significant spinal stenosis causing progressive neurological deficits, disc herniation with unremitting radiculopathy not responsive to conservative care, and unstable fractures. For non-specific chronic low back pain, the surgical evidence does not support routine use.

Fairbank J et al. "Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain." BMJ. 2005;330(7502):1233. PMID 15911537.

The overprescription context

The current treatment landscape for chronic pain reflects decades of over-reliance on procedures and medications with limited chronic efficacy and significant risks.

MRI ordering for low back pain increased sharply through the early 2000s with no corresponding improvement in disability rates. MRI findings often do not correlate with symptoms — and can trigger unnecessary escalation to intervention.
~806,000 people died of opioid overdose in the US between 1999 and 2023 (CDC).
Spinal surgery rates vary up to 14-fold regionally, indicating substantial non-clinical decision-making.

Key sources

Page last reviewed: March 7, 2026 · Authored by Claude (Anthropic AI) · Research methodology