Crooked

1. The Back Pain Industry is a Profiteering Maze of Misinformation

Back trouble, in all its permutations, costs the United States roughly $100 billion a year, more than is spent annually to treat cancer, coronary artery disease, and AIDS (acquired immunodeficiency syndrome) combined.

A broken system. The back pain industry is a microcosm of everything wrong with healthcare, driven by financial incentives rather than patient well-being. The author's six-year investigation revealed a landscape where procedures once hailed as "gold standards" were discredited, and primary care doctors inadvertently launched an opioid epidemic. This system often traps patients in a relentless loop of ineffective and harmful treatments.

Perverse incentives. Every stakeholder, from device manufacturers to painkiller companies and even lawyers, benefits financially from prolonged back pain. Workers' compensation laws, for instance, incentivize aggressive and invasive medical care, as more complex procedures lead to larger settlements. This creates a system where:

• Surgeons have investments in radiology clinics, leading to more scans.
• Interventional pain physicians profit from injections, regardless of efficacy.
• Device manufacturers push inadequately tested spinal instrumentation.

Patient vulnerability. Patients, desperate for relief, become easy targets for hype and misinformation. They tend to overestimate treatment benefits and underestimate downsides, especially when faced with providers who may not admit their limitations. This "optimism bias" often leads individuals down therapeutic dead ends, commonly resulting in more harm than help.

2. Routine Imaging and Injections Often Lead to Unnecessary Harm

“A diagnosis that is based on magnetic resonance imaging, in the absence of objective clinical findings,” Boden wrote, “may not be the cause of the patient’s pain, and an attempt at operative correction could be the first step towards disaster.”

Misleading scans. MRIs, initially seen as a diagnostic breakthrough, became a gateway to unnecessary interventions. Studies show that a vast majority of asymptomatic individuals (people without back pain) have "abnormalities" like degenerated or bulging discs, making such findings on a scan often irrelevant to the patient's actual pain. Yet, these "incidentalomas" frequently panic patients and drive them towards surgery.

Financial drivers. The proliferation of MRI machines created a strong financial incentive for doctors to order scans, often without clinical justification. Many primary care practitioners and spine surgeons set up their own radiology clinics, referring patients to themselves. This led to:

• Radiologists being pressured to find "operable" issues.
• A significant increase in referrals to spine specialists for interventions and surgery.
• The American College of Physicians recommending against routine spinal imaging.

Ineffective injections. Epidural steroid injections, a bread-and-butter procedure for interventional pain physicians, have been shown to be largely ineffective for spinal stenosis or typical low back pain, with only small, unsustained benefits for sciatica. Furthermore, these injections carry serious risks, including:

• Loss of vision, stroke, paralysis, and death.
• Dura mater puncture leading to severe headaches or adhesive arachnoiditis.
• Contaminated solutions, as seen in the NECC fungal meningitis outbreak.
• Increased risk of vertebral compression fractures due to glucocorticoids.

3. Spinal Fusion and Artificial Discs Are Overused, Risky, and Ineffective

At an American Academy of Orthopaedic Surgeons conference in the summer of 2010, a hundred surgeons were polled as to whether they’d personally have lumbar spinal fusion surgery for unspecific low back pain. The answer—from all but one—was “absolutely not.”

Surgeons' reluctance for self-surgery. Despite recommending it to patients, most spine surgeons would not undergo lumbar spinal fusion for nonspecific low back pain due to its low success rate (barely 40%) and significant risks. This procedure, which involves excising discs and connecting vertebrae with hardware, often leads to:

• Pain reduction of only about half, with continued painkiller use.
• "Failed backs" requiring repeated revision surgeries.
• "Adjacent segment deterioration" due to increased stress on other vertebral segments.

Dangerous innovations. The history of spinal implants is fraught with issues, from Steffee's unapproved screws to the interbody fusion cage and BMP-2 (Infuse Bone Graft). These devices were often rushed to market with inadequate testing and promoted for off-label uses, leading to:

• Life-threatening complications, including swelling, nerve damage, and even cancer promotion.
• Surgeons receiving millions in payments from manufacturers, creating severe conflicts of interest.
• The "federal preemption doctrine" often shielding manufacturers from lawsuits.

Artificial disc failures. Artificial disc replacements, designed to preserve motion, also proved problematic. Devices like the Charité and ProDisc-L showed poor outcomes, with many patients experiencing unrelenting pain, device breakage, or fusion around the implant. Surgeons often implanted these devices off-label, and patients traveling abroad for these "cutting-edge" procedures frequently found themselves worse off, with no legal recourse.

4. The Opioid Epidemic Was Fueled by Misleading Medical Marketing

“The reason we have a severe epidemic of opioid addiction,” Kolodny said, “is that we have overexposed the U.S. population to opioid pain medicine. The people who are using heroin are out there using heroin because they were first addicted to opioid pain medicines.”

A manufactured crisis. The widespread use of opioids for chronic non-cancer pain was not a natural evolution but a deliberate marketing strategy by pharmaceutical companies like Purdue Frederick. They leveraged medical marketing tactics, including:

• Funding "patient advocacy organizations" and "continuing medical education."
• Using charismatic doctors like Russell Portenoy to promote the drugs.
• Distributing promotional videos claiming low addiction rates (e.g., "I Got My Life Back").

Misinformation and consequences. Purdue aggressively promoted OxyContin, claiming addiction was "distinctly uncommon" and that there was "no ceiling dose." This led to:

• The Joint Commission declaring pain the "fifth vital sign," pressuring doctors to prescribe.
• State medical boards threatening licenses for insufficient pain treatment.
• A dramatic increase in opioid prescriptions, with primary care doctors writing half of them.

The human cost. The consequences were devastating. Patients like Olivier Laude and Johnny Sullivan (featured in Purdue's videos) became addicted, suffering from opioid-induced hyperalgesia (increased pain), lethargy, depression, and eventually, death. The CDC's 2016 guideline revealed a chilling statistic: "one out of every 550 patients started on opioid therapy died of opioid-related causes." This doctor-driven epidemic has created a "lost generation" of patients struggling with opioid-use disorders, often turning to heroin when prescriptions become harder to obtain.

5. Chronic Pain is a "Head Case": Your Brain's Role is Paramount

“There’s that saying, ‘It’s all in your head,’ but for me, it really was. I’m very type A. I work very hard and I say yes to too many things. I’d been through a very difficult period caring for my mother, and the stars just lined up. Stress affects different people in different ways, and unrelenting back pain was how it affected me.”

Beyond mechanics. Chronic back pain is often not solely a structural problem but a complex interplay with the central nervous system. Conditions like "central sensitization" mean the brain itself generates pain signals, even in the absence of actual injury. This neurobiological learning disorder can transform the brain, reducing gray matter density and altering communication between regions responsible for motivation and pleasure.

Psychological roadblocks. Fear-avoidant behavior, pain catastrophizing, and guarding are significant psychological barriers to recovery. Patients, often told their spines are fragile, become fixated on worst-case scenarios, inadvertently weakening muscles and perpetuating pain. John Sarno, a physiatrist, pioneered the "tension myositis syndrome" (TMS) theory, arguing that:

• Pent-up rage and emotional turmoil manifest as physical pain.
• Convincing patients their pain is emotional, not structural, can lead to recovery.
• His approach, though initially dismissed by the medical community, helped thousands.

The power of belief. Sarno's work, later supported by brain imaging, demonstrated that the mind and body are inextricably linked. Patients who embraced his mind-body connection often cancelled surgeries and stopped relying on passive treatments. The core issue is often the fear of pain and disability, which can be overcome by understanding that discomfort doesn't always equal harm.

6. Active Rehabilitation is the Proven Path to Lasting Recovery

“The worst thing you can do as a practitioner is to allow the patient to believe that a passive approach to recovery—something I do to you, or for you—is plausible, because it isn’t. There is nothing I can do for people who are not willing to maintain their gains with regular, specific exercises meant to strengthen their particular weaknesses.”

Beyond passive care. The myth that "if it hurts, don't do it" has led to muscle atrophy, stiffness, and prolonged disability. Effective rehabilitation emphasizes active, not passive, care. Chronic Pain Rehabilitation Programs (CPRPs) are interdisciplinary, intensive, and evidence-based, focusing on:

• Physical reconditioning (strengthening, stretching, aerobics).
• Cognitive behavioral interventions (stress management, sleep strategies).
• Occupational therapy and vocational training.

Functional restoration. Programs like the Rehabilitation Institute of Chicago's "Chronic Pain Boot Camp" and Dartmouth-Hitchcock's Functional Restoration Program transform disabled patients into active individuals. They challenge patients to push through discomfort, proving that movement is safe and beneficial. Key elements include:

• Non-pain-contingent, quota-based exercise.
• Eliminating kinesiophobia (fear of movement).
• Group dynamics to combat social isolation and foster camaraderie.

Cost-effective and transformative. While initially expensive, CPRPs are significantly more cost-effective than surgery in the long run, with studies showing up to a 90% reduction in healthcare costs post-rehab. They address the root causes of disability, helping patients regain function, return to work, and reduce reliance on painkillers. The success of these programs highlights the need for insurers to shift reimbursement from invasive procedures to comprehensive, active rehabilitation.

7. Master Your Movement: Posture and Body Awareness Transform Pain

“The best posture is always the next one,” explained Opsvik, and therefore the best way to sit was to cycle through various postures during the day.

Beyond "sitting straight." The conventional advice to "sit straight" is often counterproductive, leading to fatigue and poor posture. Research suggests a 135-degree torso-to-leg angle is better for disc pressure. The key is dynamic movement and awareness, not static perfection. Ergonomic solutions like the Locus workstation encourage perching, wiggling, and swaying, promoting continuous micro-movements.

Re-educating the body. Techniques like Feldenkrais, Rolfing, and the Alexander Technique focus on re-educating the body's movement patterns and improving proprioception (awareness of body in space). They help individuals:

• Unshackle from limited postural vocabularies and ingrained habits.
• Release chronic muscle tension and fascial restrictions.
• Develop "conscious control" to inhibit bad habits and foster innate good ones.

Eastern wisdom. Practices like Iyengar yoga, Tai Chi, and Qigong offer gentle, joint-sparing approaches that enhance strength, flexibility, balance, and posture. They emphasize:

• Precise structural alignment and the use of props (Iyengar).
• Spiraling, circular movements and spinal extension (Gyrotonic).
• Natural balance, fluidity, and energy flow (Tai Chi/Qigong).

These methods, often requiring dedicated practice, help individuals overcome fear of movement, reduce pain, and cultivate a strong, confident physical presence, transforming their relationship with gravity and their own bodies.

Last updated: March 1, 2026