Anyone who has endured back pain knows it is an erratic dictator. It takes hold of your psyche, demanding your attention and devotion before all else—before you can plan a hike, return to a work routine, pick up your child for a hug. So when someone offers to make that dictator disappear, it’s hard to resist—no matter what the price.

“People in pain are poor decision-makers,” says the investigative journalist Cathryn Jakobson Ramin, author of a new book, Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.

Millions of such bad decisions, she argues, have fueled a $100-billion-per-year back pain industry in the US—one that’s largely selling Americans wrong and even dangerous responses to back discomfort. These include unnecessary painkillers, injections, surgeries, and chiropractic “adjustments.”

About 80% of Americans are expected to suffer from at least one episode of lower back pain in their lifetime, and millions with chronic pain are already lost in the industry, subjected to pseudo-interventions, or taking unnecessary and addictive opioids like Vicodin or Oxycontin, then doubling down on the drugs as their tolerance and the pain escalates. (In some cases, the increased pain is actually caused by the opioids.)

The truth is, as Ramin’s extensive research indicates, all that most people need to do is keep moving.

From diagnosis to treatment, a dearth of evidence

It’s hard to choose one data point from Crooked that lays bare all the misrepresentation and snake oil in the back pain industrial complex, but a few key statistics that Ramin has collected stand out.

Spinal fusion surgery, for instance: Involving the removal of worn-out or injured discs, then the fusing together of the vertebrae above and below that disc with metal screws and cages, this is the form of elective surgery that people spend the most on in the US, costing a total of $40 billion per year. The problem is, it rarely works.

The procedure, with a price tag averaging $80,000, has a success rate of about 35%. Those most likely to benefit are the young, trim, and athletic, not the typical surgery candidates, whose average age was 54 in a 2008 study by the Spine Research Foundation. (Smoking, being overweight, and taking opioids before the surgery each also reduce the likelihood of a positive outcome.) Even its “successful” patients often end up on painkillers two years after the surgery, according to studies, Ramin writes.

Such conclusions should have shut down the market for unnecessary fusion surgeries, she proposes. Instead, the number of operations performed every year increased 600% between 1993 and 2011, jumping from 61,000 annual procedures to more than 465,000.

To be sure, some of those surgeries were required to treat dire conditions and the threat of paralysis. As Ramin writes, surgeons “do essential things: They repair traumatic injuries; they excise spinal tumors; they fix congenital abnormalities.” Such procedures are not the bread and butter for most spinal surgeons, she found, except for the elite few who tend to work at academic medical centers. Spinal surgeons more often treat people diagnosed with pain that’s labelled something like “nonspecific,” “axial,” or “functional.”

Also consider this: In a poll at a 2009 conference in Bonita Springs, Florida, 99 out of 100 surgeons who were asked whether they’d elect to have lumbar fusion surgery if it were recommended to them said “absolutely not.”

They were too keenly aware of the odds, and they would have known that after the invasive operation, the spinal sections around the welded-together vertebrae are more likely to weaken, since they’re forced to compensate for the unnatural immobility of their neighbors. Some surgeons recommend a second or third revision operation, with the rates of success dropping each time.

The procedure itself is risky, too. When you go in through the abdomen for any spinal surgery, Ramin tells Quartz, “you have to go through muscle. You detach muscles, you detach ligaments, and ligaments in particular don’t regenerate quickly at all, so you weaken the entire system.” Even when the surgeon enters the patient’s body through his or her back or side, the actual fusing is done perilously close to the spinal cord.

Another common operation, decompression surgery, or a discectomy, has better evidence to support its outcomes, especially to resolve leg pain, Ramin acknowledges. But she says even this cheaper and less invasive procedure, which eases pain by removing bone or tissue that’s putting pressure on a spinal nerve, may not be necessary for many patients.

“The problem is, when you look at the studies, two years out, the outcomes from having that procedure [for a disc herniation] and not having that procedure are the same,” she explains. “Because there is a lot of rehab involved if you do have it, and the natural history of a disc herniation is that it will go away and disintegrate within a month or so, and disappear.”

It also carries similar risks as fusion surgery. Ramin points to Steve Kerr, coach of the Golden State Warriors NBA team, who underwent decompression surgery two years ago: it apparently led to a spinal fluid leak, which caused debilitating headaches and nausea.

Even the diagnosis of back pain can involve some chicanery. Spine surgeons told Ramin that in an estimated 80% to 85% of cases, they can’t point to a person’s source of pain with accuracy, although they can see something abnormal on an X-ray or MRI. That’s because studies have shown that most people are walking around with bulging or worn out discs, but feel nothing, so these indicators on an MRI aren’t always meaningful.

As Ramin writes in Crooked, “The ambiguity inherent in diagnosing back pain makes it possible for surgeons to do practically anything they want.”

Finally, bad news for those who have turned away from modern medicine and toward chiropractors (practitioners of a drug-free approach that has gained mainstream approval): Ramin also spends a chapter debunking traditional chiropractic, that which involves cracking and “adjustments.”

Her summary of the treatment’s roots certainly inspires skepticism:

A self-proclaimed healer born in 1845 near Toronto, Daniel David Palmer was the father of chiropractic. He began as a revival tent mesmerist and entertainer who could make people fall asleep, dance wildly, or tumble into convulsions. Later, he described a “vitalistic force” or “innate intelligence” that existed in the spine; it could organize, maintain, and heal the body. But vertebral subluxations could derail that energy, with dire physiological consequences.

Subluxations are said to be spinal joints that have slipped out of alignment, and some chiropractors will explain that they lead to back pain, digestive issues, mood disorders, and more. Ramin reports that they are impossible to point at on an x-ray, because they don’t exist; a dislocated joint in your spine would be the result of a horrendous injury that sends you to the hospital, she explains, not to a massage table.

Chiropractic manipulation combined with other treatments, such as heat applications and massage, has been found to offer short- to medium-term relief for lower back pain and disability. Critics say, however, that the the forceful thrusts that chiropractors apply to the spine push the vertebral joint beyond its natural range of motion, and the World Health Organization says the modality is counter-indicated for several conditions (PDF).

If someone feels less pain after a chiropractic visit, it’s usually the result of a rush of endorphins, which eventually run out, Ramin said in a Canadian Broadcasting Corporation radio interview. Typically, the pain returns. If it doesn’t, there’s a chance a person would have had the same outcome without care.

Importantly, there are non-conventional chiropractors who have walked away from “adjustments” and other questionable therapies over the past decade or so. “They have restyled themselves as rehabilitation specialists,” which means they’re training patients in effective back-strengthening exercises as a reliable physical therapist would, she tells Quartz, “and are doing a great job with it.”

A back pain folk hero is born

Ramin wasn’t fully aware of spinal surgery’s poor rates of success when she decided to see a back surgeon for her own chronic back and leg pain nearly a decade ago. Then a freelance journalist, having just published a book on memory in middle age, she was frustrated and baffled by her own lack of progress, and her questions led her stumbling into a public health story that would take more than 600 interviews and eight years to write.

Crooked weaves together her compelling personal story and those of compatriots in back pain of all ages. It also follows the money, revealing the hidden motivations of many industry players: workers compensation insurance companies, pain management specialists, the drug companies that make narcotic painkillers, personal injury lawyers, spinal device makers, and spinal surgeons, especially the ones who advertise late at night, often touting their laser surgery. All appear to make a living by exploiting the “fix me” pleadings from people in pain.

This is not to suggest that all spine surgeons or specialists are villains, of course. Sometimes surgery is necessary, though many top spine specialists interviewed for Crooked agreed that surgery is overused. A spinal surgeon at Cedars-Sinai Medical Center in Los Angeles, Hyun Bae, explained why this might be, saying, “It’s not only a financial conflict. It’s an emotional conflict. We get paid to do the work. We want to make the patient better. So we concentrate on the good results and we dismiss the bad results.”

The problems often begin, Ramin tells Quartz, when patients are ill-informed. They might demand MRIs for acute pain, though their primary care doctor discourages it. They might also be influenced by direct-to-consumer advertising from less reputable spine centers. “When they go see his surgeon and the surgeon says, ‘I’m sorry I can’t help you this. There’s nothing I can do for you,’ the tendency is to misunderstand that, and to think ‘You’re not smart enough. You’re not good enough; you don’t have the right high-tech whiz-bang tools,’” she tells Quartz, “and I need to keep looking. I need to find someone who is smart enough to do this.’”

Carol Hartigan, M.D., medical director of the Spine Center and the Spine Rehabilitation Program at New England Baptist Hospital, tells Quartz that she agrees with most of Ramin’s critiques, though she finds the author extreme in her opinions—for example, by saying that a person should never have back surgery. Still, Hartigan says, “She did an outstanding job of researching. She had an eye for looking for flaws in the ‘industry,” and she interviewed the highest level players. She should be commended.”

Most reputable spine surgeons will discourage people from surgery when they don’t think it will be helpful, but “You do see some crazy ways that people are treated by high level clinics,”says Hartigan. They neglect to offer people an option to get better, she asserts, which, in her practice, would involve physical rehabilitation and systemically progressive resistance exercises.

After only a month in bookstores, Crooked began shooting up the Amazon bestseller list, because back pain is so universal and so emotional. “It’s part of the human condition,” Ramin told San Francisco public radio. “Few of us will make it off this mortal coil without it.”

As a person ages, the discs in one’s back naturally dry up, especially when a person isn’t active, and our lifestyles have only become more sedentary and sitting-focused, complicating matters tremendously. A meta-study published in the British Medical Journal found lower back pain to the be the number one cause of disability worldwide, affecting 83 million people globally.

Doctors are now advised not to turn to pain medication for garden variety back pain, but for years, we know too well, powerful painkillers, whose drug companies spent millions on marketing, were over-prescribed for back pain, arthritis and other conditions, creating an environment that made the drugs easy for anyone to access, and led to today’s opioids (and related heroin) crisis.

Dependence comes easy with these drugs: In March 2017, a report from the Centers for Disease Control and Prevention found that when a person takes a narcotic painkiller for one day, there’s a 6% chance that he or she will be still taking that pill a year later. If the prescription is for eight or more days, that probability rate jumps to 13.5%.



The unpopular truth about recovery

The media has raised awareness about the hustlers of the back pain industrial complex before Crooked’s publication. Surgery has been outed as, for many patients, “useless.” When, in early 2017, the American College of Physicians issued new guidelines saying that strong opioids such as Vicodin and Oxycontin should only rarely be prescribed for nonspecific back pain, reporters helped get the word out, while calling out the back pain businesses for their role in the current opioid crisis.

Nonetheless, the prescriptions and surgeries continue, partly because patients want the pain to go away—now. To many it seems counterintuitive that exercise is doable or the right solution when someone is already suffering.

As Ramin also told CBC radio, the psychologists she spoke to for the book talk about a cognitive shift that’s needed to “understand that yes when you start exercising there will be pain. There definitely will be because you are just as out of shape as all get out. But in the right hands, in the hands of a back whisperer, you can get through that and you can get strong and you can get your back muscles and the rest of your body balanced and you can straighten out your gait and you can straighten out your posture.”

The second half of Crooked is a guide to finding those right hands. Ramin shares her tips for tracking down a back whisperer—such as a physiologist or a doctorate-level physical therapist who’s also an orthopedic clinical specialist—to coach you through recovery.

She introduces Stuart McGill, a professor of kinesiology at University of Waterloo, in Ontario, Canada, and a globally recognized “back mechanic,” whose “big three” exercises she does daily:

The author is often asked for her thoughts on certain forms of exercise, such as yoga or pilates, which she also covers on her website. What she tells people, repeatedly, is that “movement is essential.”

“We’re sitting for 50 to 60 hours per week,” she says. We sit at our desks, in our cars, at the dinner table, and we sit to write email messages from bed at night. “We think three hours of exercise on the weekend will undo the problems that creates,” she laments. Even standing desks aren’t the easy out, as standing the wrong way all day can lead to different issues. Her mantra: “The best posture for sitting is always the next posture.”

Unfortunately, even as pro-exercise messages gain more traction here, some of the shadier players of the back pain industrial complex are taking their very different mantra into new markets. Ramin found that in China and Japan, spinal surgeries “are expected to nearly triple in number between 2014 and 2020, and almost double in revenues, with more than a little encouragement from US spinal device manufacturers.”

Correction: An earlier version of this story said that Steve Kerr had spinal fusion surgery. He had decompression surgery.

Read an excerpt from CROOKED: How doctors, the government, and big pharma teamed up to pump Americans full of opioids