I recently opened an email, forwarded to me by a friend who is a family physician, and it was titled, “New Guideline Strongly Recommends Against Common Treatments for Back Pain.” Well, long story short, considering I am a practicing interventional pain management physician, he is no longer my friend. Jokes aside, it was a sensational headline. However, it was not the first time I had heard about this guideline published in the British Medical Journal (BMJ). My mentors (Drs. Sayed and Deer) and I had discussed this guideline extensively prior to this email. Truthfully, we were horrified to learn that this guideline was even published, much less shared across various medical specialties. But, wait, it was published by the BMJ, so it has to be correct, right? Absolutely not, and this is now a dangerous problem.
In medicine, guidelines should serve as a roadmap for evidence-based care — aiding clinicians, improving patient outcomes, and ensuring access to necessary treatments. So, who can write guidelines? Well, apparently, anyone. What happens when guidelines are developed by nonexperts who lack real-world clinical experience? That’s simple: The guidelines can misrepresent evidence, threaten patient access, and be driven by undisclosed agendas. Spoiler alert, that’s exactly what happened with the BMJ Rapid Recommendations on interventional pain procedures developed through MAGICapp. What even is MAGICapp? No, it’s not a social network for magicians or an online dating platform. It’s a digital guideline development platform that has quietly amassed significant influence over clinical policies worldwide.
The real issue here is that although the BMJ guideline is headline worthy due to its sensational conclusions, it is very misleading and dangerous. First, let’s dive into MAGICapp and talk about their hidden agenda:
1) MAGICapp presents itself as a neutral, evidence-based platform for developing clinical guidelines. However, its financial and operational connections with organizations like the BMJ raise serious conflict-of-interest concerns. Specifically, the BMJ benefits financially from publishing guidelines. They charge fees for open-access articles and guideline development support.
2) MAGICapp’s business model relies on institutional partnerships, creating potential pressure to align recommendations with funding interests.
3) MAGICapp’s guidelines often favor generalized, restrictive interpretations of evidence, which can be weaponized by payers to deny coverage for necessary procedures.
4) MAGICapp is not just a passive tool — it actively shapes clinical policy. When those policies are driven by nonspecialists with questionable motives, patient care suffers immensely.
5) At the present time, due to the circumstances described above, MAGICapp is involved in civil litigation.
Now that we have a clearer picture of MAGICapp, let’s talk about the guideline published in BMJ. We encourage you to read the guideline yourself, but be aware of the following issues:
1) The guideline is based on cherry-picked randomized controlled trials while ignoring real-world data from registry studies. The meta-analysis relies on small, underpowered studies, leading to distorted conclusions.
2) There is a serious lack of multidisciplinary expertise, which excludes key interventional pain specialists. Nearly 50% of the authors are from a single institution and do not actively treat patients, nor do they have an interventional background. In fact, the first three authors are a chiropractor (PhD researcher), a rheumatologist, and a researcher with no clinical experience. Other contributors include medical students, postdoctoral researchers, internal medicine physicians, and physiatrists. It is crucial for a specialty-specific guideline to contain specialty-specific board-certified clinical experts who actually perform procedures on a daily basis, which would include pain management interventionalists and spine surgeons.
3) The guideline takes a “one-size-fits-all” approach that overgeneralizes against interventional care, despite evidence that most patients experience benefit. It misrepresents real-world risks, exaggerating rare complications and downplaying well-documented harms of opioid medications.
4) There were restrictive conflict-of-interest policies that eliminated leading experts from contributing, leading to skewed recommendations.
Unfortunately, this guideline’s sweeping recommendations could detrimentally impact patient access to necessary common pain procedures. The guideline panel was dominated by research methodologists and generalists, many of whom have never performed the procedures they were evaluating. This begs us to ask a few questions: How can nonspecialists accurately assess complex interventional pain procedures? Why were practicing pain physicians largely excluded from the process? What are the potential financial or institutional interests at play?
When flawed guidelines downplay the effectiveness of interventional pain procedures, the consequences extend far beyond academic debates. Insurance companies and policymakers rely on guidelines to make critical decisions on medical coverage and reimbursement. If a guideline misrepresents the evidence, which can be easily done, as demonstrated with the BMJ guideline, insurance companies can use it to deny necessary treatment approvals. This can leave patients and physicians blindsided with fewer and less effective treatment options to manage chronic pain.
As we’ve all been taught, the needs of the patient always come first. As such, in response, the American Society of Pain and Neuroscience issued a detailed rebuttal to the BMJ article, highlighting its methodological flaws, misrepresentation of evidence, and failure to incorporate expert clinical perspectives. Along with 33 other major academic professional pain medicine societies, we have strongly urged BMJ to retract this guideline and upload its commitment to rigorous, balanced, and evidence-based medicine. This is a critical time in health policy as we strive for effective, nonopioid treatment options for chronic pain. The BMJ guideline is dangerous and harmful to patient care. So, from one physician to another, please be careful when drawing conclusions based on this flawed guideline, and speak with a colleague who specializes in pain management. Similar to other clinical specialties, the practice of our specialty is not perfect, and our priority has always been to achieve great clinical outcomes with proper patient selection.
Dr. Trishul Kapoor is an interventional pain management physician and associate staff at The Cleveland Clinic Foundation. He is the assistant VP of compliance for The American Society of Pain and Neuroscience (ASPN).
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