Never use painkillers for back pain, new guidelines say

Never use painkillers to treat back pain, the American College of Physicians declares in new guidelines.

Patients should be content with massages, acupuncture, yoga, or superficial heat – even if the pain lingers up to 12 weeks.

Only when the pain becomes ‘chronic’ – lasting longer than three months – should patients turn to drugs as a last resort. 

At that point, doctors should go no further than administering ibuprofen or a similar non-steroidal anti-inflammatory drug. If that doesn’t work, they can prescribe something like tramadol. 

The American College of Physicians’ new guidelines say patients with back pain should try natural therapies for up to 12 weeks before trying over-the-counter pills or stronger opioids

Low back pain is one of the most common reasons for all physician visits in the U.S. 

Most Americans have experienced low back pain. 

Approximately one quarter of U.S. adults reported having low back pain lasting at least one day in the past three months.  

But most will start popping ibuprofen or paracetamol within days of the pain setting in. 

It is not unheard of for patients to receive opioids such as tramadol within the first three months of pain setting in.  

The new guidelines – released amid America’s drug addiction epidemic – warn this is ineffective and unnecessary.

In a radical update from the last guidelines from 2007, medics are now looking at mindfulness-based stress reduction and tai chi as first-line treatments. 

‘Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,’ said ACP president Dr Nitin Damle. ‘Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.’

The evidence showed that acetaminophen was not effective at improving pain outcomes versus placebo. 

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Low-quality evidence showed that systemic steroids were not effective in treating acute or subacute low back pain.

For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy.

This could include exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

‘For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another,’ Dr Damle said. 

‘Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.’

For patients with chronic low back pain who have had an inadequate response to non-drug therapy, ACP recommends that physicians and patients consider treatment with NSAIDs as first line therapy; or tramadol or duloxetine as second line therapy. 

Doctors should only consider opioids as an option in patients who have failed the lower-dose treatments, they say. 

Furthermore, this should only be if the potential benefits outweigh the risks for individual patients, and after a discussion of known risks and realistic benefits with patients.

‘Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose,’ said Dr Damle.

The new recommendations are based on a systematic review of randomized controlled trials and systematic reviews on noninvasive pharmacological and non-pharmacological treatments of nonradicular low back pain. 

Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability/return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

The evidence was insufficient or lacking to determine treatments for radicular low back pain. 

It was also insufficient for most physical modalities and for which patients are likely to benefit from which specific therapy. 

And the guideline does not address topical therapies or epidural injection therapies.