Pharmacologic Therapy


Continue Reading

Pharmacologic therapy should only be considered for patients with chronic low back pain if there has been an inadequate response to nonpharmacologic management.  Current guidelines suggest clinicians should consider a tiered approach when prescribing pharmacologic therapy, starting with medications that result in the greatest benefit and pose the least possible risk.7 

First-line therapy for chronic low back pain should include the use of NSAIDs that have shown efficacy in reducing pain and increasing functional ability.12 Progression to second-line therapy, should the patient not be a candidate for NSAIDs or should treatment with NSAIDs fail, includes consideration of tramadol or duloxetine.25,26 The use of these medications has been associated with decreased pain and increased functional ability in patients with chronic low back pain25,26; however, clinicians should be cautious in light of the risk for abuse associated with tramadol.27

In the setting in which all nonpharmacologic and nonnarcotic pharmacologic efforts have been exhausted and the patient continues to experience chronic low back pain, the clinician may consider the use of opioids.7 It is prudent for the clinician to discuss known risks as well as expected, realistic benefits of opioid treatment (short-term reduction in pain and increase in functional ability) with the patient prior to making the decision to prescribe this treatment for chronic low back pain.28

Related Articles

Conclusion

Low back pain has been found to have a significant economic impact, with substantial direct and indirect healthcare costs.  Providers must first distinguish between acute, subacute, and chronic presentation of low back pain before considering the initiation of treatment modalities.  Utilization of a tiered treatment approach with the combination of nonpharmacologic and nonnarcotic pharmacologic therapy has been proven most beneficial for the treatment of a majority of patients with low back pain. Use of opioid therapy should only be considered for patients with chronic low back pain that has not responded to more conservative treatment options and only if the benefits associated with the treatment outweigh the potential risks. 

References

  1. Ben-Yishay A. Understanding low back pain (lumbago). Spine-health. April 25, 2012. Accessed September 9, 2018.
  2. Henschke, N, Kamper SJ, Maher CG. The epidemiology and economic consequences of pain. Mayo Clin Proc. 2015;90(1):139-147.
  3. Thiese MS, Hegmann KT, Wood EM, et al.  Prevalence of low back pain by anatomic location and intensity in an occupational population. BMC Musculoskelet Disord.  2014;15:283.
  4. Centers for Disease Control and Prevention. Prevalence and most common causes of disability among adults — United States, 2005. Morb Mortal Weekly Rep. 2009;58(16):421-426.
  5. American Chiropractic Association. Back pain facts and statistics. Accessed September 7, 2018.
  6. Papadakis MA, McPhee SJ, Rabow MW (eds). Current Medical Diagnosis & Treatment 2014. New York: McGraw-Hill Medical; 2014.
  7. Qaseem A, Wilt TJ, McLean RM, Forciea MA; for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
  8. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Spine (Phila Pa 1976). 2016;20(31):998-1006.
  9. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back painCochrane Database Syst Rev.  2008;(4):D001929. 
  10. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29(2):172-185.
  11. von Heymann WJ, Schloemer P, Timm J, Muehlbauer B. Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo. Spine (Phila Pa 1976). 2013;38(7):540-548.
  12. Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Non-steroidal anti-inflammatory drugs for low back pain. Spine (Phila Pa 1976). 2008;33(16):1766-1774.
  13. Dreiser RL, Marty M, Ionescu E, Gold M, Liu JH. Relief of acute low back pain with diclofenac-K 12.5 mg tablets: a flexible dose, ibuprofen 200 mg and placebo-controlled clinical trial. Int J Clin Pharmacol Ther. 2003;41(9):375-385.
  14. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003:CD004252.
  15. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010;24(2):193-204.
  16. Kamper SJ, Apeldoorn AT, Chiarotto A,  et al. Multidisciplinary biopsychosocial rehabilitation for chronic  low  back  painCochrane Database Syst Rev.  2014:CD000963.
  17. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for non-specific chronic low back pain: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2013;38(24):2124-138.
  18. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315:1240-1249.
  19. Weifen W, Muheremu A, Chaohui C, Wenge L, Lei S. Effectiveness of tai chi practice for non-specific chronic low back pain on retired athletes: a randomized controlled study. J Musculoskelet Pain. 2013;21:37-45.
  20. Williams K, Abildso C, Steinberg L, et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine (Phila Pa 1976). 2009;34:2066-2076.
  21. Byström MG, Rasmussen-Barr E, Grooten WJ. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine (Phila Pa 1976). 2013;38:E350-E358.
  22. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back painCochrane Database Syst Rev.  2010:CD002014.
  23. Basford JR, Sheffield CG, Harmsen WS. Laser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain. Arch Phys Med Rehabil. 1999;80(6):647-652.
  24. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain.  Cochrane Database Syst Rev.  2011;(2):D008112.
  25. Lee JH, Lee CS; Ultracet ER Study Group. A randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of the extended-release tramadol hydrochloride/acetaminophen fixed-dose combination tablet for the treatment of chronic low back painClin Ther.  2013;35(11):1830-1840.
  26. Skljarevski V, Ossanna M, Liu-Seifert H, et al. A double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain. Eur J Neurol. 2009;16(9):1041-1048.
  27. Drug Enforcement Administration. Department of Justice. Schedule of controlled substances: placement of tramadol into schedule IV. Final rule. Fed Regist. 2014;79(127):37623-27630.
  28. Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared to placebo or other treatments for chronic  low-back  painCochrane Database Syst Rev.  2013:CD004959.