Pharmacologic Therapy

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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

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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. 


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