From the Guidelines
For back pain, I recommend starting with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) at 400-600mg every 6-8 hours or naproxen (Aleve) at 220-440mg every 12 hours, both taken with food to minimize stomach irritation, as suggested by the American College of Physicians and the American Pain Society 1.
Key Considerations
- Acetaminophen (Tylenol) at 500-1000mg every 6 hours is an alternative if you can't take NSAIDs, but it is a slightly weaker analgesic than NSAIDs 1.
- For more severe pain, your doctor might prescribe muscle relaxants like cyclobenzaprine (5-10mg) or methocarbamol (750mg) every 8 hours for short-term use (1-2 weeks), or stronger pain medications in specific cases 1.
- Opioid analgesics or tramadol are an option when used judiciously in patients with acute or chronic low back pain who have severe, disabling pain that is not controlled (or is unlikely to be controlled) with acetaminophen and NSAIDs, but potential benefits and harms should be carefully weighed before starting therapy 1.
Additional Recommendations
- Complement medication with gentle stretching, applying ice for the first 48 hours (20 minutes on, 20 minutes off), then switching to heat therapy.
- Maintain good posture, avoid prolonged sitting, and consider physical therapy for persistent pain.
- If your pain is severe, worsening, accompanied by numbness/tingling, or doesn't improve within 1-2 weeks, seek medical attention promptly.
Important Safety Considerations
- Clinicians should assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary 1.
- Skeletal muscle relaxants are associated with central nervous system adverse effects (primarily sedation) and risk-benefit profiles could vary substantially among different medications in this class 1.
From the FDA Drug Label
Tramadol hydrochloride has been studied in three long-term controlled trials involving a total of 820 patients, with 530 patients receiving tramadol hydrochloride Patients with a variety of chronic painful conditions were studied in double-blind trials of one to three months duration. Average daily doses of approximately 250 mg of tramadol hydrochloride in divided doses were generally comparable to five doses of acetaminophen 300 mg with codeine phosphate 30 mg (TYLENOL with Codeine #3) daily, five doses of aspirin 325 mg with codeine phosphate 30 mg daily, or two to three doses of acetaminophen 500 mg with oxycodone hydrochloride 5 mg (TYLOX® ) daily
Medication for back pain: Tramadol hydrochloride may be used for back pain, as it has been studied in patients with chronic painful conditions, including back pain. The recommended dose is approximately 250 mg per day in divided doses 2.
- Key points:
- Tramadol hydrochloride has been studied in long-term controlled trials for chronic pain.
- Average daily doses of 250 mg were generally comparable to other pain medications.
- Tramadol hydrochloride may be used for back pain, but the evidence is not specific to back pain.
From the Research
Medication Options for Back Pain
- Cyclobenzaprine hydrochloride is a muscle relaxant that can be effective in improving muscle spasm, reducing local pain and tenderness, and increasing range of motion in acute, painful musculoskeletal conditions, including back pain 3.
- Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate back pain 4.
- Topical NSAIDs are recommended for non-low back, musculoskeletal injuries, while acetaminophen is well tolerated but should be used with caution in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 4.
- Muscle relaxants, such as cyclobenzaprine, may be useful for acute low back pain, and adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 4.
Considerations for Chronic Low Back Pain
- Over-the-counter analgesics, including NSAIDs and acetaminophen, are the most frequently used first-line medication for chronic low back pain, and current guidelines indicate that over-the-counter medications should be the first prescribed treatment for non-specific chronic low back pain 5.
- Antidepressants, muscle relaxants, and opioids may also be effective treatments for chronic low back pain, although their use should be carefully considered due to potential risks and side effects 5, 6, 7.
- Gabapentin and pregabalin may be useful for neuropathic pain, while serotonin-norepinephrine reuptake inhibitors (SNRIs) may have a more favorable safety profile than tricyclic antidepressants (TCAs) 6.
Special Considerations for Older Adults
- Medications for spine-related pain in older adults should be used with caution due to reduced liver and renal function, comorbid medical problems, and polypharmacy 6.
- NSAIDs may be effective for arthritic and myofascial-based pain, while gabapentinoids or duloxetine may be useful for neuropathic and radicular pain 6.
- Opioids are typically avoided in the treatment of spine-related pain in older adults due to their morbidity and mortality risk, and are reserved for refractory severe pain 6, 7.