From the Guidelines
For back pain, I recommend starting with acetaminophen (Tylenol) at 650-1000mg every 6 hours (not exceeding 4000mg daily) or ibuprofen (Advil, Motrin) at 400-600mg every 6-8 hours with food (maximum 3200mg daily). Naproxen (Aleve) is another option at 220-440mg twice daily with food (maximum 1000mg daily). Begin with the lowest effective dose for 3-5 days, then reduce or stop as pain improves. Combine medication with gentle stretching, proper posture, and application of heat or ice for 15-20 minutes several times daily. If pain is severe or persists beyond 7-10 days, consult a healthcare provider. These medications work by reducing inflammation (NSAIDs like ibuprofen and naproxen) or blocking pain signals (acetaminophen) 1.
Key Considerations
- People with liver disease should avoid acetaminophen, while those with kidney problems, stomach ulcers, or heart conditions should use NSAIDs cautiously.
- Always take medication with food and stay hydrated to minimize side effects.
- Nonpharmacologic therapies such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation may be considered for patients who do not improve with self-care options 1.
- Opioid analgesics or tramadol may be considered for patients with severe, disabling pain that is not controlled with acetaminophen and NSAIDs, but potential benefits and harms should be carefully weighed before starting therapy 1.
Potential Risks and Benefits
- Acetaminophen is associated with asymptomatic elevations of aminotransferase levels at dosages of 4 g/d, but the clinical significance of these findings is uncertain 1.
- Nonselective NSAIDs are more effective for pain relief than acetaminophen, but are associated with gastrointestinal and renovascular risks 1.
- Cyclooxygenase-2–selective or most nonselective NSAIDs are associated with increased risk for myocardial infarction 1.
Monitoring and Follow-up
- Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy 1.
- Patients should be monitored for adverse events and the effectiveness of treatment, and therapy should be adjusted as needed 1.
From the FDA Drug Label
Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain. The recommended dose for back pain is 400 mg every 4 to 6 hours as necessary for relief of pain, with a maximum daily dose of 3200 mg.
- The dose should be tailored to each patient, and may be lowered or raised depending on the severity of symptoms.
- In general, the smallest dose that yields acceptable control should be employed 2.
From the Research
Medications for Back Pain
- The choice of medication for low back pain should be evidence-based and tailored to the individual patient 3.
- First-line drugs for low back pain include acetaminophen, mild opioids, and NSAIDs, with no evidence that one is more effective than the others 3.
- Non-benzodiazepine muscle relaxants and cyclic antidepressants can be considered as second-line drugs for acute and chronic low back pain, respectively 3.
Conservative Management of Low Back Pain
- Patient education is recommended for all patients with low back pain 4, 5.
- Spine manipulation and exercises are advised for patients with acute and sub-acute non-specific low back pain 4.
- Conservative management of low back pain with radiculopathy is not well-addressed in current guidelines 4.
Over-the-Counter Treatment for Chronic Low Back Pain
- Over-the-counter analgesics, such as NSAIDs and acetaminophen, are commonly used as first-line medication for low back pain 6.
- Antidepressants, muscle relaxants, and opioids can also be effective treatments for chronic low back pain 6.