How to manage a 46-year-old female patient's chronic low back pain that persists after a vehicle accident, despite treatment with acetaminophen (Tylenol) and ibuprofen?

From the Guidelines

For a 46-year-old female with persistent chronic low back pain following a vehicle accident that hasn't responded to acetaminophen and ibuprofen, a multimodal approach is recommended, prioritizing non-pharmacologic therapies and considering pharmacologic options with a strong evidence base, as suggested by the most recent guideline from the American College of Physicians 1.

Key Considerations

• The patient's chronic low back pain, given its persistence after a vehicle accident, necessitates a comprehensive approach that addresses both the physical and psychological aspects of pain.
• Non-pharmacologic therapies, such as physical therapy focusing on core strengthening and flexibility, should be initiated for 6-8 weeks, as they are recommended by recent guidelines for the management of chronic low back pain 1.
• Cognitive behavioral therapy (CBT) can be beneficial in helping patients cope with chronic pain, as it addresses the psychological component of pain perception and management.
• Topical treatments like diclofenac gel 1% applied to the painful area four times daily may provide localized relief without systemic side effects, offering a safer alternative for long-term management.

Pharmacologic Interventions

• If non-pharmacologic therapies are insufficient, pharmacologic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) can be considered as first-line therapy, given their effectiveness for pain relief in patients with chronic low back pain, as indicated by moderate-quality evidence 1.
• Tramadol or duloxetine may be considered as second-line therapy for patients who have had an inadequate response to NSAIDs, with the understanding that these medications carry their own set of risks and benefits that need to be carefully weighed.
• Opioids should only be considered after other options have failed and with a thorough discussion of their risks and benefits, due to their limited evidence for long-term efficacy and risk of dependence, as highlighted in recent clinical practice guidelines 1.

Conclusion of Recommendations

Given the complexity of chronic low back pain and the need for a personalized approach, a multimodal treatment plan that includes non-pharmacologic therapies, judicious use of pharmacologic options, and consideration of the patient's preferences and values is essential, as supported by the most recent and highest quality evidence available 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 The patient's chronic low back pain may be managed with tramadol, as it has been shown to be effective in patients with chronic painful conditions. The recommended dose is 250 mg per day in divided doses, which can be titrated to a maximum dose of 200 mg per day (50 mg four times per day) over 10 days to minimize discontinuations due to dizziness or vertigo 2.

• Key considerations:
  • Tramadol may be used as an alternative to acetaminophen with codeine or aspirin with codeine.
  • The patient should be closely monitored for adverse effects, such as dizziness or vertigo, especially during the titration period.

From the Research

Patient Assessment

To manage the 46-year-old female patient's chronic low back pain, a thorough history and physical examination should be conducted to identify the underlying cause of the pain 3. The patient's symptoms and medical history should be evaluated to determine if there are any "red flags" that may indicate a serious condition, such as radiculopathy or spinal stenosis 4.

Treatment Options

The patient has already tried acetaminophen (Tylenol) and ibuprofen, which are first-line medications for chronic low back pain 3, 5. Since these medications have not provided adequate relief, other treatment options can be considered. These may include:

• Tramadol, opioids, or other adjunctive medications for patients who do not respond to nonsteroidal anti-inflammatory drugs 3
• Acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation, which have been shown to be effective in certain clinical situations 3, 6
• Epidural steroid injections for patients with radicular symptoms, although the evidence for this treatment is mixed 3

Non-Pharmacologic Interventions

Non-pharmacologic interventions can also be considered, such as:

• Counseling and education on chronic low back pain management 4
• Exercise therapy, including physical therapy and yoga 4, 6
• Alternative therapies, such as heat, dry needling, and transcutaneous electrical nerve stimulation 4

Surgical Evaluation

Surgery may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments 3, 4. However, most patients with chronic low back pain will not require surgery.

Medication Management

When choosing medications for the treatment of low back pain, practice guidelines provide a useful starting point for making decisions, but clinicians should base therapeutic choices on individualized consideration and discussion with patients regarding the potential benefits and risks 5. The use of opioids, benzodiazepines, and other medications should be carefully considered due to their potential risks and side effects 5, 7.