From the Guidelines
For lower back pain that does not respond to typical nonsteroidal anti-inflammatory drugs (NSAIDs), the first-line narcotic treatment would be a short course of a weak opioid such as tramadol or codeine, often combined with acetaminophen. Typically, tramadol 50-100mg every 4-6 hours as needed (not exceeding 400mg daily) or codeine 30-60mg every 4-6 hours as needed would be prescribed for a limited duration of 3-7 days, as recommended by the American College of Physicians guideline 1. These medications work by binding to opioid receptors in the brain and spinal cord, altering pain perception. It's essential to use the lowest effective dose for the shortest duration possible to minimize risks of dependence, tolerance, and side effects, as emphasized in the guideline 1. Patients should be aware of common side effects including constipation, nausea, sedation, and dizziness. Preventive measures like increasing fluid intake, using stool softeners, and avoiding driving or operating machinery while taking these medications are recommended. Stronger opioids like oxycodone or hydrocodone are generally reserved for more severe pain or when weaker opioids prove ineffective, but carry higher risks of dependence and should be used with even greater caution, as noted in the guideline 1. The American College of Physicians guideline 1 provides a strong recommendation for the use of nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation for acute or subacute low back pain, and nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation for chronic low back pain. However, for patients who have had an inadequate response to nonpharmacologic therapy, pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy may be considered, with opioids being an option only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients, as stated in the guideline 1.
Some key points to consider when prescribing opioids for lower back pain include:
- Using the lowest effective dose for the shortest duration possible
- Monitoring patients for signs of dependence, tolerance, and side effects
- Providing preventive measures to minimize risks, such as increasing fluid intake and using stool softeners
- Reserving stronger opioids for more severe pain or when weaker opioids prove ineffective
- Discussing known risks and realistic benefits with patients before initiating opioid therapy, as recommended in the guideline 1.
Overall, the goal of treatment for lower back pain is to improve pain, function, and quality of life while minimizing risks and side effects, as emphasized in the guideline 1.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION
- 2 Initial Dosage Use of Oxycodone Hydrochloride Tablets as the First Opioid Analgesic Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain.
The first-line narcotic treatment for lower back pain refractory to typical non-steroidal anti-inflammatory drug (NSAID) treatment is oxycodone, with an initial dosage of 5 to 15 mg every 4 to 6 hours as needed for pain 2.
From the Research
First-Line Narcotic Treatment for Lower Back Pain
The first-line narcotic treatment for lower back pain refractory to typical non-steroidal anti-inflammatory drug (NSAID) treatment is not explicitly stated in the provided studies. However, some studies suggest the following options:
- Tramadol, which works on opioid and monoamine receptors, may be used for severe or refractory acute pain 3.
- Opioids, such as partial opioid agonist drugs, have been shown to have statistically significant treatment effects in pain relief for chronic nonspecific low back pain patients 4.
- Low-dose tramadol plus non-steroidal anti-inflammatory drug combination therapy may prevent the transition of acute low back pain to chronic low back pain 5.
Key Findings
- A systematic review and meta-analysis found that cyclo-oxygenase-2 (COX-2) nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for chronic nonspecific low back pain, while tramadol shows no statistically significant effect on pain relief 4.
- A retrospective study found that low-dose tramadol plus non-steroidal anti-inflammatory drug combination therapy improves visual analog scale scores and may prevent the transition to chronic low back pain 5.
- A randomized, double-blind, placebo-controlled trial found that combining naproxen with orphenadrine or methocarbamol does not improve functional outcomes compared to naproxen plus placebo for acute low back pain 6.
Treatment Options
- Tramadol: may be used for severe or refractory acute pain 3, 5.
- Opioids: may be used for chronic nonspecific low back pain, but with caution due to the risk of adverse effects 3, 4.
- COX-2 NSAIDs: are effective for chronic nonspecific low back pain 4.
- Low-dose tramadol plus non-steroidal anti-inflammatory drug combination therapy: may prevent the transition of acute low back pain to chronic low back pain 5.