What are the recommended medications for back pain?

Recommended Medications for Back Pain

NSAIDs are the first-line medication for back pain, with better efficacy than acetaminophen for both acute and chronic low back pain. 1

First-Line Medications

NSAIDs

• Most effective first-line option for acute back pain 2, 1
• Superior to placebo for global improvement (RR, 1.24) 2
• Ibuprofen 400-600mg every 6 hours as needed is a common effective regimen 1
• No evidence that any specific NSAID is superior to others for pain relief 2
• Consider cardiovascular and gastrointestinal risk factors before prescribing 1

Acetaminophen

• Alternative first-line option if NSAIDs are contraindicated 1
• Dosage: 1000mg three to four times daily (maximum 4g/day) 1
• Slightly less effective than NSAIDs but has better safety profile 2, 1
• For chronic low back pain, acetaminophen is inferior to NSAIDs 2

Second-Line Medications

Muscle Relaxants

• Effective for short-term relief of acute low back pain 2
• Cyclobenzaprine (5-10mg three times daily) has the best evidence 1
• Patients nearly 5 times more likely to report improvement by day 14 compared to placebo 1
• All cause central nervous system effects, primarily sedation 1
• Limit use to 2-3 weeks maximum 1
• Greatest effect is in the first 4 days of treatment 1

Specific Muscle Relaxant Options:

• Cyclobenzaprine: Most evidence for effectiveness; side effects include drowsiness, dry mouth, dizziness 1
• Tizanidine: Well-studied but has risk of hepatotoxicity 2, 1
• Carisoprodol: Effective but has potential for abuse 1
• Baclofen/Dantrolene: Limited evidence for efficacy in low back pain 1

Third-Line Medications

Antidepressants

• Tricyclic antidepressants are effective for chronic low back pain 2
• Selective serotonin reuptake inhibitors and trazodone have not shown effectiveness 2
• Serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine) have limited evaluation 2

Opioids and Tramadol

• Only consider when other options have failed for severe, disabling pain 2, 3
• Substantial risks including abuse, addiction, and tolerance 2
• Tramadol is indicated for moderate to moderately severe pain 3
• Failure to respond should lead to reassessment and alternative therapies 2

Other Medication Options

• Gabapentin: Small, short-term benefits for patients with radiculopathy 2
• Benzodiazepines: Similar effectiveness to muscle relaxants but with higher risks of abuse, addiction, and tolerance 2
• Herbal therapies: Devil's claw, willow bark, and capsicum may be safe options for acute exacerbations of chronic low back pain 2

Medications to Avoid

• Systemic corticosteroids: Not recommended for low back pain with or without sciatica as they have not been shown to be more effective than placebo 2, 1

Special Considerations

Elderly Patients

• Use lower doses (2.5-5mg) of muscle relaxants due to increased sensitivity to sedative effects 1

Patients with Hepatic Impairment

• Use cyclobenzaprine with caution, starting with 5mg and titrating slowly 1
• Avoid in moderate to severe impairment 1

Patients Who Need to Remain Alert

• Consider lower doses (5mg) or extended-release formulations of muscle relaxants 1

Non-Pharmacologic Treatments

• Application of heat via heating pads or heated blankets for acute low back pain 1
• Spinal manipulation for patients who don't improve with first-line treatments after 1-2 weeks 1
• Exercise therapy has high-quality evidence for improving function 1
• Patients should remain active, continuing normal daily activities as much as pain allows 1

Common Pitfalls to Avoid

1. Routine imaging for uncomplicated low back pain at 3 weeks duration provides no clinical benefit 1
2. Long-term use of muscle relaxants beyond 2-3 weeks 1
3. Using opioids as first-line therapy 2, 1
4. Prescribing systemic corticosteroids for low back pain 2, 1
5. Extended bed rest, which can worsen outcomes 1, 4