What are the next steps for a 62-year-old with ongoing left-sided mid-back pain that is tender and painful, unresponsive to Naproxen (naproxen), for 5 weeks without red flags?

Management of Persistent Low Back Pain After Naproxen Failure

For a 62-year-old with ongoing left-sided mid-back pain for 5 weeks that has not responded to naproxen, the recommended next step is to initiate a multimodal approach with physical therapy and consider adding a muscle relaxant such as cyclobenzaprine, while avoiding opioid medications. 1

Assessment of Current Situation

• Naproxen (an NSAID) has failed to provide adequate relief after 5 weeks of use, indicating the need for treatment modification 2
• The absence of red flags is reassuring but persistent pain requires escalation of care 1
• At 5 weeks, this pain is classified as subacute (4-12 weeks duration) and requires a different approach than acute pain 1

Pharmacological Options

First-line alternatives:

• Switch to a different NSAID such as meloxicam (7.5-15mg once daily) which may be better tolerated or more effective for some patients 3
• Add acetaminophen (up to 3000mg/day) as part of a multimodal approach for pain relief 1, 4
• Consider adding a muscle relaxant such as cyclobenzaprine for short-term use, particularly if muscle spasm is present 2, 1

Second-line options:

• Tricyclic antidepressants (e.g., amitriptyline at low doses) can be effective for chronic pain and may help if the pain persists 2
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) may be beneficial if pain continues beyond 12 weeks 2, 1

Medications to avoid:

• Opioids (including tramadol) should not be added as they have not demonstrated superior efficacy to NSAIDs plus muscle relaxants for back pain and carry significant risks 2, 5
• Systemic corticosteroids are not recommended as they have not shown efficacy greater than placebo for low back pain 2, 1

Non-Pharmacological Interventions

• Physical therapy with focus on thoracic and lumbar stabilization exercises should be initiated immediately 2, 1
• Application of heat via heating pads for short-term relief 4
• Weight-bearing exercises to improve core strength and spinal stability 2
• Consider referral for spinal manipulation if pain persists despite other interventions 1
• Yoga or other structured exercise programs may be beneficial for ongoing pain management 4

Monitoring and Follow-up

• Reassess in 2-3 weeks to evaluate response to the new treatment regimen 1
• If no improvement occurs with these interventions, consider diagnostic imaging (MRI) to rule out specific pathologies, especially if symptoms persist beyond 12 weeks 1
• Monitor for medication side effects, particularly gastrointestinal issues with continued NSAID use 2, 4

Common Pitfalls to Avoid

• Continuing ineffective medication (naproxen) without making changes 1
• Premature imaging without a trial of conservative management first 1
• Prescribing opioids for non-specific back pain, as they don't improve outcomes compared to NSAIDs plus muscle relaxants but carry significant risks 2, 5
• Bed rest, which can prolong recovery and lead to deconditioning 1, 4

By implementing this comprehensive approach focusing on both pharmacological and non-pharmacological interventions, most patients with subacute back pain will experience significant improvement in symptoms and function.