What are the pharmacological management options for back pain?

Pharmacological Management of Back Pain

First-Line Treatment: NSAIDs Are the Primary Option

For both acute and chronic low back pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line pharmacological treatment, providing small to moderate pain relief that typically lasts less than 3 months. 1, 2

Acute Low Back Pain

• NSAIDs provide meaningful pain relief with a mean improvement of approximately 8.4 points on a 0-100 scale compared to placebo, with effects visible within the first week 1
• Acetaminophen is NOT effective for acute low back pain and should not be used—a large placebo-controlled trial found no difference in pain, function, or adverse events 1
• Skeletal muscle relaxants are effective for short-term pain relief in acute low back pain but cause significant sedation, limiting their utility 1
• Use NSAIDs such as ibuprofen (400-800 mg three times daily) or naproxen (500 mg twice daily) for 1-2 weeks 2, 3

Chronic Low Back Pain

• NSAIDs remain first-line with moderate evidence showing pain reduction of approximately 12.4 points on a 0-100 scale, though recent trials suggest smaller effects (4-6 points on a 0-10 scale) 1, 2
• Duloxetine (60-120 mg daily) is the preferred second-line agent when NSAIDs provide inadequate relief, with moderate evidence for modest pain reduction in chronic low back pain 1, 2
• Tramadol can be considered as second-line if duloxetine is ineffective or contraindicated, though it carries risks of nausea, dizziness, constipation, and cognitive effects 2, 4

Critical Medication Choices by Pain Type

Non-Radicular (Mechanical) Low Back Pain

• Start with NSAIDs (ibuprofen or naproxen) at standard doses 2
• If depression coexists with pain, use duloxetine 60 mg daily, titrating to 120 mg if needed 2
• Avoid acetaminophen as monotherapy—it is ineffective 1

Radicular Pain (Sciatica)

• Gabapentin or pregabalin may be effective for the neuropathic component, though evidence is inconsistent and of low quality 1, 5
• Benzodiazepines are NOT effective for radiculopathy and may worsen pain 1
• Systemic corticosteroids are NOT effective for radicular low back pain 1

Medications to Avoid

• Acetaminophen: Ineffective for acute low back pain based on high-quality placebo-controlled trial 1
• Benzodiazepines: Ineffective for radiculopathy and nonradicular pain, with insufficient evidence overall 1
• Systemic corticosteroids: Not effective for pain relief in radicular or nonradicular low back pain 1
• Tricyclic antidepressants: No difference versus placebo for chronic low back pain in recent meta-analyses 1
• Antiseizure medications (except for neuropathic radicular pain): Insufficient evidence to determine effects 1

Opioid Use: Reserve for Severe Refractory Pain Only

• Opioids show only modest short-term effects (less than 3 months) for chronic low back pain with moderate evidence 1
• Trials were NOT designed to assess serious harms such as overdose or opioid use disorder due to short duration and exclusion of high-risk patients 1
• Use only for severe acute pain unresponsive to other treatments, prescribe for fixed short periods (3-7 days maximum), and implement risk mitigation strategies 4, 6
• Observational studies link prescribed opioids to overdose risk—avoid in chronic low back pain management 1

Safety Considerations and Monitoring

NSAID Precautions

• Gastrointestinal risks: Increased bleeding risk, especially with prolonged use, corticosteroids, anticoagulants, older age, or alcohol use 2, 3
• Cardiovascular risks: Avoid in patients with heart disease; risk increases with longer use 2, 3
• Renal risks: Use caution in chronic kidney disease; monitor renal function 3, 7
• Use lowest effective dose for shortest duration needed 2, 3

Duloxetine Precautions

• Common adverse effects include nausea, drowsiness, and dizziness 2
• Start at 30 mg daily for one week before increasing to 60 mg to minimize nausea 2

Tramadol Precautions

• Causes nausea, dizziness, constipation, vomiting, and drowsiness 2
• Risk of cognitive impairment in older adults 7
• Has opioid-like addiction potential despite being classified differently 4

Treatment Algorithm

1. Start with NSAIDs (ibuprofen 400-800 mg TID or naproxen 500 mg BID) for 1-3 weeks 1, 2
2. If inadequate response after 2 weeks, add or switch to duloxetine 60 mg daily (increase to 120 mg if needed after 1 week) 2
3. For radicular pain with neuropathic features, consider adding gabapentin 300-900 mg TID or pregabalin 150-600 mg/day in divided doses 5, 7
4. If still inadequate, consider tramadol 50-100 mg every 4-6 hours (maximum 400 mg/day) for short-term use 2, 4
5. Reassess effectiveness and adverse effects every 2-4 weeks; discontinue ineffective medications 2

Common Pitfalls to Avoid

• Do not prescribe acetaminophen alone for acute low back pain—it does not work 1
• Do not use benzodiazepines for back pain of any type—they are ineffective and may worsen outcomes 1
• Do not prescribe systemic corticosteroids for back pain—they provide no benefit 1
• Do not continue ineffective medications beyond 2-4 weeks without reassessment 2
• Do not use opioids as first-line therapy or for chronic management except in rare refractory cases with careful monitoring 1, 4, 6