What medications are recommended for back pain?

Medications for Back Pain

For acute low back pain, start with NSAIDs or acetaminophen as first-line therapy; for chronic low back pain, NSAIDs remain first-line, with duloxetine or tricyclic antidepressants as second-line options, particularly when neuropathic features are present. 1, 2

Acute Low Back Pain (< 4 weeks)

First-Line Pharmacotherapy

• NSAIDs are the preferred initial medication, demonstrating clear superiority over placebo with a relative risk of 1.24 for global improvement after 1 week 3
• Acetaminophen was traditionally recommended alongside NSAIDs, though recent high-quality evidence shows it provides no benefit over placebo for recovery time in acute low back pain 4
• No specific NSAID has proven superior to others—celecoxib, ibuprofen, and naproxen are equally effective 3
• Selective COX-2 inhibitors like celecoxib offer fewer gastrointestinal side effects than traditional NSAIDs 2

Adjunctive Therapy for Severe Pain

• Skeletal muscle relaxants provide moderate short-term benefits for 1-2 weeks maximum 2
• Cyclobenzaprine has the strongest evidence among muscle relaxants, with pooled data from 20 trials (n=1553) showing superiority to placebo for short-term global improvement 2
• Start cyclobenzaprine 5 mg at bedtime and titrate to 10 mg if needed 5
• Do not use muscle relaxants beyond 2 weeks—no evidence supports longer duration and sedation risks increase 2, 5
• Combining NSAIDs with muscle relaxants enhances pain relief but increases central nervous system adverse events, particularly drowsiness 2

Medications to Avoid in Acute Low Back Pain

• Systemic corticosteroids are not recommended—they show no superiority over placebo 2, 6
• Benzodiazepines should be avoided due to abuse potential and lack of FDA approval for low back pain 2
• Opioids are not first-line due to abuse potential, though they are more potent analgesics 7

Chronic Low Back Pain (> 12 weeks)

First-Line Pharmacotherapy

• NSAIDs remain the initial medication of choice, with moderate short-term efficacy demonstrated in higher-quality trials 2, 8
• NSAIDs show superiority to placebo in chronic low back pain, though most trials were only 2 weeks duration 3
• Monitor cardiovascular risk with longer NSAID use and higher doses 2

Second-Line Options for Inadequate Response

• Duloxetine 30-60 mg daily provides small but meaningful improvements in pain intensity and function with moderate-quality evidence 2, 6
• Start duloxetine 30 mg daily for one week, then increase to 60 mg daily 6
• Duloxetine is particularly useful when chronic pain is accompanied by depression 2
• Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime, titrated to 75-150 mg) have moderate efficacy for chronic low back pain 2, 6
• Amitriptyline is especially useful for patients with sleep disturbance 6

Medications to Avoid in Chronic Low Back Pain

• Do not use muscle relaxants—no evidence supports efficacy beyond 2 weeks and risks of sedation, falls, and cognitive impairment increase with prolonged use 2, 6
• Systemic corticosteroids are ineffective 2, 6
• Benzodiazepines are ineffective and carry substantial risks of abuse and addiction 6
• Opioids should be reserved only as a last resort after all other options have failed, given limited evidence for modest short-term effects and significant risks including nausea, constipation, and aberrant drug-related behavior 6

Radicular Pain/Sciatica

Neuropathic Component Treatment

• Gabapentin is first-choice for the neuropathic component, showing small to moderate short-term benefits for radiculopathy 2
• Titrate gabapentin to therapeutic dosing of 1200-3600 mg/day in divided doses 6
• Adjust gabapentin dosing in renal impairment and monitor for sedation, dizziness, and peripheral edema 2, 6
• NSAIDs alone show no difference from placebo for predominantly radicular symptoms, making them a poor choice when used as monotherapy 3

Combination Approach for Radiculopathy

• Start with an NSAID to target the inflammatory component 2
• Add gabapentin for the neuropathic component of radiculopathy 2
• If response is insufficient after 2-4 weeks, add duloxetine or a tricyclic antidepressant 2, 6
• For acute exacerbations, consider a short-term skeletal muscle relaxant (≤1-2 weeks) 2

Medications That Don't Work for Radiculopathy

• Pregabalin shows no benefit for chronic nonradicular back pain and may worsen function 2
• Benzodiazepines are ineffective for radiculopathy based on low-quality evidence 2
• Neither gabapentin nor pregabalin is FDA-approved specifically for low back pain with or without radiculopathy 2

Critical Monitoring and Reassessment

• Reassess pain intensity and functional status at 2-4 weeks after initiating or adjusting medications using a 0-10 pain scale 6
• Monitor duloxetine-specific adverse effects including nausea, dry mouth, and blood pressure elevation 6
• Check renal function before escalating gabapentin doses 6
• If no meaningful improvement occurs after 4-6 weeks of optimized pharmacotherapy, refer for interventional procedures or multidisciplinary pain management 6

Key Pitfalls to Avoid

• Do not prescribe muscle relaxants for chronic low back pain—evidence only supports use up to 2 weeks 2, 6
• Do not use muscle relaxants in elderly patients without careful consideration of fall risk and cognitive impairment from sedation 2
• Do not expect muscle relaxants to work alone—combine with NSAIDs or acetaminophen and patient education about remaining active 2
• Most NSAID trials were only 2 weeks duration, making long-term benefit-risk assessment difficult 3
• Do not routinely obtain imaging in patients with nonspecific low back pain 1