What medications are recommended for treating back pain?

Medications for Back Pain

First-Line Treatment Recommendations

For acute low back pain (<4 weeks), NSAIDs are the recommended first-line medication, providing moderate pain relief and functional improvement over placebo, while acetaminophen shows no benefit and should not be used. 1

For chronic low back pain (>12 weeks), NSAIDs remain first-line for pain relief, with duloxetine or tricyclic antidepressants (such as amitriptyline) as effective second-line options when NSAIDs are insufficient or contraindicated. 1, 2, 3

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Acute Low Back Pain (<4 weeks)

NSAIDs (First-Line)

• NSAIDs provide superior pain relief compared to placebo, with a 24% greater likelihood of global improvement and 29% reduced need for additional analgesics after 1 week. 1
• No specific NSAID is superior to others—choose based on patient factors and side effect profile. 1
• COX-2 selective inhibitors (like celecoxib) have fewer gastrointestinal side effects than traditional NSAIDs but similar efficacy. 2
• Critical limitation: Most trials evaluated only 2 weeks of therapy; cardiovascular and gastrointestinal risks increase with longer duration and higher doses. 1, 2

Acetaminophen (Not Recommended)

• Acetaminophen shows no benefit over placebo for acute low back pain in high-quality trials, with median recovery time of 17 days for acetaminophen versus 16 days for placebo. 1, 4
• Despite being historically recommended as first-line, the 2017 American College of Physicians guideline explicitly downgraded this recommendation based on lack of efficacy. 1

Skeletal Muscle Relaxants (Short-Term Adjunct)

• Cyclobenzaprine provides moderate short-term pain relief (2-7 days) when added to NSAIDs for severe acute pain. 1, 2, 5
• Start with 5 mg three times daily, particularly in elderly patients; can increase to 10 mg three times daily if tolerated. 5
• Limit use to ≤2 weeks maximum—no evidence supports longer duration, and sedation/fall risk increases with prolonged use. 2, 6
• Tizanidine is an alternative with similar efficacy but monitor for hepatotoxicity. 2
• Avoid methocarbamol—cyclobenzaprine has substantially more evidence supporting its use. 2

Opioids (Use With Extreme Caution)

• Insufficient evidence exists for opioids in acute low back pain, and they should be avoided given addiction risks and lack of proven benefit. 1
• If absolutely necessary for severe pain unresponsive to NSAIDs plus muscle relaxants, use the lowest effective dose for the shortest duration (≤3-7 days). 7, 8

Systemic Corticosteroids (Not Recommended)

• Do not use systemic corticosteroids—they show no benefit over placebo for acute low back pain with or without sciatica. 1, 2

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Chronic Low Back Pain (>12 weeks)

NSAIDs (First-Line)

• NSAIDs provide small to moderate pain improvement and small functional improvement in chronic low back pain. 1
• Key caveat: Evidence is limited to short-term use; long-term cardiovascular and gastrointestinal risks must be weighed against benefits. 1, 2

Duloxetine (Second-Line)

• Duloxetine 60 mg daily provides small but significant improvements in both pain intensity and function compared to placebo in chronic low back pain. 1, 9
• FDA-approved specifically for chronic musculoskeletal pain including chronic low back pain. 9
• Particularly useful when chronic pain coexists with depression. 2
• Dosing: Start 30 mg daily for 1 week, then increase to 60 mg daily; doses above 60 mg show no additional benefit but increase adverse effects. 9
• Common side effects include nausea, dry mouth, somnolence, and constipation. 9

Tricyclic Antidepressants (Second-Line Alternative)

• Amitriptyline and other tricyclics show moderate efficacy for chronic low back pain based on higher-quality evidence. 2, 3
• Start with low doses (10-25 mg at bedtime) and titrate slowly to minimize anticholinergic side effects. 2

Gabapentin/Pregabalin (Only for Radiculopathy)

• Gabapentin is effective ONLY for radicular pain/sciatica, NOT for axial chronic low back pain. 2, 3
• For radiculopathy, gabapentin shows small to moderate short-term benefits; titrate to 1200-3600 mg/day in divided doses. 2
• Adjust dose in renal impairment (eGFR 37-50 mL/min requires dose reduction). 3
• Pregabalin shows no benefit for nonradicular chronic low back pain and may worsen function. 2
• Monitor for sedation, dizziness, and peripheral edema. 2

Opioids (Last Resort Only)

• Strong opioids (morphine, oxymorphone, hydromorphone) provide only small short-term pain improvement (~1 point on 0-10 scale) with significant risks. 1
• Tramadol shows moderate short-term pain relief with fewer addiction risks than strong opioids. 1
• Reserve for refractory cases only after exhausting non-opioid options, and use time-limited trials with frequent reassessment. 1

Muscle Relaxants (Not Recommended)

• Do not use muscle relaxants for chronic low back pain—no evidence supports efficacy beyond 2 weeks, and they carry significant sedation and fall risks. 2, 6
• The American Geriatrics Society explicitly warns against their use in older adults. 2

Acetaminophen (Not Recommended)

• Acetaminophen is slightly inferior to NSAIDs for chronic pain (standardized mean difference ~0.3) and should not be used as monotherapy. 1

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Radicular Pain/Sciatica

Treatment Algorithm for Radiculopathy

1. Start with NSAIDs for the inflammatory component. 2
2. Add gabapentin (titrate to 1200-3600 mg/day) specifically for the neuropathic/radicular component. 2, 3
3. If insufficient response, add duloxetine or a tricyclic antidepressant for additional pain modulation. 2
4. For acute exacerbations, consider short-term skeletal muscle relaxant (≤2 weeks). 2
5. Avoid systemic corticosteroids—they show no benefit for sciatica. 1, 2

NSAIDs for Sciatica

• One systematic review found no difference between NSAIDs and placebo specifically for back pain with sciatica (3 trials). 1
• However, NSAIDs remain reasonable for the inflammatory component when combined with neuropathic agents. 2

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Critical Pitfalls to Avoid

• Do not prescribe acetaminophen for low back pain—high-quality evidence shows no benefit over placebo. 1, 4
• Do not use gabapentin/pregabalin for nonradicular chronic low back pain—they are ineffective and cause unnecessary side effects. 2, 3
• Do not prescribe muscle relaxants beyond 2 weeks—no evidence supports longer use, and risks increase substantially. 2
• Do not use systemic corticosteroids for any type of low back pain—they are ineffective. 1, 2
• Do not prescribe opioids as first-line therapy—reserve for refractory cases only with time-limited trials. 1
• Do not use baclofen for back pain—tizanidine has better evidence and safety profile if a muscle relaxant is needed. 6
• Always adjust gabapentin dosing in renal impairment to avoid toxicity. 3
• Monitor for cardiovascular and gastrointestinal risks with prolonged NSAID use, especially in elderly patients or those with cardiovascular disease. 1, 2