What is the recommended treatment for a patient presenting with back pain?

Prescription for Back Pain

First-Line Pharmacologic Treatment

For most patients with back pain, prescribe NSAIDs (such as ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily) as the preferred first-line medication, combined with explicit instructions to remain active and avoid bed rest. 1

NSAID Prescribing Details

• NSAIDs provide small to moderate pain relief superior to acetaminophen for acute low back pain 1
• Prescribe at the lowest effective dose for the shortest duration necessary (typically 7-14 days initially) 2, 1
• Before prescribing, assess cardiovascular and gastrointestinal risk factors, as NSAIDs carry risks for myocardial infarction, GI bleeding, and renal complications 2
• Most head-to-head trials show no differences between different NSAIDs, so selection can be based on cost and availability 1
• Consider co-administration with a proton-pump inhibitor in higher-risk patients 2

Alternative First-Line Option

• Acetaminophen 500-1000 mg every 6 hours (maximum 4 g/day) is an acceptable alternative for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain 1
• Monitor for hepatotoxicity at maximum doses, especially in elderly patients or those with hepatic impairment 1
• Acetaminophen causes asymptomatic aminotransferase elevations at 4 g/day even in healthy adults 2

Essential Non-Pharmacologic Instructions (Must Include in Prescription)

Critical: Write explicit instructions to remain active and avoid bed rest, as activity restriction prolongs recovery and delays return to normal function. 2, 1

• Advise application of superficial heat via heating pads or heated blankets for short-term symptomatic relief 2, 1
• Provide evidence-based self-care education materials (such as "The Back Book") 2
• Reassure that 90% of episodes resolve within 6 weeks regardless of treatment 3

Second-Line Pharmacologic Options (If Severe Pain Persists After 2-4 Days)

Skeletal Muscle Relaxants

• Add cyclobenzaprine 5 mg three times daily for short-term use (≤1-2 weeks maximum) if severe pain with muscle spasm persists 1, 4, 5
• Cyclobenzaprine improves short-term pain relief after 2-4 days compared to placebo 1
• Critical warning: All skeletal muscle relaxants cause central nervous system adverse effects, primarily sedation 1, 5
• In hepatic impairment, start with 5 mg dose and titrate slowly; avoid in moderate to severe hepatic insufficiency 5
• No evidence supports use beyond 1-2 weeks, and risks increase with longer duration 4

When NSAIDs and Muscle Relaxants Fail

• For severe, disabling pain uncontrolled by NSAIDs and muscle relaxants, consider opioid analgesics (such as oxycodone 5-10 mg every 4-6 hours) or tramadol 50-100 mg every 4-6 hours 2, 1
• Critical caveat: Opioids carry substantial risks including aberrant drug-related behaviors, abuse potential, and addiction 2, 1
• Carefully weigh benefits and harms before initiating, and prescribe only time-limited courses (3-7 days maximum initially) 2

Treatments NOT to Prescribe

• Do NOT prescribe systemic corticosteroids - they are no more effective than placebo for acute low back pain with or without sciatica 1, 4
• Do NOT prescribe benzodiazepines as first-line therapy - they show similar effectiveness to muscle relaxants but carry higher risks for abuse, addiction, and tolerance 1
• Do NOT prescribe bed rest or activity restriction - this provides no benefit and delays recovery 1, 6
• Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute low back pain 1

Sample Prescription Format

Rx #1: Ibuprofen 600 mg tablets

• Sig: Take 1 tablet by mouth every 6-8 hours as needed for pain
• Disp: #40 tablets
• Refills: 0
• Instructions: Take with food. Do not exceed 3200 mg in 24 hours. Stop if stomach pain, black stools, or chest pain occurs.

Rx #2 (if needed after 2-4 days): Cyclobenzaprine 5 mg tablets

• Sig: Take 1 tablet by mouth three times daily for muscle spasm
• Disp: #21 tablets (7-day supply)
• Refills: 0
• Instructions: May cause drowsiness. Do not drive or operate machinery until you know how this affects you. Use for maximum 1-2 weeks only.

Written Instructions (provide to patient):

• Remain active and continue ordinary activities within limits permitted by pain
• Apply heating pad to painful area for 15-20 minutes several times daily
• Avoid bed rest - this will prolong your recovery
• Return to work as soon as possible, even with modified duties
• Most back pain resolves within 4-6 weeks regardless of treatment

When to Reassess or Refer

• If no improvement after 4-6 weeks despite first-line treatment, consider spinal manipulation by appropriately trained providers or expand to exercise therapy 2, 1
• Obtain MRI only if patient is a potential candidate for surgery or epidural injection and symptoms persist beyond 4-6 weeks 6
• Extended medication courses should only continue if patient shows clear ongoing benefits without major adverse events 6