What are the management options for a patient with chronic lower back pain who cannot take Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Management of Chronic Lower Back Pain Without NSAIDs

For patients with chronic low back pain who cannot take NSAIDs, start with duloxetine 30 mg daily for one week, then increase to 60 mg daily, as this is the only medication with moderate-quality evidence showing meaningful improvements in both pain intensity and function for chronic low back pain. 1

First-Line Pharmacologic Approach

Duloxetine (Preferred)

• Duloxetine is specifically recommended by the American College of Physicians as a first-line alternative when NSAIDs are contraindicated, with moderate-quality evidence demonstrating modest but clinically meaningful effects on chronic low back pain 1
• Start at 30 mg daily for one week to assess tolerability, then increase to 60 mg daily as the therapeutic dose 2, 3
• This SNRI antidepressant has a more favorable safety profile compared to tricyclic antidepressants, particularly in older adults 2
• Effects are sustained beyond the short-term (>4 weeks), unlike most other pharmacologic options 1

Acetaminophen (Limited Role)

• While historically recommended as first-line, new evidence from 2017 shows acetaminophen is actually ineffective for acute low back pain and provides minimal benefit for chronic pain 1
• If used, limit to 3-4 grams daily maximum, recognizing it provides weaker analgesia than NSAIDs (less than 10 points on a 100-point pain scale) 1
• Consider as an adjunct only, not as monotherapy for moderate-to-severe chronic pain 1

Second-Line Options When Duloxetine Fails

Tramadol

• Moderate-quality evidence shows tramadol achieves moderate short-term pain relief and small improvements in function compared to placebo 1
• Start with 25-50 mg every 6 hours as needed, maximum 200-400 mg daily 4, 3
• Tramadol has dual mechanism (weak opioid + SNRI properties) providing analgesia without full opioid risks, but monitor for dizziness, confusion, constipation, and falls 2, 4
• Limit to 2-4 weeks while optimizing other therapies 4

Skeletal Muscle Relaxants (Acute Exacerbations Only)

• Muscle relaxants are effective only for short-term pain relief (up to 1-2 weeks) and should NOT be used for chronic ongoing pain 1, 3
• Cyclobenzaprine 5 mg three times daily is the most evidence-based choice if acute muscle spasm is present 3
• Moderate-quality evidence shows improvement after 2-7 days, but sedation is common and efficacy declines after the first week 1, 3
• Avoid in older adults due to high risk of sedation, confusion, and falls 2, 3

Third-Line Options for Refractory Pain

Opioids (Use With Extreme Caution)

• Moderate-quality evidence shows strong opioids (morphine, oxymorphone, hydromorphone) provide small short-term improvement (approximately 1 point on 0-10 pain scale) 1
• Reserve for very severe, disabling pain in appropriately selected patients after all other options have failed 1
• Evidence is limited to short-term trials (<16 weeks), and studies were not designed to assess serious harms including abuse, addiction, and overdose 1
• If prescribed, use the lowest effective dose for the shortest duration necessary, with close monitoring 1

Gabapentin/Pregabalin (If Radicular Component Present)

• Consider gabapentin 100-300 mg at bedtime, titrating to 1200-3600 mg daily in divided doses over 2-4 weeks if neuropathic pain or radiculopathy is present 4
• Evidence is insufficient for pure nonspecific chronic low back pain without radicular symptoms 1

Medications to Explicitly Avoid

• Benzodiazepines: No evidence for efficacy in chronic low back pain or radiculopathy, with significant risks of dependence, sedation, and falls 1, 4, 3
• Systemic corticosteroids: Low-quality evidence shows no superiority over placebo for low back pain with or without sciatica 1, 4
• Tricyclic antidepressants in older adults: Excessive anticholinergic effects and fall risk outweigh modest uncertain benefits 2, 3

Essential Nonpharmacologic Therapies (Not Optional)

The American College of Physicians strongly recommends initiating nonpharmacologic therapies alongside any medication, as these provide comparable or superior benefits without medication risks:

• Physical therapy and structured exercise programs (most important) 1, 2, 3
• Spinal manipulation 1, 3
• Massage therapy 1, 3
• Cognitive behavioral therapy for chronic pain management 1, 4, 3
• Self-care education using evidence-based resources 1
• Application of heat for short-term relief 1

Clinical Algorithm

1. Start duloxetine 30 mg daily for one week, then increase to 60 mg daily 1, 2
2. Simultaneously initiate physical therapy and exercise program 1, 2, 3
3. If inadequate response after 4-6 weeks, add tramadol 25-50 mg every 6 hours as needed (maximum 2-4 weeks) 1, 4
4. If still inadequate and radicular symptoms present, add gabapentin titrated to therapeutic dose 4
5. If severe refractory pain after 8-12 weeks of optimized therapy, consider pain management referral for interventional options (epidural steroid injections) before considering opioids 4, 5

Critical Monitoring Points

• Assess pain intensity (0-10 scale) and functional status at 2-4 weeks after initiating duloxetine 4
• Monitor for duloxetine side effects: nausea, dry mouth, dizziness, constipation 2
• If tramadol is added, monitor for CNS depression, falls risk, and serotonin syndrome (when combined with duloxetine) 2, 4
• Reassess need for continuation of all medications at 8-12 weeks, as most pharmacologic benefits are short-term 1

Common Pitfalls to Avoid

• Do not continue muscle relaxants beyond 1-2 weeks - efficacy declines and adverse effects accumulate 1, 3
• Do not use acetaminophen as monotherapy expecting significant pain relief - evidence shows minimal benefit 1
• Do not prescribe opioids without exhausting all other options first and establishing clear functional goals 1
• Do not rely solely on medications - nonpharmacologic therapies are equally or more effective and should always be included 1, 2, 3