What medication is recommended for an adult with chronic right-sided back pain and no significant medical history?

Medication for Right-Sided Back Pain

Start with NSAIDs (ibuprofen 400-800 mg every 6 hours or naproxen 500 mg twice daily) as first-line therapy, combined with advice to remain active. 1

Initial Pharmacologic Approach

• Acetaminophen or NSAIDs are the first-line medication options for most patients with low back pain, with NSAIDs showing moderate short-term efficacy for pain relief. 1
• Ibuprofen should be dosed at 400-800 mg three to four times daily (maximum 3200 mg/day), taken with meals or milk if gastrointestinal complaints occur. 2
• Use the lowest effective NSAID dose for the shortest duration necessary, as longer use and higher doses increase cardiovascular risk including heart attack and stroke. 3

If Pain Persists: Determine Pain Pattern

You must distinguish between nonspecific back pain versus radicular pain (sciatica) to guide medication selection.

For Nonspecific Back Pain (No Leg Pain/Numbness)

• Add a skeletal muscle relaxant (cyclobenzaprine) for short-term use (≤1-2 weeks) if severe pain persists despite NSAIDs, as combination therapy provides enhanced relief. 1, 3
• If pain remains uncontrolled after 2-4 weeks, add a tricyclic antidepressant (amitriptyline) or duloxetine 30-60 mg daily, which have moderate efficacy for chronic low back pain. 3, 4
• Do not use gabapentin or pregabalin for nonspecific back pain without radiculopathy, as they are ineffective and carry significant risk of adverse effects. 4

For Radicular Pain (Pain Radiating Down Leg)

• Add gabapentin titrated to 1200-3600 mg/day in divided doses for the neuropathic component of radiculopathy, as it shows small to moderate short-term benefits specifically for radicular pain. 3
• Start gabapentin at 100-300 mg/day and titrate slowly to minimize sedation and dizziness, particularly in older adults. 3
• Combining gabapentin with a tricyclic antidepressant (nortriptyline) or duloxetine is superior to either medication alone for neuropathic pain. 3

Medications to Avoid

• Do not prescribe systemic corticosteroids, as they have been shown to be ineffective compared to placebo for low back pain with or without sciatica. 3
• Avoid benzodiazepines, as they are ineffective for radiculopathy and carry risks of abuse, addiction, and tolerance. 3
• Limit opioid use (including tramadol) to time-limited trials only after insufficient response to other therapies, as evidence for long-term efficacy is limited and abuse risks are substantial. 1, 3

Critical Non-Pharmacologic Component

• Advise the patient to remain active and avoid bed rest, as activity restriction prolongs recovery. 1, 3
• Provide structured patient education about the expected course and self-care options, which is as effective as costlier interventions. 1, 3

When to Reassess or Refer

• Reassess in 4 weeks to evaluate medication response and consider referral to pain management or spine specialist if pain remains uncontrolled despite optimized therapy. 3
• Consider imaging (MRI preferred) only if symptoms persist beyond 4-6 weeks or if red flags are present (fever, unexplained weight loss, history of cancer, progressive neurologic deficits). 1