What are the appropriate next‑step pharmacologic and non‑pharmacologic management options for a patient with chronic low back pain who cannot take nonsteroidal anti‑inflammatory drugs (NSAIDs) and has declined acetaminophen (paracetamol) and epidural steroid injections?

Management of Chronic Lower Back Pain When NSAIDs and Acetaminophen Are Not Options

Start duloxetine 30 mg daily for one week, then increase to 60 mg daily, while simultaneously initiating a structured nonpharmacologic therapy program including physical therapy, exercise, and cognitive behavioral therapy. 1

First-Line Pharmacologic Option: Duloxetine

Duloxetine is the preferred first-line medication when NSAIDs are contraindicated and acetaminophen has been declined, based on moderate-quality evidence showing modest but clinically meaningful effects on both pain intensity and function in chronic low back pain. 2, 1

Dosing Strategy

• Start at 30 mg daily for one week to assess tolerability, then increase to the therapeutic dose of 60 mg daily 1
• This SNRI antidepressant demonstrates sustained effects beyond short-term use (>4 weeks), unlike most other pharmacologic options 1
• Duloxetine has a more favorable safety profile compared to tricyclic antidepressants, particularly in older adults 1

Monitoring

• Monitor for common side effects: nausea, dry mouth, dizziness, and constipation 1
• Assess pain intensity (0-10 scale) and functional status at 2-4 weeks after initiating therapy 1
• Reassess need for continuation at 8-12 weeks, as most pharmacologic benefits are short-term 1

Essential Nonpharmacologic Therapies (Must Be Initiated Concurrently)

The American College of Physicians strongly recommends nonpharmacologic therapies as the foundation of chronic low back pain management, providing comparable or superior benefits without medication risks. 2, 3, 1

High-Quality Evidence Options

• Exercise therapy: Moderate-quality evidence for pain reduction and functional improvement 2, 3
• Multidisciplinary rehabilitation: Moderate-quality evidence for comprehensive pain management 2, 3
• Cognitive behavioral therapy: Addresses psychosocial factors that predict chronicity including depression, catastrophizing, and fear-avoidance beliefs 2, 3
• Mindfulness-based stress reduction: Moderate-quality evidence for chronic pain 2, 3

Additional Effective Options

• Acupuncture: Moderate-quality evidence for chronic low back pain 2, 3
• Spinal manipulation: Low-quality evidence but may provide benefit 2, 3
• Massage therapy: Low-quality evidence for symptom relief 2, 3, 1
• Tai chi or yoga: Low-quality evidence but reasonable adjunctive options 2, 3
• Superficial heat application: For short-term relief 3, 1

Second-Line Pharmacologic Option: Tramadol

If duloxetine provides inadequate response after 4-6 weeks, add tramadol 25-50 mg every 6 hours as needed (maximum duration 2-4 weeks while optimizing other therapies). 1

• Tramadol achieves moderate short-term pain relief and small improvements in function compared to placebo, with moderate-quality evidence 2, 1
• The dual mechanism (weak opioid + SNRI properties) provides analgesia without full opioid risks 1
• Monitor closely for dizziness, confusion, constipation, and falls, especially in older adults 1
• Limit use to 2-4 weeks to avoid dependence 1

Third-Line Options for Refractory Pain

Skeletal Muscle Relaxants

• Evidence comparing SMRs versus placebo for chronic low back pain is insufficient 2
• Low-quality evidence shows no differences between different SMRs for chronic pain 2
• May be considered as short-term adjunctive therapy, but high sedation rates limit utility 2

Gabapentinoids

• Consider gabapentin only if neuropathic pain or radiculopathy is present 1
• Evidence is insufficient for pure nonspecific chronic low back pain without radicular symptoms 1

Opioids (Last Resort Only)

Opioids should be reserved for very severe, disabling pain in appropriately selected patients after all other options have failed. 1

• Strong opioids (tapentadol, morphine, hydromorphone, oxymorphone) provide small short-term improvement (approximately 1 point on 0-10 pain scale) with moderate-quality evidence 2, 1
• Buprenorphine patches show less than 1 point improvement on pain scale with low-quality evidence 2
• The minimal clinical benefit must be weighed against significant risks including abuse potential, dependence, and adverse effects 2

Options to Avoid

Medications Without Benefit

• Tricyclic antidepressants (TCAs) and SSRIs: Moderate-quality evidence shows no difference in pain compared to placebo 2
• Systemic corticosteroids: Moderate-quality evidence shows no benefit for chronic low back pain 2
• Benzodiazepines: Limited evidence (tetrazepam showed some benefit at 5-7 days, but not recommended for chronic use) 2
• Antiseizure medications: Insufficient evidence for chronic low back pain without radiculopathy 2

Clinical Algorithm Summary

1. Week 1: Start duloxetine 30 mg daily + initiate physical therapy and structured exercise program 1
2. Week 2: Increase duloxetine to 60 mg daily + continue nonpharmacologic therapies 1
3. Weeks 2-4: Assess response; add cognitive behavioral therapy or other evidence-based nonpharmacologic options 1
4. Weeks 4-6: If inadequate response, add tramadol 25-50 mg every 6 hours as needed (maximum 2-4 weeks) 1
5. Week 8-12: Reassess all medications; discontinue if no sustained benefit 1
6. If radicular symptoms present: Consider adding gabapentin 1
7. If still refractory: Consider opioids only after comprehensive discussion of risks/benefits and with close monitoring 1

Critical Pitfalls to Avoid

• Do not rely solely on pharmacologic therapy: Nonpharmacologic treatments provide comparable or superior benefits and should always be the foundation of management 2, 3, 1
• Avoid long-term medication use without clear ongoing benefit: Most pharmacologic benefits are short-term only 1
• Do not prescribe opioids as first or second-line therapy: Reserve for severe, refractory cases only 2, 1
• Do not ignore psychosocial factors: Depression, catastrophizing, fear-avoidance beliefs, and job dissatisfaction predict chronicity and must be addressed 3
• Avoid routine imaging: Not indicated for nonspecific chronic low back pain without red flags 3