From the Guidelines
For chronic low back pain management without narcotic medications, I strongly recommend a multi-modal approach combining physical therapy, non-opioid medications, and lifestyle modifications, as supported by the American College of Physicians guideline 1.
Key Recommendations
- Start with non-pharmacologic treatment, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation, as these have been shown to be effective in managing chronic low back pain 1.
- Consider nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line pharmacologic treatment, or tramadol or duloxetine as second-line therapy, as recommended by the American College of Physicians guideline 1.
- Regular physical therapy focusing on core strengthening exercises, stretching, and proper body mechanics is essential for long-term improvement.
- Heat therapy (20 minutes several times daily) and cold packs can provide temporary relief.
- Maintaining proper posture, ergonomic workspaces, regular low-impact exercise like swimming or walking, and weight management all contribute to reducing back pain.
Non-Pharmacologic Interventions
- Exercise: core strengthening exercises, stretching, and proper body mechanics
- Mind-body therapies: mindfulness-based stress reduction, tai chi, yoga, progressive relaxation, cognitive behavioral therapy
- Alternative therapies: acupuncture, spinal manipulation, electromyography biofeedback, low-level laser therapy, operant therapy
Pharmacologic Interventions
- NSAIDs: ibuprofen (400-800mg three times daily with food) or naproxen (220-500mg twice daily)
- Muscle relaxants: cyclobenzaprine (5-10mg at bedtime) for short periods
- Topical treatments: diclofenac gel (1% applied to the affected area 3-4 times daily) or lidocaine patches
- Duloxetine (30-60mg daily) for pain with a neuropathic component
Lifestyle Modifications
- Maintaining proper posture and ergonomic workspaces
- Regular low-impact exercise, such as swimming or walking
- Weight management
These approaches work by addressing inflammation, muscle tension, and nerve sensitization while improving physical function and strength, offering effective pain control without the risks of dependence and side effects associated with narcotic medications.
From the FDA Drug Label
NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain Cyclobenzaprine produces clinical improvement whether or not sedation occurs.
The answer to chronic low back pain not requiring narcotic pain meds is:
- Cyclobenzaprine can be used for muscle spasm, and it has been shown to produce clinical improvement.
- Naproxen is an NSAID that can be used to treat pain and inflammation. Key points to consider:
- The use of cyclobenzaprine and naproxen should be done under the guidance of a healthcare provider, as they may have side effects and interact with other medications.
- It is essential to follow the recommended dosage and to monitor for any adverse reactions. 2 3
From the Research
Treatment Options for Chronic Low Back Pain
- Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat people with low back pain, especially people with acute back pain 4.
- Short term NSAID use is also recommended for pain relief in people with chronic back pain 4.
- There is low quality evidence that NSAIDs are more effective than placebo, with a mean difference in pain intensity score from baseline of -3.30 (95% CI -5.33 to -1.27) on a 0 to 100 visual analogue scale (VAS) with a median follow-up of 56 days (interquartile range (IQR) 13 to 91 days) 4.
Alternative Treatment Options
- Non-pharmacologic therapies such as physical and chiropractic therapy, yoga, and acupuncture are generally helpful, but often ineffective as monotherapy 5.
- There are several novel opioids and other analgesics in development that may be a useful addition to the treatment options for patients with chronic pain 5.
- Home-based exercise has been shown to improve disability more than NSAIDs, but pain scores were similar 4.
Comparison of Treatment Options
- There is moderate evidence that NSAIDs are not more effective than paracetamol for acute low back pain, but paracetamol had fewer side effects 6, 7, 8.
- There is strong evidence that various types of NSAIDs, including COX-2 NSAIDs, are equally effective for acute low back pain 6, 7, 8.
- COX-2 NSAIDs had statistically significantly fewer side effects than traditional NSAIDs 8.