Meds for Back Pain - What Works and What Doesn't

Short Attention Span Summary

Acetaminophen - good hepatotoxin, bad for back pain
This was a big systematic review of medications for treating low back pain.

  • Acetaminophen was ineffective.
  • NSAIDs were effective but had more side effects than acetaminophen.
  • Tramadol, tapentadol, or opioids were no more effective than NSAIDs for acute low back pain but had a small effect for chronic low back pain, though there was no accounting for the risk of addiction or overdose.
  • Muscle relaxers were better than placebo for acute pain but of questionable benefit as an add-on to NSAIDs for chronic pain, and they caused sedation.
  • Evidence for benzodiazepines was mixed, but higher quality trials showed worsening of radicular pain and no improvement in function.
  • Antidepressants were not helpful for chronic pain, with the exception of duloxetine, which reduced pain by less than a point on a 10-point scale.
  • Anti-seizure medications, like pregabalin or gabapentin, were unhelpful for chronic pain.  A new NEJM study showed pregabalin also didn't help acute sciatica either - more on this next month.
  • Steroids did not help non-radicular pain and were mixed for radicular pain: one study with mild improvement in function, two with no change.

Spoon Feed
Pharmacologic treatments for acute low back pain were moderately helpful, at best, and included NSAIDs, possibly muscle relaxers, and steroids, but only for radicular pain.  There was no evidence to support use of acetaminophen, opiates, benzodiazepines, antidepressants, or anti-seizure medications for acute low back pain.


Abstract

Ann Intern Med. 2017 Feb 14. doi: 10.7326/M16-2458. [Epub ahead of print]

Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline.

Chou R1, Deyo R1, Friedly J1, Skelly A1, Weimer M1, Fu R1, Dana T1, Kraegel P1, Griffin J1, Grusing S1.

Author information:

1From Oregon Health & Science University, Portland, Oregon; University of Washington, Seattle, Washington; and Spectrum Research, Tacoma, Washington.

Abstract

Background:

A 2007 American College of Physicians guideline addressed pharmacologic options for low back pain. New evidence and medications have now become available.

Purpose:

To review the current evidence on systemic pharmacologic therapies for acute or chronic nonradicular or radicular low back pain.

Data Sources:

Ovid MEDLINE (January 2008 through November 2016), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists.

Study Selection:

Randomized trials that reported pain, function, or harms of systemic medications versus placebo or another intervention.

Data Extraction:

One investigator abstracted data, and a second verified accuracy; 2 investigators independently assessed study quality.

Data Synthesis:

The number of trials ranged from 9 (benzodiazepines) to 70 (nonsteroidal anti-inflammatory drugs). New evidence found that acetaminophen was ineffective for acute low back pain, nonsteroidal anti-inflammatory drugs had smaller benefits for chronic low back pain than previously observed, duloxetine was effective for chronic low back pain, and benzodiazepines were ineffective for radiculopathy. For opioids, evidence remains limited to short-term trials showing modest effects for chronic low back pain; trials were not designed to assess serious harms. Skeletal muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation. Systemic corticosteroids do not seem to be effective. For effective interventions, pain relief was small to moderate and generally short-term; improvements in function were generally smaller. Evidence is insufficient to determine the effects of antiseizure medications.

Limitations:

Qualitatively synthesized new trials with prior meta-analyses. Only English-language studies were included, many of which had methodological shortcomings. Medications injected for local effects were not addressed.

Conclusion:

Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.

Primary Funding Source:

Agency for Healthcare Research and Quality. (PROSPERO: CRD42014014735).

PMID: 28192790 [PubMed - as supplied by publisher]