Low back pain is one of the most common reasons people visit a doctor. But don’t expect to walk away with a prescription. You’re likely to be told to try a nondrug treatment first.
This is especially true if your doctor subscribes to recommendations from the American College of Physicians (ACP), a professional group that in February 2017 issued updated guidelines for treating various types of low back pain.
What to try instead
The ACP guidelines emphasize conservative treatment with therapies such as heat wraps, acupuncture, and massage, since most episodes of low back pain will clear up with little or no treatment in less than six weeks.
If those first-line therapies fail to provide enough pain relief, patients should be directed to try a non-steroidal anti-inflammatory drug (NSAID) or muscle relaxant.
No longer recommended is acetaminophen (Tylenol and others) because studies have shown that it is no more effective than placebo for back pain. The ACP also strongly discouraged the use of opioids because of their potential for harm, cautioning that these drugs only be prescribed as a last-resort therapy, after a discussion between doctor and patient about the potential serious risks and realistic benefits.
The ACP, which represents primary care doctors, published its updated guidelines for the noninvasive treatment of non-radicular subacute, acute, and chronic low back pain. The ACP’s previous guidelines were issued in 2007.
“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” says Nitin S. Damle, ACP president. “Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”
Back pain is a major health issue and second only to upper respiratory illness as a reason for seeing a doctor.
There are two main types of low back pain: radicular and nonradicular. Radicular is associated with damage to the nerves in the lower spine. Pain may start there but typically radiates down the leg. Nonradicular pain shows no signs of nerve damage. It’s typically localized in the lower spine and surrounding tissue.
The ACP’s treatment recommendations are based on studies of both kinds of back pain. Because the ACP did not find enough strong evidence to warrant major changes for treating radicular pain, the guidelines’ major focus is on three categories of nonradicular pain:
• Acute (pain that lasts 4 weeks or less)
• Subacute (pain that lasts 4 to 12 weeks)
• Chronic (pain that lasts more than 12 weeks)
Both acute and subacute back pain, like a common cold, often resolve on their own. Doctors are urged to help patients understand this and avoid ordering unneeded tests and prescribing costly drugs such as opioids, which could cause accidental overdose or addiction.
If treatment is necessary for pain relief, patients and doctors should first consider using nondrug therapies such as:
• Superficial heat (heat wraps placed on the skin)
• Spinal manipulation
For chronic back pain, the recommendation is similar. Patients and doctors should consider non-drug options first, including:
• Multidisciplinary rehabilitation (combining physical and psychological treatment)
• Mindfulness-based stress reduction
• Tai chi
• Motor-control exercise (focused on restoring coordination, control, and strength of muscles supporting the spine)
• Progressive relaxation (tensing and then relaxing the affected muscles)
• Electromyography biofeedback (a method of retraining tense muscles by using feedback from sensors placed on the skin)
• Low-level laser therapy
• Psychological therapies
• Spinal manipulation
Only if the response to nondrug therapies is inadequate should patients and doctors consider using NSAIDs, such as ibuprofen, or skeletal muscle relaxants. If NSAIDs fail to relieve chronic pain, the antidepressant duloxetine (Cymbalta) can be considered. Another option is tramadol, a nonopioid drug that acts on the opioid receptor but has a lower risk of dependence.
The clearest message from the guidelines is that both doctor and patient need to work together to choose the most effective, appropriate therapy. Every recommendation clearly states that options must be considered not just by the doctor, but by the patient and doctor together.
You’ll need to be an active participant in your own care. Consider yourself and your doctor as a team. Your doctor has the training to help you understand what the options are and what the possible outcome and effects will be. But only you can say what you’re willing or able to try, or financially afford. Working together can help ensure that the care you get is the care you really need.