Which oral medications are used in the treatment of chronic low back pain (LBP)?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Some authors contend that analgesics like acetaminophen are a reasonable first step for the treatment of cLBP [56, 57] , although others disagree and advocate its use only when treating acute LBP. [58] There is evidence that acetaminophen has a similar efficacy to nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with acute LBP; however, little direct evidence exists regarding the efficacy of acetaminophen in cLBP. [59] The possible beneficial effects of long-term acetaminophen use must be weighed against potential adverse hepatic and renal effects. [60]

There is strong evidence that both traditional and cyclooxygenase-2-specific NSAIDs are more efficacious than a placebo for reducing LBP in the short term, although the effects tend to be small. [59] One small randomized study suggested that the NSAID diflunisal had a greater efficacy than acetaminophen. [61] In addition, their findings demonstrate that the various NSAIDs are, on average, equally efficacious. [62] Gastrointestinal, renal, and potential cardiac toxicities must be considered with long-term NSAID use. [59] .

During the acute phase following biomechanical injury to the spine, where there are no fractures, subluxation, other serious osseous lesions, or significant neurological sequelae, mild narcotic analgesics may assist patients in minimizing inactivity and safely maximizing the increase in activity, including prescribed therapeutic exercises. NSAIDs and muscle spasmolytics used during the day or at bedtime may also provide some benefit. [18, 53]

The best available evidence advocates the use of an antidepressant, analgesic, or both for chronic back pain. When starting a new medication, patients should be educated as to why a medication is chosen and its expected risks and benefits. Patient preferences concerning medications should be considered, especially after they are informed of potential risks. When anxiety lingers regarding the risks or side effects of a medication (eg, NSAIDs or muscle relaxants), a short trial of the medication at a low dosage over 3-4 days can be effective for assessing the patient's tolerance and response to the drug, as well as alleviating patient and physician concerns. Most patients require medications in relatively high therapeutic ranges over a protractile period of time. [63]

Patients may be resistant to multiple therapeutic approaches and may require more individualized medication combinations, including other analgesics. Pooled data from large groups of patients have shown that no one medication in any of the various drug classes provides more benefit to the patient than another. [63] Furthermore, predicting which patient will respond best to which medication within that class is impossible. Better studies with greater numbers of patients and longer follow-up times are needed to better compare classes of medications, including simple analgesics, muscle relaxants, and NSAIDs. [57]

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