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 The leading web portal for pharmacy resources, news, education and careers March 22, 2018
Pharmacy Choice - Low Back Pain Disease State Management - March 22, 2018

Low Back Pain Disease State Management

Low Back Pain - Updated Treatment Guidelines
by Gina D. Moore, PharmD, MBA

Low back pain is a typical complaint for which patients come to a pharmacy seeking over-the-counter treatment. The prevalence of low back pain in the U.S. is substantial; approximately one out of four adults report experiencing low back pain at least one day during the prior 90 day period. Costs associated with low back pain are also significant in terms of both healthcare dollars and lost wages and productivity.

The American College of Physicians released updated treatment guidelines earlier this year, which address comparative efficacy and safety of noninvasive pharmacologic and nonpharmacologic treatments. The guidelines are based on a robust evidence review of over 175 clinical studies published during the last decade, and address acute, subacute, and chronic back pain. Acute back pain was defined a lasting less than 4 weeks, subacute pain as lasting from 4 to 12 weeks, and chronic pain as lasting for more than 12 weeks.

The guidelines provide three treatment recommendations. The first recommendation is for acute or subacute low back pain and note most patients improve over time regardless of the treatment modality. If treatment is pursued, nonpharmacologic treatment is preferred as there a few safety considerations with non-drug approaches. Nonpharmacologic treatments include heat, massage, acupuncture, and spinal manipulation. Of interest is data demonstrating a heat wrap provided better pain relief than did either acetaminophen or ibuprofen after one to two days, although the quality of the evidence was rated low. If pharmacologic therapy is desired, the guidelines recommend either a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant. The authors note no difference between various NSAID agents or between skeletal muscle relaxants. When considering NSAID agents, clinicians should assess the patient for possible risk factors, particularly the patient's risk for gastrointestinal bleeding and recommend the lowest effective dose for the shortest duration necessary. NSAIDs may also compromise renal function, and the patient assessed for possible risk factors. Studies evaluating acetaminophen use in low back showed no benefit over placebo.

For patients with chronic low back pain, the second recommendation from the guidelines preferentially recommends nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, and a variety of other options including tai chi, mindfulness-based stress reduction, yoga, acupuncture, and spinal manipulation. The data is not compelling to recommend one option versus another; all demonstrate a small to moderate benefit. Regimens that included both strength training and stretching were most effective. Patients should be referred to individuals with appropriate physical therapy training for exercise recommendations.

The third recommendation addresses patients with chronic low back pain with an inadequate response to nonpharmacologic therapies, specifically which pharmacologic options might be considered as the next step. Nonsteroidal agents are considered first-line therapy; one agent is not preferred over another. All have only a small or moderate effect on pain and no to small impact on functional improvement. Patients should be assessed for benefit versus risk, and treated with the lowest effective dose for the shortest duration needed. Second line therapies include both tramadol and duloxetine. In short-term studies, tramadol moderately improved pain and had a small impact on function. Duloxetine had a small effect on both pain and function. Opioids may be considered, but only as the last option and only in patients where other options have failed. Available evidence show only a small benefit on pain and function with opioid therapy. Opioids are associated with significant side effects, but also pose considerable risk for addiction, abuse, and overdose. Contrary to earlier guidelines, tricyclic antidepressant agents did not demonstrate an improvement in pain scores or functionality. Studies that evaluated selective serotonin reuptake inhibitors (SSRIs) also did not demonstrate improvement in pain.

Because of the high prevalence of low back pain and accessibility of pharmacists, patients frequently seek the advice of their local pharmacist on appropriate treatment. Pharmacists should counsel patients that most cases of acute or subacute low back pain resolve on their own, regardless of the intervention. Superficial heat is an appropriate first choice for patients desiring treatment. Heat wraps and patches are often readily available in the pharmacy. If the patient prefers pharmacologic therapy, an over-the-counter NSAID could be recommended, but at the lowest effective dose and for a short duration. Patients who may have opioids at home, or might seek to acquire an opioid from a friend or family member, should be counseled that opioid medications are of limited benefit at best, and carry significant risk of harm.
  1. Deyo RA, Mizra SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys. Spine 2006;31:2724-2727.
  2. Qassem A, Wilt TJ, MacLean RM, Fociea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2017;166:514-530.

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