We over-estimate the benefits when prescribing medicines for non-specific low back pain

Most pain medicines have the potential for harm, with little or no benefit over placebo, in the setting of non-specific low back pain.

‘Non-specific low back pain’ is diagnosed when there is pain, but no identifiable spinal pathology. This entity is very common and is generally managed with regular pain medications. There is however limited evidence for the benefit of these medicines above placebo.

A variety of different types of medication are used to treat back pain. Paracetamol, NSAIDs and opioids are all very frequently prescribed. Unlike paracetamol, NSAIDs and opioids have been shown to have some benefit – however both of these have significant harm profiles with acute and regular use. Anti-depressants and anti-convulsants are also widely prescribed. There is low-quality evidence for the use of anti-depressants in chronic non-specific low back pain, however a moderate risk of harm is identified. There are no clinical trials supporting the efficacy of anti-convulsants in this patient group. Muscle relaxants have been shown to give significant pain reduction have a significant risk of side effects. Finally there is little evidence of any benefit from oral or intra-muscular corticosteroids for non-specific back pain. The use of some pain medications are also prohibited by the World Anti-Doping Agency (WADA) and this must be taken into account when prescribing for athletes.

Medicines should not be the mainstay of treatment for non-specific low back pain. In most situations education, physiotherapy and topical treatments should be routinely trialled before offering medication. Actively discontinuing medications that are no longer of benefit and making clear therapeutic goals between the doctor and patient should be a focus. When medication is used it should be prescribed at the lowest effective dose for the shortest time period. Clear information about the potential harm associated with the medication use should also be given. Medication should ideally be reserved for patients who have failed a trial of non-pharmacological management and/or those with severe pain as a way of keeping them active.

A final consideration is the common practice of self-prescribing. The increased availability of medicines means that this often happens, and the importance of education for athletes in this setting should be realised.

To learn more about the management of back pain complete the ‘Lumbar Spine’ module in the FIFA Diploma in Football Medicine.

Traeger AC, Buchbinder R, Harris IA, et al. Avoid routinely prescribing medicines for non-specific low back pain.
Br J Sports Med.  Published Online First: 07 March 2018. doi: 10.1136/bjsports-2017-098614


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BangouraMark FulcherDr Sharon WardleAntonio Gildrlabelle Recent comment authors
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This is one of the leading arguments for making Chiropractors the entry point/gatekeepers to for evaluation and management of the spine. Chiropractors are already licensed primary care physicians in the state of Illinois (USA). Rx and even OTC drugs should be a last resort not a frontline therapy!


Yes, I agree that chiropractors can be a much added benefit for any professional football/soccer team at any level. I’ve been on contract as a chiropractor with the Atalanta soccer team in Italy’s top “Serie A” division for over 14 years and have enjoyed being an “added value” to the medical staff and contributing to the success we have had in the normal season and UEFA European League competition.


As chiropractors we do not use medications at all for minor persistent spinal subluxations. We diagnose and adjust then advise the patient re posture at work and at home. Medications mask pain. They also mask the fact that the source of the pain has not been correctly diagnosed. They do not cure anything. Of course there are occasions that they assist in making the patient more comfortable in the acute phase but beyond that do more harm than good.

Mark Fulcher

Nice comments guys. I think that all clinicians need to re-consider how back pain is treated. Empowering the player to manage their own pain with education and physical activity, with the support of an experienced clinician, is the key strategy.


Les analgésiques sont des médicaments qui doivent être utilisés avec prudence car certains peuvent induire les sportifs en cas de contrôle antidopage lors des grandes compétitions
Le traitement de la douleurdepant de l intensité et du siege
Les analgésiques sont divisés en paliers en fonction du traitement
Palier 1 2 3
Les analgésiques périphériques sont beaucoup plus utilisé que les centraux à cause de leur combinaison
En général le médecin du sport doit connaître la liste des médicaments prohibes pour le grand plaisir du sportif