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.
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