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Treating lower back pain – new guidelines!

By Jason Poquette,
BPharm, R.Ph

Of all the types of pain that pester patients, lower back pain may be the most pestering of them all. Nearly 30% of American adults admit to having some degree of lower back pain in the past 3 months. Lower back pain is the single leading cause of disability worldwide. And Americans spend a lot of green backs treating bad backs, upwards of $50 billion each year.

No wonder the American College of Physicians (ACP) recently released new guidelines for treating lower back pain and have published their findings in the current issue of JAMA (the Journal of the American Medical Association).

Patients should note that ACP researchers carefully examined many studies and treatment options when making their latest recommendations. They weighed the quality of the evidence (some studies are better than others), they considered risks vs. benefits, and they shared their results with peers for additional feedback. The result was a concise but comprehensive guide to help physicians (and pharmacists, and patients!) treat lower back pain.

Lower back pain (LBP) can be divided into categories based on the length of time the patient has been suffering. “Acute” LBP is pain lasting less than 4 weeks. “Subacute” lasts 4-12 weeks. And “Chronic” is pain lasting longer than 12 weeks. Thankfully, the vast majority of LBP sufferers have either acute or subacute pain, and it generally resolves no matter what treatment is used in less than 3 months.

For the treatment of LBP lasting up to 12 weeks the ACP strongly recommended both non-pharmacologic and pharmacologic treatments, determined mostly by patient preference.

Non-pharmacologic recommendations included things like heat, massage, acupuncture or spinal manipulation.

As for the medications recommended, typically a family of drugs called NSAIDs (Non-Steroidal Anti-Inflammatory Agents) are used, as well as muscle relaxants. Some NSAIDs are available without prescription and include products like ibuprofen or naproxen. These should be used with caution in patients with a history of GI bleeding or ulcers, patients on blood thinners, or patients with liver or kidney disease. Always check with your doctor or pharmacist about any potential drug interactions as well. Muscle relaxants, like cyclobenzaprine or baclofen, are available only by prescription and may cause drowsiness.

The ACP also addressed the issue of treating chronic (longer than 12 weeks) LBP. Since long-term exposure to many prescription medications raises certain risks, they strongly recommend trying non-pharmacologic approaches first. But when this is insufficient, the evidence suggests using medication like NSAIDs, tramadol (a prescription-only pain reliever) or duloxetine.

The duloxetine recommendation is interesting. Originally developed as a treatment for depression, this medication was found to significantly reduce patient perception of pain and improve quality of life for individuals with chronic LBP. However, patients should understand that treatment with duloxetine sometimes causes side effects including dizziness, dry mouth and nausea.

The ACP guidelines also clearly advocate using stronger medications, like opioids, only if all other treatment options have failed.

So what should you do if you have lower back pain?

As a pharmacist I’m often confronted with patients experiencing unexplained, acute lower back pain. Sometimes this merits an immediate trip to the doctor. When the pain is accompanied by a fever, or due to trauma (a serious fall or car accident), or accompanied by numbness or tingling, it should be referred to your physician. Also, if a patient has other medical conditions which might make the LBP more concerning, this should be treated by an MD.

Most LBP, however, is temporary. Patients should rest, use heat and think about some of the treatment options mentioned above for acute LBP. The pestering pain may persist for a few days, but options for relief are thankfully plentiful, tolerable and hopefully helpful as well.