It is a quiet afternoon at the Primary Care Clinic, so you decide to open MyChart to catch up on your messages. You come across a message from a patient who came into clinic earlier in the week clutching his lumbar spine in pain after lifting a couch in his apartment. On physical exam, he was found to have nonspecific low back pain and paraspinal muscle tenderness without radiculopathy. He has type 2 diabetes complicated by stage 3a chronic kidney disease, so you recommended he take acetaminophen every 4 hours, apply a heating pad, do gentle stretching exercises, and call if it was not getting better after a week.
His message today says, “Doc, my back is killing me. Tylenol just isn’t touching it. Can you give me something stronger for the pain?”
What do you do?
Nonspecific back pain is a common problem, representing the third largest portion of total national health spending in the United States after diabetes and ischemic heart disease. Up to 8 out of 10 people will experience back pain in their lifetime.1 Fortunately, in 5 of these 8 patients, the initial insult is self-limited and will resolve in a few weeks despite approximately 60% of all patients with back pain receiving no particular intervention for their pain. However, symptoms may be significantly painful and debilitating for other patients, and some will request “stronger” medications like opioids to control their pain.
Understandably, many physicians hesitate to prescribe opioids unless there is a strong evidence base for their efficacy. Opioids are agonists of the mu, kappa, or delta opioid receptors that modulate pain sensation in the central nervous system. Chronic opioid use causes altered expression of mu opioid receptors at the synapse between neurons of the ventral tegmental area and nucleus accumbens, leading to weaker disinhibition of dopamine release in reward pathways and increased tolerance to opioids over time.2 Opioid addiction has become a problem of epidemic proportions in the United States, with an estimated 46,802 deaths from opioid overdose in 2018.3 One prospective study of 518,195 opioid-naïve patients who were prescribed an opioid for low back pain found that 1.4% of the cohort developed chronic opioid use,4 suggesting that this common condition may play a role in the current opioid crisis.
Do opioids actually work for low back pain? Outcomes in the literature are mixed, suggesting short-term benefits for pain and minimal benefits for function.5 In systematic reviews, opioids have not been shown to expedite a patient’s return to work or improve functional outcomes on patient questionnaires. Furthermore, other studies indicate that these modest reductions in pain do not represent a clinically meaningful difference in patient-reported pain scores compared to treatment with a placebo.6 Of note, randomized controlled trials of opiate use for low back pain are often short-term (<16 weeks), have high dropout rates, and selective inclusion criteria that may limit external validity and prevent generalizability of their findings to the typical clinic population. Taking into account lukewarm efficacy outcomes, the dangerous adverse effects of opioid use, and the risk of abuse, primary care providers often defer prescribing opiates until patients have failed first- (and sometimes second-) line therapy or refer the patient to a pain specialist for opioid management.
You start composing a message to your patient. You are not comfortable placing him on an opioid just yet, but you do not want to leave him in pain. You recall that low back pain is difficult to treat because it is both nociceptive and neuropathic. You wonder what effective alternatives are available.
The most commonly prescribed non-opioid medications for low back pain are nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen/paracetamol, skeletal muscle relaxants, and antidepressants.7,8 Both acetaminophen and NSAIDs work by reducing prostaglandin-mediated inflammation. The patient’s initial message suggested that acetaminophen was not sufficient for his pain. This is consistent with the findings of 3 large randomized clinical trials, including the landmark Paracetamol for Low-Back Pain (PACE) trial, which compared two different doses of acetaminophen and placebo for pain relief in low back pain.9 No trial to date has suggested clear benefits from using acetaminophen for low back pain.10 NSAIDs may be used short-term in patients with normal renal function but have also exhibited only modest benefits in pain reduction. A systematic review of 70 studies assessing the effects of NSAIDs on low back pain using a 0-100 visual analog pain scale suggested regular NSAID use was associated with a mean 8-point reduction compared to placebo for acute back pain and 10-point reduction for chronic back pain.11 Neither acetaminophen nor NSAIDs have shown any evidence of effect on sciatica symptoms.
By contrast, skeletal muscle relaxants work to decrease reactionary paraspinal muscle spasm around the inflamed low spine. The skeletal muscle relaxants most commonly prescribed in the United States include baclofen and cyclobenzaprine. In systematic reviews, skeletal muscle relaxants were shown to provide a short-term reduction in low back pain levels (measured by visual analog scale) by 30%.11 However, skeletal muscle relaxants should be used sparingly and only for short treatment courses, as they may cause sedation and respiratory depression.
One particularly debilitating and pervasive component of low back pain is sciatic neuralgia, or neuropathic pain that radiates down the posterior leg along the course of the sciatic nerve. Hypothesized anti-sciatica treatments include antidepressants, benzodiazepines, and oral glucocorticoids. While selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) have not shown benefit over placebo specifically among patients with comorbid depression and chronic sciatica, small benefits have been demonstrated with the use of the serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine.12 Placebo-controlled trials of the long-term benzodiazepine diazepam in radicular low back pain actually found no difference in pain outcomes and some have found that benzodiazepine use is associated with worsening of functional outcomes, perhaps due to the rate of adverse events such as somnolence, fatigue, and lightheadedness.13 Finally, studies have assessed the use of short-term oral corticosteroid tapers to reduce paraspinal inflammation and have found no benefits in pain reduction or improved function.14
Since medications seem to have only moderate effects at best, are there other treatments that we can offer to the patient? Since greater body mass index often represents greater force on the lumbar spine, it is not surprising that diet and physical therapy programs have shown benefit for the patient with low back pain in a small randomized controlled trial.15 Other treatments that have shown benefit in small clinical trials include yoga,16 tai chi,17 mindfulness-based stress reduction, 5% lidocaine patches,18 neodymium-doped yttrium aluminum garnet laser therapy,19 and continuous low-heat wrap application.20 Treatments that have shown inconsistent benefits for back pain compared to established treatments include spinal manipulation, acupuncture, massage, traction treatments, and lumbar supports.17,21 Regular exercise programs have not been shown to reduce active back pain but may prevent future episodes from occurring.
For the patient with intractable back pain, a referral to Pain Management for epidural steroid injections may be considered. A 2015 systematic review by Chou and colleagues evaluated epidural steroid injections for patients with radiculopathy and patients with spinal stenosis.22 Their review of 30 placebo-controlled trials of patients with radiculopathy suggested that these injections are associated with a short-term, 10% reduction in pain severity on a visual analog scale. However, in 8 placebo-controlled trials assessing patients with spinal stenosis, epidural steroid injections were not shown to significantly improve pain or function.
Finally, if the patient were to present with neurologic “red flag” symptoms such as dermatomal sensory or motor loss, autonomic dysfunction and saddle anesthesia consistent with cauda equina syndrome, or systemic symptoms suggestive of infection or cancer, this may warrant an urgent referral to Neurosurgery Clinic. The neurosurgeon may also be helpful in more common spinal pathologies such as spinal stenosis, herniated discs, spondylosis (degenerative changes of the spinal disc), or non-radicular back pain that is non-responsive to pharmacologic and lifestyle interventions. If these pathologies are identified on spinal radiograph or magnetic resonance imaging, neurosurgeries such as a posterior decompressive laminectomy for spinal stenosis,23 microdiscectomy for a herniated disc,24 or spinal fusion for nonradicular back pain or spondylosis25 have shown superior reductions in visual analog scale pain scores compared to nonpharmacologic conservative care.
Nonspecific low back pain is difficult to treat. Most injuries seem to resolve with “tincture of time” and modest benefits from known therapies. However, in a subset of patients, pain is persistent and causes long-term disability. It is likely that “low back pain” does not represent one specific injury, and current studies are limited by heterogeneous study populations.
Perhaps you will have a good answer for your patient with low back pain in the future. For now, treating low back pain is more of an art than a science. You prescribe him a short course of baclofen, refer him to a formal physical therapy program, and tell him you will follow up in one week. His back pain resolves after 10 days and he thanks you for your help.
Elyse Berlinberg is a 3rd year medical student at NYU Grossman School of Medicine
Reviewed Michael Tanner, MD, Associate Editor, Clinical Correlations
Image courtesy of Wikimedia Commons, source: https://www.myupchar.com/en/disease/back-pain
- Kim LH, Vail D, Azad TD, et al. Expenditures and health care utilization among adults with newly diagnosed low back and lower extremity pain. JAMA Netw Open. 2019; 2(5):e193676. doi:10.1001/jamanetworkopen.2019.3676 https://pubmed.ncbi.nlm.nih.gov/31074820/
- Langlois LD, Nugent FS. Opiates and plasticity in the ventral tegmental area. ACS Chem Neurosci. 2017. doi:10.1021/acschemneuro.7b00281 https://pubmed.ncbi.nlm.nih.gov/28768409/
- Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020;69(11):290-297. doi:10.15585/mmwr.mm6911a4 https://www.cdc.gov/mmwr/volumes/69/wr/mm6911a4.htm
- Moshfegh J, George SZ, Sun E. Risk and risk factors for chronic opioid use among opioid-naive patients with newly diagnosed musculoskeletal pain in the neck, shoulder, knee, or low back. Ann Intern Med. 2018;170(7):504-505. doi:10.7326/M18-2261
- Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ. 2015;350:g6380. doi:10.1136/bmj.g6380 https://pubmed.ncbi.nlm.nih.gov/25561513/
- Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(7):958-968. doi:10.1001/jamainternmed.2016.1251
- Fritz JM, Brennan GP, Hunter SJ, Magel JS. Initial management decisions after a new consultation for low back pain: implications of the usage of physical therapy for subsequent health care costs and utilization. Arch Phys Med Rehabil. 2013;94(5):808-816. doi:https://doi.org/10.1016/j.apmr.2013.01.008
- Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. doi:https://doi.org/10.1016/S0140-6736(18)30489-6
- Schreijenberg M, Lin CWC, McLachlan AJ, et al. Paracetamol is ineffective for acute low back pain even for patients who comply with treatment: complier average causal effect analysis of a randomized controlled trial. Pain. 2019;160(12):2848-2854. doi:10.1097/j.pain.0000000000001685
- Koes B, Schreijenberg M, Tkachev A. Paracetamol for low back pain: the state of the research field. Expert Rev Clin Pharmacol. September 2020;13(9):1059-1066. doi:10.1080/17512433.2020.1817738
- Chou R, Deyo R, Friedly J, et al. Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):480-492. doi:10.7326/M16-2458
- Urquhart DM, Hoving JL, Assendelft WWJJ, Roland M, van Tulder MW. Antidepressants for non‐specific low back pain. Cochrane Database Syst Rev. 2008;(1):CD001703. doi:10.1002/14651858.CD001703.pub3
- Hingorani K. Diazepam in backache: a double-blind controlled trial. Rheumatology. 1966;8(8):303-306. doi:10.1093/rheumatology/8.8.303
- Holve RL, Barkan H. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med. 2008;21(5):469-474. doi:10.3122/jabfm.2008.05.070220
- Torlak MS, Bagcaci S, Akpinar E, Okutan O, Nazli MS, Kuccukturk S. The effect of intermittent diet and/or physical therapy in patients with chronic low back pain: A single-blinded randomized controlled trial. EXPLORE (NY). 2020;S1550-8307(20):30284-86. doi:https://doi.org/10.1016/j.explore.2020.08.003
- Zhu F, Zhang M, Wang D, Hong Q, Zeng C, Chen W. Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS One. 2020;15(9):e0238544. https://doi.org/10.1371/journal.pone.0238544.
- Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493-505. doi:10.7326/M16-2459
- Galer BS, Gammaitoni AR, Oleka N, Jensen MP, Argoff CE. Use of the lidocaine patch 5% in reducing intensity of various pain qualities reported by patients with low-back pain. Curr Med Res Opin. 2004;20 Suppl2:S5-S12. doi:10.1185/030079904X12933
- Abdelbasset WK, Nambi G, Elsayed SH, et al. Short-term clinical efficacy of the pulsed Nd:YAG laser therapy on chronic nonspecific low back pain: A randomized controlled study. Medicine (Baltimore). 2020;99(36):e22098. https://journals.lww.com/md-journal/Fulltext/2020/09040/Short_term_clinical_efficacy_of_the_pulsed_Nd_YAG.101.aspx.
- Nadler SF, Steiner DJ, Erasala GN, et al. Continuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Spine (Phila Pa 1976). 2002;27(10):1012-1017. https://journals.lww.com/spinejournal/Fulltext/2002/05150/Continuous_Low_Level_Heat_Wrap_Therapy_Provides.3.aspx.
- Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4)-343-350.
- Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis. Ann Intern Med. 2015;163(5):373-381. doi:10.7326/M15-0934
- Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358(8):794-810. doi:10.1056/NEJMoa0707136
- Bailey CS, Rasoulinejad P, Taylor D, et al. Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. N Engl J Med. 2020;382(12):1093-1102. doi:10.1056/NEJMoa1912658
- Yavin D, Casha S, Wiebe S, et al. Lumbar fusion for degenerative disease: a systematic review and meta-analysis. Neurosurgery. 2017;80(5):701-715. doi:10.1093/neuros/nyw162