People with LBP may be offered non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.
NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE Guideline [NG59] November 2016. Available at: https://www.nice.org.uk/guidance/NG59
Consider oral non-steroidal anti-inflammatory drugs(NSAIDS) for managing low back pain, taking into account potential differences in gastrointestinal, liver, and cardio-renal toxicity, and the person’s risk factors, including age.
When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastro-protective treatment.
Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time.
Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective.
Do not routinely offer opioids for managing acute low back pain.
Do not offer opioids for managing chronic low back pain.
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
There is conflicting evidence that oral and injectable NSAIDs are effective versus placebo or no treatment for acute low back pain.
There is evidence that the effect of opioid or compound analgesics is similar to NSAIDs for treatment of acute low back pain.
NSAIDs have a similar effect to opioid analgesics, combined paracetamol-opioid analgesics and to each other in their effect on acute low back pain.
There is insufficient evidence that NSAIDs are more effective than muscle relaxants and anti-anxiety agents in acute low back pain
There are no randomised controlled trials investigating the efficacy of opioids and compound analgesics in acute low back pain.
No Level I or II Evidence
In general, opioids and compound analgesics have a substantially increased risk of side effects compared with paracetamol alone.
Serious adverse effects of NSAIDs include gastrointestinal complications (e.g. bleeding, perforation).
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
NSAIDs may be used for short-term pain relief in patients with acute and subacute low back pain
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
Prescribe medication, if necessary, for pain relief preferably to be taken at regular intervals. First choice acetaminophen; second choice NSAIDs. Only consider adding a short course of muscle relaxant (benzodiazepines, cyclobenzaprine, or antispasticity drugs) on its own, or added to NSAIDs, if acetaminophen or NSAIDs have failed to reduce pain. Serious adverse effects of NSAIDs include gastrointestinal complications (e.g., bleeding, perforation, and increased blood pressure). Drowsiness, dizziness, and dependency are common adverse effects of muscle relaxants
Recommend acetaminophen and NSAIDs A proton pump inhibitor (PPI) should be considered for patients over 45 years of age when using an oral NSAID/COX-2 inhibitor. Cardiovascular, renal, gastrointestinal risks, and comorbidities need to be taken into account when prescribing any NSAID. NSAIDs are associated with mild to moderately severe side effects such as: abdominal pain, bleeding, diarrhea, edema, dry mouth, rash, dizziness, headache, and tiredness.
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Useful for pain and inflammation. In mild cases, they may be the only drugs required for analgesia. Chronic use of NSAIDs is generally not recommended due to increased risk of cardiovascular events and GI bleeding.
Opioids: Should be reserved for the treatment of acute severe low back pain. There are circumstances where prolonged use of opioids is justified based on diagnosis and severity of functional deficits, and in these cases, it should be documented and justified. In mild to moderate cases of low back pain, opioid medication should be used cautiously on a case-by-case basis.
Qaseem A, Wilt TJ, McLean RM, Forciea 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. doi:10.7326/M16-2367
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)
Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M etal. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2017 Apr 20. doi: 10.1007/s00586-017-5099-2. [Epub ahead of print]
Do only offer patients with recent onset LBP opioids in addition to usual care after careful consideration, as the evidence points towards no short-term effect
Do only offer patients with recent onset LBP NSAIDs in addition to usual care after careful consideration, as the evidence points towards no short-term effect