Medications for Low Back Pain: Helpful or Harmful?

It has been estimated that half of Americans will experience low back pain each year.  Approximately 80% will experience low back pain at some point in their lifetime.  Now the good news: It is estimated that about 90% of those who experience back pain will recover well within a few weeks or months.  The other 10% may go on to experience chronic disabling back pain that remains resistant to treatment.   Identifying factors which may lead to chronic pain is a complex matter.   Some believe that controlling the initial intensity of pain is the key.  However, the research does not strongly support this idea.  In fact, efforts to control pain with medication may actually be more harmful than helpful.

Opioids, Low Back Pain, and Depression

Recent practice guidelines published in the European Spine Journal recommend against the use of imaging (MRI or CT scans), injection, anti-inflammatory medications (ibuprofen, etc), and opioids. These same guidelines suggest using patient education, exercise, and manual therapy should be the first treatments used for those with low back pain or sciatica.  Contrary to popular belief, research does not support the use of opioids for short-term pain relief in those with back pain or sciatica.

In the United States, there is a strong association between depression, low back pain, and being prescribed opioid medication.  Individuals with low back pain and a history of depression are more likely to be prescribed opioid medication.  Not only are individuals with depression more likely to be prescribed opioids, but the dosage these individuals are prescribed is twice as high per year compared to those who have no history of depression.  It is then reasonable to theorize that individuals with a history of depression are more likely to develop a dependency or addiction to these powerful medications.   Given the proven benefits of exercise for depression and low back pain, exercise should be used as a first line treatment for these individuals before considering prescription medication.

Muscle Relaxants and Low Back Pain

Muscle relaxants may offer a safer pharmacological option to manage back pain compared to opioids.  Research does suggest a potential short-term benefit to using muscle relaxants when pain is severe.  However, evidence is lacking to support the use of these medications for patients with low back pain lasting greater than 3 months.  Adverse reactions to these medications are usually minimal and similar to those experienced with placebo.

Anti-Inflammatory Medications

The best available evidence suggests a very small and non-significant benefit to using non-steroidal inflammatory medications for back pain and sciatica.  The benefits to using these medications for a new episode of back pain is questionable and the side effects can be severe.  The most serious side effects include ulcers, cardiovascular events (heart attack or stroke), and kidney failure.  If these medications are used, short-term doses should be used in order to minimize risk.

Closing Thoughts

I am not a medical physician.  I cannot prescribe medication and I cannot counsel anyone who is currently taking prescription medication.  However, I do hope that anyone taking prescription medication for low back pain understands the risks, especially with using opioids.  Please carefully discuss these risks with your physician.  Living an active medication-free life, with little or no pain, is possible and always a reasonable goal.

References

  1. Smith JA, Fuino RL, Pesis-Katz I, et al. Differences in opioid prescribing in low back pain patients with and without depression: A cross- sectional study of a national sample from the United States. Pain Reports. 2017;2:1-7.
  2. Ransmussen-Barr E, Held U, Grooten W, et al. Non-steroidal anti-inflammatory drugs for sciatica (Review ). Cochrane Database Syst Rev. 2016;(10):1-53. doi:10.1002/14651858.CD012382.www.cochranelibrary.com.
  3. Shaheed CA, Maher CG, Williams KA, Mclachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017;21:228-237. doi:10.1002/ejp.907.
  4. Stochkendahl MJ, Kjaer P, Hartvigsen J. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27:60-75. doi:10.1007/s00586-017-5099-2.