Pharmacological management for nonspecific low back pain

Before considering pharmacological management, ensure other components of nonspecific low back pain management have been implemented, in particular patient education and reassurance—see Management for acute nonspecific low back pain and Management for chronic nonspecific low back pain for details.

Explain to the patient that the goal of pharmacological management is to reduce, rather than abolish, pain so that physical function can be maintained. Oral analgesia might be useful to facilitate exercise and staying active, but advise patients that some pain with activity is likely and reassure them that this does not imply damage to the spine.

There is moderate- to high-certainty evidence that nonsteroidal anti-inflammatory drugs (NSAIDs) provide a very small short-term benefit that may or may not be important. All of the NSAIDs listed below are equally effective and drug choice should be based on patient factors (eg comorbidities)—see Choosing an NSAID for advice on drug choice. For pain associated with nonspecific low back pain, use:

The potential short-term and limited benefits of an NSAID should be weighed against its potential harms, particularly in patients at high risk of harms. See Principles of NSAID use for musculoskeletal pain for information.

Evidence indicates that paracetamol is ineffective for nonspecific low back pain. However, individual patients may experience a benefit and, because of its favourable safety profile, a trial of paracetamol may be considered if NSAIDs are contraindicated, not tolerated or have been found to be ineffective previously. Use:

For patients with pain that persists throughout the day, or if there is inadequate response to ‘as necessary’ dosing, consider a trial of regular rather than ‘as necessary’ dosing of oral analgesia.

Oral corticosteroids are occasionally used short term as part of an analgesic strategy for severe acute nonspecific low back pain, but high-certainty evidence of benefit is lacking. Given the significant adverse effects of long-term corticosteroid use, oral corticosteroids should not be used for chronic nonspecific low back pain.

Although commonly prescribed, opioids have a very limited role in the management of nonspecific low back pain. Evidence for efficacy of opioids in acute low back pain is lacking. In chronic low back pain, opioids provide only modest short-term pain relief and evidence for long-term efficacy is lacking. Opioids are associated with a significant risk of harms and delayed return to work. Opioids may be considered for patients with severe pain that is not adequately relieved with other measures and is interfering with the patient’s ability to function. If opioids are used, they should be prescribed on a short-term trial basis, as part of an overall pain management strategy, with clear goals and regular review of treatment response and adverse effects. Before starting an opioid, a plan for stopping ineffective therapy should be in place and discussed with the patient. If treatment response is inadequate, exercise caution before increasing the dose as there may be no added benefit and an increased risk of harms. For information on the harms associated with opioid use, see Opioid-related harms.

Studies of up to one year in patients with chronic low back pain indicate that tapentadol may have a more favourable safety profile than oxycodone; however, the long-term safety of tapentadol is not known and the same precautions as for other opioids apply.

Prolonged use of opioids indicates the need for specialist assessment—see Opioids for the management of musculoskeletal pain for more information.

There is no evidence that muscle relaxants are effective for persisting or chronic nonspecific low back pain. In the acute setting (used for less than 4 days), there is evidence that muscle relaxants may reduce pain and muscle tension, and increase mobility, but their harms may outweigh any benefits, particularly in older patients. Drowsiness, dizziness, increased risk of falls and dependency are common adverse effects.

Gabapentinoids are not recommended for the management of nonspecific low back pain. Despite their increasing use, there is moderate- to high-certainty evidence that gabapentinoids are ineffective for low back pain. In addition, use of gabapentinoids increases the risk of adverse effects, particularly when combined with opioidsEnke, 2018.

Antidepressants are not recommended for the management of nonspecific low back pain. There is moderate- to very low- certainty evidence that antidepressants have no or limited benefit for pain and disability associated with low back painFerreira, 2021.