No Drugs for Back Pain, New Guidelines Say

The American College of Physicians says to use natural and alternative therapies first.
Source: https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168

Skip the meds. Lower back pain—one of the most common reasons for a doctor’s visit—is best treated with alternative, natural and psychological therapies, say new guidelines from the American College of Physicians.

Opioids—one of the most commonly prescribed medications for pain relief and a source of increasing addiction and death—should only be considered for chronic back pain when other alternatives—natural and prescription—don’t work, say the guidelines published Monday in the Annals of Internal Medicine.

Even acetaminophen, which includes the brand name Tylenol, is no longer recommended for acute lower back pain relief due to a 2014 study in the journal The Lancet that showed it was no more effective than placebo. “For consumers who need to treat their minor aches and pains due to backache, Tylenol is a short-term treatment option when used as directed,” said a spokesperson for Johnson & Johnson Consumer, which manufacturers Tylenol.

The new guidelines could influence how doctors treat patients with complaints of back pain. They are an update from 2007’s and include a review of more than 150 studies. Recommendations were broken down into acute and subacute lower back pain, which is pain lasting less than 12 weeks, and chronic pain, which is pain lasting more than 12 weeks. They don't apply to radicular low back pain, sometimes referred to as sciatica, which is caused by compression of the nerves in the spine and can result in leg pain.

For acute and subacute pain, the guidelines recommend nondrug therapies first, such as applying heat, massage, acupuncture or spinal manipulation, which is often done by a chiropractor. If a patient requests drugs, the first line of treatment should be nonsteroidal anti-inflammatory drugs (NSAIDS)—over-the-counter, such as Advil, or prescription, such as celecoxib (brand name Celebrex), or muscle relaxants, such as cyclobenzaprine (brand name Flexeril).

For chronic back pain, the guidelines recommend patients also first try nondrug therapies, such as acupuncture, exercise, rehabilitation therapy and mindfulness-based stress reduction. They also recommend, with less robust data backing them up, yoga, tai chi, motor control exercises, which focus on central core stabilization, and other psychological approaches, such as cognitive behavioral therapy.

The reviews focused on improving pain and function. Psychological conditions such as depression and anxiety are often present in people with lower back pain and may even predispose them to developing it, or the back pain can worsen depression, said Roger Chou, a professor in the department of medical informatics and clinical epidemiology at Oregon Health & Science University and first author on the two reviews done to inform the guidelines.

If such treatments fail to provide relief, the ACP says NSAIDS should be the first medicine that is used. The second line of treatment should be duloxetine—sold under the brand name Cymbalta and commonly used to treat depression and anxiety—or tramadol, an opioid-like narcotic which is less potent than standard opioids such as oxycodone or fentanyl—but can still cause physical dependence.

The guidelines warn that opioids should only be considered an option if the doctor and patient have a discussion about the known risks of the drugs and if used at the lowest possible dose for the shortest period. Because lower back pain is the most common reason non-cancer patients are prescribed opioids, experts believe it is a common gateway to opioid addiction as well as transitioning to heroin, said Steven Atlas, director of practice-based research at Massachusetts General Hospital, who authored an editorial accompanying the guidelines.

About 80% of adults experience low back pain at some point in their lifetimes and it is the most common cause of job-related disability and a leading contributor to missed work days, according to the National Institute of Neurological Disorders and Stroke. Causes of low back pain are varied and include changes in the spine, nerves, muscle or discs in the back and they way they move.

Pain can begin abruptly as a result of an accident or by lifting something heavy. More often, though, it develops over time due to age-related changes of the spine and disc degeneration, according to the NINDS website, part of the National Institutes of Health. NINDS says most back pain occurs between ages 30 and 50. Individuals who gain weight and don’t exercise are at risk, as are those who exercise intensely after long breaks of not exercising. Poor posture or being inactive can also contribute to injuries.

“About one-quarter of U.S. adults have had back pain in the past few months,” said Nitin Damle, president of the ACP. “We are advocating for really trying the non-pharmacologic approach initially, especially for acute and subacute back pain.” Opioids, even for chronic pain, are “prescribed more often than we would like to see.”

Dr. Atlas said many of the non-medication based treatments cited in the study have only moderate-to-low-quality evidence to prove their effectiveness.

“The magnitude of the benefit—for both non-pharmacological treatment and medicines—isn’t particularly strong,” said Dr. Atlas. “It’s not like we have big home runs.”

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Write to Sumathi Reddy at sumathi.reddy@wsj.com