Don't reach for pills for most chronic low back pain

woman with a strong backache in the city park with her hand on the back (Manuel Faba Ortega)

People should try non-drug treatment options like massage or stretching for most cases of chronic low back pain before choosing treatment with over-the-counter or prescription drugs, according to new guidelines.

If the pain began recently, the guidelines recommend superficial heat, massage, acupuncture or spinal manipulation. If patients wish to take medication, they should use nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or skeletal muscle relaxants prescribed by a doctor. Acetaminophen and steroids are not recommended for low back pain, according to the guidelines.

But for chronic low back pain - defined as pain that's lasted more than 12 weeks - the American College of Physicians (ACP) recommends people hold off on medications.

The new guidelines apply to low back pain that does not radiate to other parts of the body like the legs, said Dr. Nitin Damle of the Alpert Medical School of Brown University in Providence, Rhode Island, who is president of the ACP.

Patients with low back pain that radiates to other parts of the body need further evaluation, he told Reuters Health.

Low back pain is one of the most common reasons people visit U.S. doctors' offices each year, according to the ACP in the Annals of Internal Medicine. About a quarter of U.S. adults report low back pain at least one day during the previous three months.

"Most back pain is self-limited," said Damle. "It's common, will go away given enough time and patients can help themselves initially by trying some heat and stretching before going to see a physician."

The new guidelines are based on a review of studies that looked at the use of drug and non-drug therapies for low back pain. The review did not look at creams or injections, however.

Based on the review, the ACP recommends that people who have been suffering with chronic low back pain try non-drug therapies such as exercise, acupuncture, mindfulness-based stress reduction, tai chi, yoga, biofeedback, cognitive behavioral therapy or spinal manipulation.

If those methods don't work, the guidelines say the next step should be NSAIDs or the pain medications duloxetine, which is marketed as Cymbalta, or tramadol, which is marketed as Ultram.

Opioids should only be considered as last resorts, and only prescribed after doctors discuss their risks and benefits with patients.

"If you're going to have to use opioids, use them in the smallest dose possible with the least frequency and smallest prescription," said Damle.

The new recommendations are very reasonable, said Dr. Joel Press, who is physiatrist-in-chief at the Hospital for Special Surgery in New York City.

"Anything you can do with these non-pharmaceuticals that can get you moving faster is going to get you better in the end," said Press, who was not involved in crafting the new guidelines.

"I hope this reinforces to physicians and patients that a lot of these non-pharmaceutical treatments can have a lot of success," he told Reuters Health.