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Treatment of Chronic Low Back Pain with Medications

Management of chronic low back pain (CLBP) has proven to be very challenging. The authors sought to evaluate the most commonly prescribed medications and their efficacy in CLBP.

The authors of the study reviewed existing literature on the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs); muscle relaxants, and simple nonopioid analgesics in the treatment of CLBP. The NSAIDs included nonselective products such as ibuprofen and naproxen. The newer products are considered selective NSAIDS and include COX-2 inhibitors such as etoricoxib, celecoxib, and refocoxib. Antispasmodic agents included two main categories, benzodiazepines and nonbenzodiazepines. Simple analgesics included acetaminophen and tramadol, capsaicin and lidoderm patches.

NSAIDs are indicated for muscle aches and pains, backaches, and arthritis. Muscle relaxants to include cyclobenzaprine, metaxolone, methocarbamol, and carisoprodol are indicated for acute painful musculoskeletal conditions. Baclofen and tizanidine are indicated for upper motor neuron induced spasticity. Benzodiazepines such as diazepam are indicated for muscle spasticity, local painful musculoskeletal spasm, and anxiety.

Among the simple nonopioid medications reviewed were acetamenophen, tramadol, capsaicin plaster, and lidoderm patches. Acetamenophen is indicated for mild muscular aches, backaches, and arthritis. It should be avoided in patients with liver disease or who consume more than three alcoholic beverages a day. Tramadol is indicated for moderate to moderately severe chronic pain and acts on opioid receptors as well as serotonin and norepinephrine reuptake. It can increase risk of seizure and suicide risk however.

After reviewing available literature, it appears that NSAIDS are effective in short-term relief of CLBP. Given possible adverse side effects of nonselective and selective NSAIDs, their costs, and costs associated with side effects such as gastrointestinal complications, myocardial infarction, worsening congestive heart failure and renal disease, it is suggested that a nonselective NSAID is more cost effective for low risk patients. For patients who are high risk, a nonselective NSAID plus a proton pump inhibitor seemed to be the most cost effective.

Studies did not provide evidence that muscle relaxants were beneficial for long-term use in CLBP.

Tramadol 200mg to 400mg daily or in combination with acetaminophen was shown to improve CLBP and disability. Review of studies using capsaicin showed moderate to poor efficacy. There were no randomized controlled trials available to evaluate the efficacy of lidoderm patches in CLBP.

References: G. Malanga, E. Wolff. Evidence-informed management of chronic low back pain with nonsteroidal anti-inflammatory drugs, muscle relaxants, and simple analgesics. The Spine Journal. January/February 2008. Volume 8. Issue 1. Pp.173-184.

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