Drug Therapy as First-Line Treatment for Lower Back Pain in Question


Evidence-based recommendations urge physicians and patients to skip drug therapy as a first-line treatment for nonradicular lower back pain.

The American College of Physicians (ACP) has released updated clinical practice guidelines regarding the treatment of lower back pain in Annals of Internal Medicine. The evidence-based recommendations urge physicians and patients to skip drug therapy as a first-line treatment for nonradicular lower back pain.

The ACP recommends opting for treatments that include non-drug therapies, such as massage, acupuncture, spinal manipulation, tai chi, and yoga to treat acute or subacute pain. Patients who desire drug treatment should use nonsteroidal anti-inflammatory (NSAIDs) or skeletal muscle relaxants, but should avoid narcotics unless all other therapies fail.

The updated guidelines are based on clinical evidence that indicates acetaminophen treatment is not effective at improving back pain compared to a placebo. The ACP recommends non-drug therapies, suggesting exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

The ACP emphasizes that physicians should avoid prescribing unnecessary and potentially harmful drugs, especially narcotics, to treat acute and subacute low back pain.

Patients who experience chronic low back pain that has not responded to non-drug therapy should consider treatment with NSAIDs as first-line therapy, and tramadol or duloxetine as second-line therapy. The guidelines stress that physicians should only consider opioids as a last-line treatment option in patients who have exhibited an inadequate response to other therapies.

“For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another,” Nitin S. Damle, MD, MS, MACP, president, ACP, said in a press release. “Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”

The ACP’s clinical guidelines are based on extensive review of high-quality evidence from clinical trials and studies.


American College of Physicians issues guideline for treating nonradicular low back pain [news release]. Philadelphia. ACP’s website. https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain. Feb. 14, 2017.

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