Pharmacological treatments for low back pain

Practice
By
Hannah Khalil
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Presenting the most current evidence from an overview of Cochrane reviews.

Background

Low back pain (LBP) is a common health condition that affects about 7% of the population worldwide.1 It has a significant impact on quality of life, as it can affect an individual’s productivity and work. Abajobir et al estimated the overall disability from LBP to be about 57.65 million years for those affected with the disease.2

LBP is also considered the 7th biggest cause of disease burden in women, and the 10th in men.1 Pharmacological management options for LBP consists of analgesics, such as paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, and other classes of drugs.3-5 They are used to control pain and improve physical function. This can be achieved through different mechanisms, such as modulating sensory nerve function, decreasing inflammation, reducing muscular spasm and changing the availability of signalling chemicals in the brain.6

To date, many Cochrane reviews have been published on the management of LBP, and this summary of evidence from these reviews can inform practitioners on the best effective management for LBP.

Characteristics of the studies

The Cochrane reviews reported on six pharmacological interventions: paracetamol, NSAIDs, muscle relaxants, benzodiazepines, opioids and antidepressants. Both acute and chronic LBP were considered.

Quality of the studies

Five reviews had high confidence in their findings, one had moderate confidence, and one had low confidence.

Conclusion

Current evidence suggests NSAIDs and muscle relaxants may provide relief from acute LBP based on moderate evidence. For chronic LBP, NSAIDs and opioids may provide a small benefit on controlling pain based on low to high certainty of evidence. Adverse events are higher in opioids than in NSAIDs.

Implications for practice and research

The current results may not be consistent with current guidelines, and hence clinical judgment needs to be exercised. Most of the included studies are outdated (more than 10 years old), and newer studies with combination drugs need to be undertaken to guide current practice.

Results

  • The Cochrane Database of Systematic Reviews was searched from inception to June 2021, for reviews of randomised controlled trials (RCTs) that examined pharmacological interventions for adults with non-specific LBP. 
  • The outcomes of interest in acute and chronic LBP included pain, physical function, safety, participants’ ratings of improvement, health-related quality of life and workplace participation. 
  • The overview of reviews included seven Cochrane reviews, which comprised of 103 studies and 22,238 participants. 
  • The authors found that both NSAIDs and muscle relaxants might reduce pain in the short term (less than 3 months) for acute LBP. Muscle relaxants had more adverse events than NSAIDs. 
  • Paracetamol had no effect on acute LBP. No reviews addressed opioids and antidepressants for acute LBP. 
  • For chronic LBP, opioids might be beneficial in relieving pain in the short term but they were associated with adverse events such as nausea, headache, constipation and dizziness. 
  • NSAIDs were also found to be potentially beneficial in reducing chronic LBP with minimal adverse events.
  • Antidepressants had no effect on chronic LBP.

References

  1. Cashin AG, Wand BM, O’Connell NE, Lee H, Rizzo RRN, Bagg MK, O’Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2023, Issue 4. Art. No.: CD013815. DOI: 10.1002/14651858.CD013815.pub2
  2. AbajobirAA, AbateKH, AbbafatiC, AbbasKM, Abd-AllahF, AbdulkaderRS, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study. Lancet 2017;390(10100):1211-59.
  3. Van der Gaag WH, Roelofs PD, Enthoven WT, Van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for acute low back pain. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No: CD013581. [DOI: 10.1002/14651858.CD013581]
  4. Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No: CD012230. [DOI: 10.1002/14651858.CD012230]
  5. Van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low-back pain. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No: CD004252. [DOI: 10.1002/14651858.CD004252]
  6. Bagg MK, McLachlan AJ, Maher CG, Kamper SJ, Williams CM, Henschke N, et al. Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: a network meta-analysis. Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No: CD013045. [DOI: 10.1002/14651858.CD013045]

Our author

Associate Professor Hannah Khalil Bpharm, Mpharm, PhD, AACPA is the Lead of Health Services Administration at Latrobe University. She is also Editor in Chief of Current Opinion in Epidemiology and Public Health.