Back pain medical treatment

see also Back pain treatment

a) for the initial short-term period,acetaminophen (APAP) or NSAIDs may be used. In one study ¹⁾ of acute LBP, NSAIDs did not add any benefit to APAP + standard education.

b) stronger analgesics—mostly opioids—may be required for severe pain, usually severe radicular pain. For non-specific back pain, there was no earlier return to full activity than with NSAIDs or APAP ²⁾

Opioids should not be used > 2–3 weeks, at which time NSAIDs should be instituted unless contraindicated.

a) the therapeutic objective is to reduce pain by relieving muscle spasm.However, muscle spasms have not been proven to cause pain and the most commonly used muscle relaxants have no peripheral effect on muscle spasm

b) probably more effective than placebo, but have not been shown to be more effective than NSAIDs, and their use in combination with NSAIDs has not been shown to be more effective than use of NSAIDs alone

c) potential for side effects: drowsiness (in up to 30%). Most manufacturers recommend use for < 2–3 weeks. Agents such as chlorzoxazone (Parafon Forte® and others) may be associated with risk of serious and potentially fatal hepatotoxicity ³⁾

There is uncertainty regarding the relative benefit of paracetamol and diclofenac and regarding the additional effect of pain medication compared with advice only in patients with acute low back pain.

Low back pain patients are often treated with Nonsteroidal antiinflammatory drug and benzodiazepines. The former is an evidence-based intervention, whereas the efficacy of the latter has not been established ⁴⁾.

Markman et al., examine the stark contrast between the successes and failures of the clinical development of analgesics for different types of chronic low back pain (CLBP) syndrome over the past three decades. Multiple drugs with differing mechanisms of action have been developed for nonspecific axial-predominant low back syndromes and yet not a single therapy is indicated for any neuropathic low back pain syndrome (e.g., sciatica). Clinician findings have informed the entry criteria for neuropathic low back pain clinical trials, whereas entry criteria of axial CLBP trials have prioritized only patient reports of pain. This key difference could account for the lack of success in developing therapies for neuropathic low back pain in an era marked by successful development of analgesics for other types of CLBP as well as many chronic pain syndromes associated with nerve injury, such as postherpetic neuralgia (PHN) ⁵⁾.

A wide range of medications are used to treat acute and chronic low back pain. Some are available over the counter (OTC); others require a physician’s prescription. Certain drugs, even those available OTC, may be unsafe during pregnancy, may interact with other medications, cause side effects, or lead to serious adverse effects such as liver damage or gastrointestinal ulcers and bleeding. Consultation with a Healthcare provider is advised before use. The following are the main types of medications used for low back pain:

Analgesic medications are those specifically designed to relieve pain. They include OTC acetaminophen and aspirin, as well as prescription opioids such as codeine, oxycodone, hydrocodone, and morphine. Opioids should be used only for a short period of time and under a physician’s supervision. People can develop a tolerance to opioids and require increasingly higher dosages to achieve the same effect. Opioids can also be addictive. Their side effects can include drowsiness, constipation, decreased reaction time, and impaired judgment. Some specialists are concerned that chronic use of opioids is detrimental to people with back pain because they can aggravate depression, leading to a worsening of the pain.

Nonsteroidal anti-inflammatory drugs (NSAIDS) relieve pain and inflammation and include OTC formulations (ibuprofen, ketoprofen, and naproxen sodium). Several others, including a type of NSAID called COX-2 inhibitors, are available only by prescription. Long-term use of NSAIDs has been associated with stomach irritation, ulcers, heartburn, diarrhea, fluid retention, and in rare cases, kidney dysfunction and cardiovascular disease. The longer a person uses NSAIDs the more likely they are to develop side effects. Many other drugs cannot be taken at the same time a person is treated with NSAIDs because they alter the way the body processes or eliminates other medications.

Anticonvulsants—drugs primarily used to treat seizures—may be useful in treating people with radiculopathy and radicular pain.

Antidepressants such as tricyclics and serotonin and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain, but their benefit for nonspecific low back pain is unproven, according to a review of studies assessing their benefit.

Counter-irritants such as creams or sprays applied topically stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Topical analgesics reduce inflammation and stimulate blood flow.

Medical cannabis is becoming an acceptable treatment modality in medicine, especially for pain relief. Concurrently, cannabis use is becoming more prevalent worldwide, a public demand-driven trend despite the lack of established scientific basis. This observational open-label study sought to investigate the effectiveness of cannabis therapy for alleviating low back pain symptoms.

Methods: Two types of cannabis treatment modalities were sequentially administered to chronic low back pain patients. After an initial 1-month washout period (WO1), the first modality was cannabidiol (CBD)-rich sublingual extract treatment administered for 10 months. Following another washout period, the second modality, Δ9-tetrahydrocannabinol (THC)-rich smoked inflorescence (whole dried cannabis flowers) was administered for 12 months.

Results: Enrolled in the study were 24 patients whose advanced imaging studies (i.e. computerized tomography or magnetic resonance imaging of the lumbar spine) revealed disc herniation or spinal stenosis. Three patients dropped out of extract therapy treatment but resumed study participation to receive THC-rich smoking therapy. After a minimum of 2 years, cannabis therapy had reduced lower back pain symptoms, as assessed by Oswestry Disability Index, the SF-12 patient-reported outcome questionnaire, and the visual analogue scale. Pain reduction was not significant during the extract treatment part of the study; however, pain reduction was significant during the inhaled therapy part of the study.

Conclusions: Our findings indicate that inhaled THC-rich therapy is more effective than CBD-rich sublingual extract therapy for treating low back pain and that cannabis therapy is safe and effective for chronic low back pain ⁶⁾.