New Low Back Pain Guidelines Recommend Drug-Free Treatments First

The American College of Physicians (ACP) recently issued new clinical guidelines recommending that physicians avoid prescribing pain management drugs when treating acute or subacute low back pain (Ann Intern Med. 2017; DOI: 10.7326/M16-2367).

The ACP’s updated clinical practice guidelines were developed based on an extensive review of the highest quality evidence available, including randomized control trials and data from observational studies. These recommendations update guidelines published by ACP in 2007.

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” Nitin S Damle, MD, MS, MACP, president of ACP, said in a press release. "Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”

According to the new guidelines, nonradicular low back pain is associated with high costs, with the total costs attributable to low back pain in the United States estimated at $100 billion in 2006.

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“Low back pain is one of the most common reasons for all physician visits in the United States,” Amir Qaseem, MD, PhD, vice president of clinical policy at ACP, and colleagues wrote in the guidelines.

As a result of ineffective treatments, ACP now recommends that physicians and patients initially select non-drug therapies including superficial heat, massage, exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

“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,” Dr. Damle said. “Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”

According to the new guidelines, if nonpharmaceutical approaches to treatment fail, nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants are recommended.

The recommended prescription drugs also include Ultram (tramadol; Janssen) or Cymbalta (duloxetine; Eli Lilly) as second-line therapy. ACP says a clinician should only consider opioids as an option in patients who have failed all prior treatments due to the risk of addiction.

“Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose,” Dr Damle said.

—Julie Gould