Roger Chou, MD; Laurie Hoyt Huffman, MS
Disclaimer: No statement in this article should be construed as an official position of the American Pain Society.
Acknowledgments: The authors thank Jayne Schablaske and Michelle Pappas for administrative support.
Grant Support: This article is based on research conducted at the Oregon Evidence-based Practice Center with funding from the American Pain Society.
Potential Financial Conflicts of Interest: Honoraria: R. Chou (Bayer HealthCare Pharmaceuticals).
Requests for Single Reprints: Roger Chou, MD, Oregon Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Chou and Ms. Huffman: Oregon Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239.
Medications are the most frequently prescribed therapy for low back pain. A challenge in choosing pharmacologic therapy is that each class of medication is associated with a unique balance of risks and benefits.
To assess benefits and harms of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, benzodiazepines, antiepileptic drugs, skeletal muscle relaxants, opioid analgesics, tramadol, and systemic corticosteroids for acute or chronic low back pain (with or without leg pain).
English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching reference lists and additional citations suggested by experts.
Systematic reviews and randomized trials of dual therapy or monotherapy with 1 or more of the preceding medications for acute or chronic low back pain that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.
We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.
We found good evidence that NSAIDs, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) are effective for pain relief. The magnitude of benefit was moderate (effect size of 0.5 to 0.8, improvement of 10 to 20 points on a 100-point visual analogue pain scale, or relative risk of 1.25 to 2.00 for the proportion of patients experiencing clinically significant pain relief), except in the case of tricyclic antidepressants (for which the benefit was small to moderate). We also found fair evidence that acetaminophen, opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief. We found good evidence that systemic corticosteroids are ineffective. Adverse events, such as sedation, varied by medication, although reliable data on serious and long-term harms are sparse. Most trials were short term (≤4 weeks). Few data address efficacy of dual-medication therapy compared with monotherapy, or beneficial effects on functional outcomes.
Our primary source of data was systematic reviews. We included non–English-language trials only if they were included in English-language systematic reviews.
Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.
Chou R, Huffman LH. Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med. ;147:505–514. doi: 10.7326/0003-4819-147-7-200710020-00008
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Published: Ann Intern Med. 2007;147(7):505-514.
Back Pain, Guidelines, Rheumatology.
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