Roger Chou, MD; Richard Deyo, MD, MPH; Janna Friedly, MD; Andrea Skelly, PhD, MPH; Melissa Weimer, DO, MCR; Rochelle Fu, PhD; Tracy Dana, MLS; Paul Kraegel, MSW; Jessica Griffin, MS; Sara Grusing, BA
Disclaimer: The authors of this manuscript are responsible for its content. A representative from the Agency for Healthcare Research and Quality (AHRQ) served as a Contracting Officer's Technical Representative and provided technical assistance during the conduct of the full evidence report and provided comments on draft versions of the full evidence report. The AHRQ did not directly participate in the literature search; determination of study eligibility criteria; data analysis or interpretation; or preparation, review, or approval of the manuscript for publication. Statements in the report should not be construed as endorsement by AHRQ or the U.S. Department of Health and Human Services. The AHRQ retains a license to display, reproduce, and distribute the data and the report from which this manuscript was derived under the terms of the Agency's contract with the author.
Grant Support: By contract HHSA290201200014I from AHRQ, U.S. Department of Health and Human Services.
Disclosures: Dr. Chou reports grants from AHRQ and funds for manuscript preparation from ACP during the conduct of the study. Dr. Deyo reports grants from AHRQ during the conduct of the study; grants from the National Institutes of Health (NIH), AHRQ, Centers for Disease Control and Prevention, and Patient-Centered Outcomes Research Institute (PCORI) outside the submitted work; personal fees from UpToDate and other support from Kaiser Permanente outside the submitted work; and a financial gift from NuVasive as part of a lifetime achievement award from the International Society for Study of the Lumbar Spine. Dr. Friedly reports grants from AHRQ during the conduct of the study and grants from PCORI and NIH outside the submitted work. Dr. Skelly reports grants from AHRQ during the conduct of the study and other support from the Washington State Health Technology Assessment Program and AOSpine North America outside the submitted work. Dr. Weimer, Ms. Dana, and Ms. Grusing reports grants from AHRQ during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2458.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See PROSPERO (www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42014014735). Statistical code: Not applicable. Data set: See the Supplement and full report (available at www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=2178).
Requests for Single Reprints: Roger Chou, MD, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Chou and Fu and Ms. Dana, Ms. Griffin, and Ms. Grusing: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239.
Dr. Deyo: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR 97239.
Dr. Friedly: Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359612, Seattle, WA 98104.
Dr. Skelly: Spectrum Research, Atrium Court, 705 South 9th Street, Suite 203, Tacoma, WA 98405.
Dr. Weimer: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L-475, Portland, OR 97239.
Mr. Kraegel: Department of Pharmacy, University of Washington, Box 357630, H375 Health Science Building, Seattle, WA 98195.
Author Contributions: Conception and design: R. Chou, J. Friedly, M. Weimer.
Analysis and interpretation of the data: R. Chou, R. Deyo, J. Friedly, A. Skelly, M. Weimer, R. Fu, T. Dana, J. Griffin.
Drafting of the article: R. Chou, A. Skelly, R. Fu, J. Griffin, S. Grusing.
Critical revision of the article for important intellectual content: R. Chou, R. Deyo, J. Friedly, M. Weimer, J. Griffin.
Final approval of the article: R. Chou, R. Deyo, J. Friedly, M. Weimer, R. Fu.
Statistical expertise: R. Chou, R. Fu.
Obtaining of funding: R. Chou.
Administrative, technical, or logistic support: T. Dana, P. Kraegel, J. Griffin, S. Grusing.
Collection and assembly of data: R. Chou, R. Deyo, A. Skelly, M. Weimer, T. Dana, P. Kraegel, J. Griffin, S. Grusing.
A 2007 American College of Physicians guideline addressed pharmacologic options for low back pain. New evidence and medications have now become available.
To review the current evidence on systemic pharmacologic therapies for acute or chronic nonradicular or radicular low back pain.
Ovid MEDLINE (January 2008 through November 2016), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists.
Randomized trials that reported pain, function, or harms of systemic medications versus placebo or another intervention.
One investigator abstracted data, and a second verified accuracy; 2 investigators independently assessed study quality.
The number of trials ranged from 9 (benzodiazepines) to 70 (nonsteroidal anti-inflammatory drugs). New evidence found that acetaminophen was ineffective for acute low back pain, nonsteroidal anti-inflammatory drugs had smaller benefits for chronic low back pain than previously observed, duloxetine was effective for chronic low back pain, and benzodiazepines were ineffective for radiculopathy. For opioids, evidence remains limited to short-term trials showing modest effects for chronic low back pain; trials were not designed to assess serious harms. Skeletal muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation. Systemic corticosteroids do not seem to be effective. For effective interventions, pain relief was small to moderate and generally short-term; improvements in function were generally smaller. Evidence is insufficient to determine the effects of antiseizure medications.
Qualitatively synthesized new trials with prior meta-analyses. Only English-language studies were included, many of which had methodological shortcomings. Medications injected for local effects were not addressed.
Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.
Agency for Healthcare Research and Quality. (PROSPERO: CRD42014014735)
Table 1. Definitions for Magnitude of Effects, Based on Mean Between-Group Differences
Summary of evidence search and selection.
ACP = American College of Physicians; AHRQ = Agency for Healthcare Research and Quality; APS = American Pain Society; NSAID = nonsteroidal anti-inflammatory drug; RCT = randomized, controlled trial; SR = systematic review.
* Cochrane databases include the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews.
† Other sources include prior reports, reference lists of relevant articles, and systematic reviews.
‡ Publications may be included or excluded for multiple reasons.
Table 2. Pharmacologic Therapies Versus Placebo for Acute Low Back Pain
Table 3. Pharmacologic Therapies Versus Placebo for Chronic Low Back Pain
Table 4. Pharmacologic Therapies Versus Placebo for Radicular Low Back Pain
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Primary Care Unit, ASL RM 1, Rome, Italy
March 8, 2017
MEDICINES NOT POISONS
Back pain is one of the most difficult conditions to treat. There is no ideal treatment to cure LBP. The doctor has to choose the most effective analgesic strategy in the individual patient, according to etiopathogenetic diagnosis of pain.There is no ideal drug and not all patients can be treated with NSAIDs, glucocorticoids, paracetamol, tramadol, etc. Many patients have strong contraindications to NSAIDs. For this reason, when the systemically is contraindicated (for cardiovascular risk or gasrtointestinale), it could use low doses of NSAIDs for local street to treat localized pain (mesotherapy).Also non-pharmacological techniques can be useful, but not all patients can be charged for paying therapies not reimbursed by the health system.In addition, we must consider that analgesics are not poisons, and it should be emphasized that opioids, if used properly, are effective weapons useful to reduce the suffering of the sick.Finally, we must take into account that the drugs have indications approved by regulatory authorities, unlike yoga, massage and other techniques that can be "proposed" to patients even by non-medical personnel.As a patient complains LBP, and pain becomes chronic and the quality of life is compromised, doctors should not be afraid to use a multimodal therapeutic strategy, where more drugs (each at the minimum tolerated dose) combined with other non-pharmacological techniques.I am strongly convinced that the medicines are not poisons, when used correctly, and that non-pharmacological techniques can help patients by reducing the dose of medication needed.
Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, et al. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166:480–492. doi: 10.7326/M16-2458
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Published: Ann Intern Med. 2017;166(7):480-492.
Published at www.annals.org on 14 February 2017
Back Pain, Neurology, Neuropathy, Rheumatology.
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