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Low Back Pain: Nonpharmacologic and Pharmacologic Interventions

for Health Care Providers

Table 1. Nonpharmacologic and Pharmacologic Interventions

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  • Patient education
  • Activity modification
  • Exercise
  • Physical therapy
  • Self-application of heat or cold to back
  • Manipulation
  • Patient education topics include expectations for rapid recovery, avoiding worry, coping with having a sore back, methods of symptom control, activity modifications, recognition of certain red-flag symptoms, and follow-up.
  • Limited bed rest: <48 hours. Patients who go on longer bed rest have less improvement in pain and function than those who remain ambulatory.
  • Activity modification should be minimal for acute back pain: Modifications might include limiting prolonged unsupported sitting, avoiding heavy lifting, and avoiding bending or twisting the back when lifting.
  • Maintain or start aerobic conditioning exercises, including swimming, walking, and stationary biking.
  • Avoid physical therapy for 2 weeks after onset of acute back pain.
  • Conduct workplace ergonomics evaluation if the back pain is related to work activities.
  • Manipulation may be helpful in the first month of symptoms for selected patients who do not have radiculopathy or severe or progressive neurologic deficits. Refer to practitioners with specific training in manipulation (eg, osteopathic physicians).
(for dosages and additional information, see Pain Medications)
  • First-line analgesic because of its safety profile.
  • Use for patients who cannot tolerate NSAIDs.
  • Possible adverse effects include hepatotoxicity (especially if taken with alcohol) and nephrotoxicity (with chronic overdose).
(eg, ibuprofen, naproxen)
  • First-line analgesic; may be combined with
  • Avoid use for patients with peptic ulcer disease or cirrhosis.
Tricyclic antidepressants (TCAs)
(eg, amitriptyline, nortriptyline)
  • Consider for neuropathic pain; also consider as an adjunct for any type of LBP unresponsive to acetaminophen and NSAIDs.
  • Anticholinergic and other adverse effects, especially at higher doses.
Muscle relaxants
  • Cyclobenzaprine
  • Baclofen
  • May be useful as adjunctive therapy for acute back pain but not recommended for chronic or subacute back pain.
  • Epidural steroid injections
  • Medications may include corticosteroids, lidocaine, and opioids
  • For short-term relief of radicular pain; consider after failure of conservative treatment, as means of avoiding surgery.
  • Refer to back pain specialist or orthopedist.
  • Opiate analgesics

  • Options include:
    • Tramadol
      (not a typical opiate; exact mechanism of action is unknown; acts in part as a central opioid agonist)
  • Weak opioids
    • Codeine
    • Hydrocodone + acetaminophen
    • Oxycodone + acetaminophen

  • Strong opioids
    • Morphine
    • Oxycodone
    • Hydromorphone
    • Fentanyl transdermal
  • Consider opioids for patients who have severe pain refractory to the interventions listed above (nonpharmacologic and pharmacologic) or cannot receive those therapies.
  • For very short-term use in severe acute exacerbations, and for severely disabling chronic back pain; start with weak opioids; assess safety, efficacy, and usage; titrate up and move to strong opioids as needed.
  • Use the lowest effective dosage.
  • If needed for acute flares, limit use to a designated short period of time.
  • If needed for chronic pain, try to use a sustained-release opioid with scheduled dosing around the clock, with shorter-acting opioids for breakthrough pain as needed.
  • Risk of dependence, overdose: monitor closely.
  • Adverse effects include oversedation, hypotension, respiratory depression, central nervous system stimulation or somnolence, dizziness, constipation, nausea, and pruritus.
  • Note that tramadol 37.5 mg + acetaminophen 325 mg has shown pain relief equivalent to codeine 30 mg + acetaminophen 325 mg but with fewer side effects (major side effect: headache).
  • Chronic opioid therapy should incorporate an opioid use agreement that includes functional goals for outcome, not reduced pain intensity alone.

From Low Back Pain
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009