Keep individual patients in mind when treating back pain

Medications still play a role, but what’s best and for whom is not clear

Back problems are a common cause of pain for Americans. Pharmacologic and nonpharmacologic options are available, but what works for one patient may not necessarily be the best option for someone else.

Elizabeth Casserly, PharmD, BCPS, a pain management clinical specialist at Cleveland Clinic, said when she hears the words “back pain,” it’ s akin to a patient saying they have a stomach ache in terms of diagnoses. There are so many factors involved, including the patient’s age and overall health status.

“It’s really important to know what you are dealing with to even know where you are going to go,” said Casserly.

Before following any guidelines or looking at any treatment modalities, a provider can get more context by asking the patient some basic questions, according to David Craig, PharmD, from Moffitt Cancer Center.

Those questions can include: What caused the back pain? Is it acute or chronic? How has the patient already tried to treat it?

Low back pain recommendations from the American College of Physicians (ACP), in 2017, categorize back pain into acute, subacute, and chronic, based upon the duration of the back pain. For all three categories, authors suggest patients should try nonpharmacologic treatments first. When medication is desired with acute or subacute low back pain, the evidence says NSAIDs or skeletal muscle relaxers are appropriate choices.

Robert McLean, MD, FACP, who was one of the authors of the ACP guidelines and is an associate professor of medicine at Yale School of Medicine, said that for chronic low back pain, there is a role for NSAIDs, tramadol, and duloxetine. However, the guidelines recommend that pharmacologic treatment for chronic low back pain should only be considered when the initial courses of various types of nonpharmacologic treatment, such as physical therapy, are not working for the patient.

Casserly said that when they need to intervene with medications, they generally go down two paths: for a patient experiencing an arthritis type of issue, they head toward NSAIDs or acetaminophen. If it’ s a nerve-related issue, the patient might end up on a neuropathic agent like gabapentin or pregabalin. One caveat, however, is that it can often be 6 to 8 weeks before these medications take full effect.

In general, more research is needed to understand the role of neuropathic agents in pain management. Many providers are prescribing them more often to treat back pain, especially as a substitute for opioids, but some experts worry about the limited supporting evidence, as some studies have suggested.

At the same time, NSAIDs have clear, recognized risks. Long-term use of NSAIDs warrant monitoring along with routine labs for blood count and liver, said McLean. In addition, underlying medical conditions can have an impact on the safety and risk profile if one is considering using NSAIDs.

According to McLean, moderate quality evidence has shown that tricyclic antidepressants did not effectively

improve pain or function for chronic low back pain. This was also the case for selective serotonin reuptake inhibitors. For patients with acute and subacute low back pain, the evidence found that systemic steroids did not show overall benefit, even for patients with radicular symptoms.

For the full article, please visit for the October 2018 issue of Pharmacy Today.