Overcoming Pain

Why people experience chronic pain, and the power they have to de-intensify it

The “BEST” Medication For Chronic Low Back Pain

The "best" treatment is the one that works.

Medications are the most frequently recommended treatment for low back pain. Research has shown that 80% of primary care patients with low back pain were prescribed at least one medication when seen by the primary care provider; more than one third were prescribed two or more medications.

The most commonly prescribed drugs for low back pain are nonsteroidal anti-inflammatory drugs (NSAIDs) such as Motrin and naproxen, muscle relaxants, and opioid-based pain killers. Other medications regularly prescribed for chronic low back pain include benzodiazepines such as Valium, cortisone-type drugs, anti-depressant medications and anti-seizure medications. Of course, many patients use over-the-counter medications such as Tylenol, aspirin, and NSAIDs such as Advil.

A challenge to many health care providers involves the choosing of the safest and most effective medication for a given patient. A more disturbing thought involves the possibility that many of the medications physicians prescribe may have little benefit. Thanks to a recent review by the American Pain Society and the American College of Physicians, published in the October 02, 2008 edition of Annals of Internal Medicine, there is a little more statistical certainty behind the decision to treat with a particular medication.

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The authors found clear evidence that Tylenol, NSAIDs, and tricyclic anti-depressants were effective for chronic low back pain, at least for short-term pain relief. Effects, however, were "moderate"-not overwhelming. The authors also found fair evidence that tramadol, benzodiazepines, and gabapentin are effective for pain relief.

Interestingly, the interpretation of the effectiveness of opioids for low back was considered a challenge by the researchers. However, recent reviews of studies on opioids have concluded that for various chronic pain conditions opioids are of moderate benefit.

Comparing the various drug classes to one another is extremely difficult, due to the lack of head-to-head trials. Likewise, there are few head-to-head trials examining drugs within the same class.

On the other hand, there is much data on the differences in side effect profiles for the various classes of medications. For example, muscle relaxants, benzodiazepines, and tricyclic antidepressants cause sedation. Opioids are associated with high rates of sedation and constipation.

It would appear that for mild or moderate pain, a trial of Tylenol might be a reasonable initial treatment, as for most patients it is safer than NSAIDs. Unfortunately, Tylenol is a less effective pain medication; so, for more severe pain perhaps an NSAID would be best. For severe pain, a trial of opioid drugs would be reasonable in order to achieve pain relief and improve function, keeping in mind all the while the potential for abuse.

In making the decision to treat chronic low back pain, patient and physician must discuss the possibilities and predispositions for side effects, drug interactions, and drug costs. After discussing with the chronic pain sufferer the severity and length of time of pain, then the decision can be made as to the best treatment for that particular patient.

It will still be the case in many cases that the "best" treatment is the one that works.

 

 

Mark Borigini, M.D., is a board-certified rheumatologist who has devoted his career to treating illnesses that cause chronic pain and disability.

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