ACP recommends drug-free treatment for low back pain

The ACP recently released an updated clinical practice guideline and two evidence reviews recommending that physicians avoid prescribing drugs, especially narcotics, for patients with acute or subacute nonradicular low back pain; instead, patients should be treated first with nonpharmaceutical therapies, such as superficial heat, massage, acupuncture, spinal manipulation or yoga.

“Low back pain is one of the most common reasons for all physician visits in the United States,” Amir Qaseem, MD, PhD, from the ACP, and colleagues wrote. “Most Americans have experienced low back pain, and approximately one quarter of U.S. adults reported having low back pain lasting at least 1 day in the past 3 months. Low back pain is associated with high costs, including those related to health care as well as indirect costs from missed work or reduced productivity.”

The guideline, published in Annals of Internal Medicine, is based on a systematic review of randomized controlled trials published through April 2015 that evaluated noninvasive pharmacological and non-pharmacological treatments of acute or chronic nonradicular or radicular low back pain. The researchers assessed clinical outcomes including reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability or return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction and adverse effects. After their analysis, the ACP made three essential recommendations for adults with acute, subacute or chronic nonradicular low back pain.

Clinicians should advise patients with acute or subacute low back pain to select a nonpharmacologic approach to treat their condition. These treatments include superficial heat, massage, acupuncture or spinal manipulation. NSAIDs or skeletal muscle relaxants should be used if pharmacologic treatment is desired. Acetaminophen and systematic steroids were ineffective in treating acute or subacute low back pain.

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” Nitin S. Damle, MD, MS, MACP, president of the ACP, said in a press release. “Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”

Nonpharmacologic treatment, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, Tai Chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy or spinal manipulation, should initially be used to treat chronic low back pain.

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“For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another,” Damle said. “Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”

If patients with chronic low back pain respond inadequately to nonpharmacologic therapy, pharmacologic treatment with NSAIDs as first-line therapy or tramadol or duloxetine as second line therapy should be considered. Opioids should only be considered if all other treatments fail or if the potential benefits outweigh the risks for individual patients. In addition, clinicians must discuss the known risks and realistic benefits of opioids with patients before prescribing.

“Physicians should consider opioids as a last option for treatment ... as they are associated with substantial harms, including the risk of addiction or accidental overdose,” Damle said.

Treatments for radicular low back pain were not determined due to insufficient or lacking evidence, according to the researchers.

In an accompanying editorial, Steven J. Atlas, MD, MPH, of Massachusetts General Hospital, wrote that these new ACP recommendations are likely a major change for primary care physicians.

He noted that there is still a need for more trials to fill evidence gaps and strategies to reduce the use of low-value services.

“Nevertheless, rigorous reviews of existing evidence and their application in practice guidelines remain an underpinning that should drive efforts not only to decrease the use of therapies without demonstrated benefit but also to show that the therapies being used improve real-world outcomes for patients with low back pain,” Atlas concluded. – by Alaina Tedesco

References:

Atlas SJ. Ann Intern Med. 2017;doi:10.7326/M17-0923.

Chou, et al. Ann Intern Med. 2017;doi:10.7326/M16-2459.

Qaseem A, et al. Ann Intern Med. 2017;doi:10.7326/M16-2367.

Disclosure: The development of this guideline was supported by the ACP operating budget. Atlas reports royalty payments from UpToDate and personal fees from Healthwise.