Nonpharmacologic treatment first for low-back pain, ACP guideline recommends

Clinicians treating patients with acute, sub-acute, or chronic low-back pain should select nonpharmacologic treatment first, according to an updated, simplified ACP guideline.

To provide guidance based on the efficacy, comparative effectiveness, and safety of noninvasive pharmacologic and nonpharmacologic treatments for acute (<4 weeks), subacute (4 to 12 weeks), and chronic (>12 weeks) low back pain in primary care, researchers for the Agency for Healthcare Research and Quality conducted two systematic reviews. They evaluated the outcomes of reduction or elimination of pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability, return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

The ACP guideline and the reviews of pharmacologic and nonpharmacologic therapies appeared in the Feb. 14 Annals of Internal Medicine.

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence), the guideline states. Clinicians and patients considering medicines should select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Clinicians should also provide patients with evidence-based information about their expected course, advise them to remain active as tolerated, and provide information about effective self-care options. Clinicians and patients should use a shared decision-making approach to select the most appropriate treatment based on patient preferences, availability, harms, and costs of the interventions, the guideline continues.

For chronic low back pain, clinicians and patients should start nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

Fewer harms are associated with nonpharmacologic interventions than with drugs, the guideline states. Patients with chronic low back pain who have an inadequate response to nonpharmacologic therapy should consider pharmacologic treatment with NSAIDs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option after these treatments fail, and only if potential benefits outweigh the risks. Physicians should discuss risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

For second-line therapies, moderate-quality evidence showed that tramadol had a moderate effect on pain and a small effect on function in the short term. The guideline cautioned that tramadol is a narcotic and has potential risk for abuse. Moderate quality evidence showed that duloxetine had a small effect on pain and function and that opioids (morphine, oxymorphone, hydromorphone, and tapentadol) had a small effect on short-term pain and function. Low-quality evidence showed that buprenorphine (patch or sublingual) resulted in a small improvement in pain.

The guideline continued that opioids are associated with substantial harms, should be the last treatment option considered, and should be considered only in patients for whom other therapies have failed. Moderate-quality evidence showed no difference in pain or function when different long-acting opioids were compared with one another.

An editorial noted that low back pain is common, and its management may be a good example of low-value health care, which it described as expensive tests and therapies that deliver limited benefits. “Greater use of effective treatments, whether for acute symptoms managed in the primary care setting or chronic, disabling pain that typically involves a range of specialists, might help patients who are suffering, clinicians who are frustrated with providing treatments that often do not help, and insurers who pay the bills.”