By Bianca Nogrady
A systematic review has put another nail in the coffin of pharmacological therapies for low back pain.
The review for an American College of Physicians clinical practice guideline concluded that paracetamol was ineffective, and other systemic medications (such as NSAIDs, benzodiazepines, corticosteroids and opioids) showed only small to moderate short-term effects on pain.
The paper, published in the Annals of Internal Medicine, reviewed 46 publications – both systematic reviews and randomised controlled trials – which reported pain, function or harms related to systemic medications.
The 10 paracetamol trials in the review, including a recent Australian randomised placebo-controlled trial, showed the drug was ineffective against acute low back pain, although it did have a lower risk of adverse events than NSAIDs.
There were 70 NSAID trials, with a Cochrane systematic review reporting small improvements in pain intensity for both acute and chronic low back pain compared with placebo. Trials subsequent to the Cochrane review found small or no effect on pain.
Researchers found that the evidence for opioids was limited to short-term trials that showed modest effects for chronic low back pain. However, many trials were not designed to address longer-term adverse effects such as overdose, abuse or addiction.
Skeletal muscle relaxants were found to be effective for short-term relief of acute but not chronic low back pain. These were associated with an increased risk of adverse events, particularly sedation.
The Cochrane review of antidepressants found no effect on pain or function; however, subsequent trials of the antidepressant duloxetine reported small effects on pain and function compared with placebo.
There was insufficient evidence to judge the effectiveness of systemic corticosteroids and anticonvulsants.
Commenting on the review, Professor Chris Maher, Director of the Musculoskeletal Division at The George Institute for Global Health, Sydney, said the review and guidelines make it clear for the first time that medicines have a lesser role in the management of low back pain than previously thought.
‘I was surprised that a medical organisation would come out so strongly against the use of pain medicines; it’s a very brave and honest step,’ Professor Maher told Pain Management Today.
Professor Maher said doctors now faced the challenge of managing patients without relying on medication.
‘If they’ve got acute low back pain, the suggestion is give advice on self-management and review them to see if they have recovered,’ he said. ‘Most people with acute low back will do reasonably well so don’t do too much; reassure them and get them going.’ However chronic low back pain may require earlier intervention with nonpharmacological therapy.
‘Doctors need to now start to form partnerships with local physiotherapists and psychologists to provide this other care, he said.’
Ann Intern Med 2017; doi: 10.7326/M16-2458.
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