Best medications for low back pain, according to new research

By Sandee LaMotte, CNN

Ouch, that aching back! Perhaps it’s from sitting too long, picking up a heavy object, a sudden slip or fall, or an aging spine — whatever the cause, sudden pain in the lower back is a common complaint.

In fact, low back pain is the leading cause of years lived with disability globally, with neck pain coming in at No. 4, according to the 2016 Global Burden of Disease Study. Low back pain is called “acute” when symptoms last between one and 12 weeks and “chronic” when the pain lasts three months or longer.

People often reach for over-the-counter pain medication to help. But which type of pain med is most effective?

A new study, published Wednesday in the Journal of Orthopaedic Research, attempted to find out. Researchers culled through mountains of published studies and found 18 randomized clinical trials that focused specifically on lower back pain that lasted no more than 12 weeks.

The study looked at the following types of analgesics: aspirin; acetaminophen (Tylenol, Paracetamol and Panadol); and nonsteroidal anti-inflammatory drugs, called NSAIDs for short, of which there are many.

Some common NSAIDs are ibuprofen (Advil, Motrin, PediaCare); naproxen (Aleve, Naxen, Naprosyn, Stirlescent); and celecoxib (Celebrex, Elyxyb), which is not available over the counter.

Researchers also included muscle relaxers in the study, which are not available without a prescription.

The study found the very best medication for acute lower back pain was a combination of an NSAID combined with a prescription muscle relaxer — that combo was effective in reducing pain and disability by the end of one week.

However, muscle relaxers don’t work in quite the way you might think, said Dr. Eliana Cardozo, assistant professor of rehabilitation medicine at the Icahn School of Medicine at Mount Sinai in New York City.

“They don’t go to the muscle and relax it. Instead, they work centrally in our brain where they make us sleepy and that kind of relaxes our body,” said Cardozo, who was not involved in the study.

“It’s hard to use them during the day for pain,” she added. “Personally I like to use muscle relaxers for people having pain at night.”

Combining an NSAID with acetaminophen was associated with a greater improvement than taking an NSAID alone, the study found.

“But when I looked at the actual data in the study, I can’t say that it really makes enough of a difference to add the two medicines — it was only a very small benefit,” Cardozo said.

Taking acetaminophen alone did not reduce pain significantly, the study found.

The results of the study only apply to lower back pain that isn’t ongoing and chronic, stressed the study’s corresponding author, Dr. Filippo Migliorini of the department of orthopedic, trauma, and reconstructive surgery, Universitätsklinikum Aachen in Germany.

Before any such intervention is recommended, the physician should be sure to rule out any “possible specific cause of pain that may require specific actions or diagnostics, for example, a history of cancer or recent trauma,” Migliorini and his coauthors wrote.

Side effects of pain medications

Another issue with using pain medications is they have potentially serious side effects. Medical professionals urge caution when taking acetaminophen during pregnancy. The pain reliever can cause rash, hives and breathing difficulties and, in high or frequent doses, potentially impact fetal development. Only 4,000 milligrams of acetaminophen can be taken per day. An overdose can lead to liver damage or liver failure, according to the National Library of Medicine.

Side effects from NSAIDs can include indigestion, diarrhea, headaches, dizziness, allergic reactions, and “in rare cases, problems with your liver, kidneys or heart and circulation, such as heart failure, heart attacks and strokes,” the UK National Health Service noted.

Using NSAIDs for some time can lead to stomach ulcers, which can cause internal bleeding and anemia, the NHS said.

“If someone’s perfectly healthy and they have no other issues, then it’s fine to take NSAIDs around the clock for a week — but only a week,” Cardozo said. “And if someone has high blood pressure, asthma, heart disease or a peptic ulcer, those people should not be taking NSAIDs constantly.”

Widespread problem

It’s estimated 4 out of 5 people will experience low back pain in their lives, according to the Cleveland Clinic. Due to ongoing deterioration of the spongy disks between back vertebrae, anyone older than 30 is at higher risk for low back pain.

So are people with excess weight due to the increase in pressure on joints and disks, along with people who smoke, drink a lot of alcohol or have a sedentary lifestyle, according to the Cleveland Clinic. Even people with depression and anxiety are at greater risk.

People with prior episodes of acute low back pain are at risk for ongoing, chronic symptoms, according to the North American Spine Society.

Antidepressants are not recommended for the treatment of low back pain, according to clinical guidelines developed by the society. Nor are oral or intravenous steroids. “Opioid pain medications should be cautiously limited and restricted to short duration for the treatment of low back pain,” the guidelines state.

However, over-the-counter gels and creams containing capsicum, or chile peppers, are recommended, and it’s possible that spinal manipulative therapy may help, although studies are mixed.

Exercise is highly recommended: “Remaining active is preferred and likely results in better short-term outcomes than does bed rest,” the guidelines said.

“People can start some exercises right away, such as gentle stretching and core stabilizing exercises, which can strengthen the back,” Cardozo said. “Now these are not sit ups or crunches — so seeing a physical therapist to get some starting exercises can be very helpful.”

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Correction: A prior version of this story incorrectly stated that acetaminophen was not recommended during pregnancy. Medical professionals urge caution when taking it during pregnancy.