Uncertainty surrounding analgesic use for back pain

Filip Vukasin

27/03/2023 4:18:57 PM

Research shows low confidence for most medicines prescribed for acute lower back pain, with experts recommending a ‘cautious approach’.

Person with low back pain
The evidence base for medications treating low back pain was not as rich as researchers previously believed.

A new study published in The BMJ shows there is considerable uncertainty when it comes to analgesics for acute lower back pain and suggests clinicians should take a ‘cautious approach’ to their use.
The systematic review and meta-analysis from Neuroscience Research Australia (NeuRA) analysed 98 randomised controlled trials involving more than 15,000 participants over six decades and determined there was low or very low confidence for most medications.
Lead author, Dr Michael Wewege, told newsGP he was surprised by the findings.
‘We set out to do this study because GPs are deciding which of these medicines they should give to their patients,’ he said.
‘But there are no formal guidelines to help answer this question and we thought the evidence base would be rich. Ultimately it wasn’t.’
Dr Wewege said their study highlights that while there are many different medicines clinicians can use, the research on them has been poor.
‘There are some high-quality studies, including two good ones from Australia,’ he said.
‘But unfortunately, 90% of the research that’s done is not done well and this is why we have low confidence.’
Acute non-specific low back pain is defined as lasting under six weeks. In Australia, approximately 61% of patients are prescribed an analgesic to manage their symptoms.
According to the Health of the Nation 2022 report, musculoskeletal issues are the second most common general practice presentation. The direct costs of low back pain amounted to approximately $1 billion a 2001 study suggested, with a further $8 billion in indirect costs.
Professor James McAuley, Director for the Centre for Pain IMPACT at NeuRA, said the study recognises the complexities in acute low back pain and treatment.
‘Despite over 60 years of research, we are still uncertain whether any analgesic medicine provides meaningful pain relief for people with low back pain,’ he said.
‘Patients should be reassured that acute low back pain is very likely to resolve by itself over time, regardless of whether or not they take medicines.
‘We recommend that doctors and patients take a cautious approach to managing acute low back pain with analgesic medicines until higher quality trials of head-to-head comparisons are available.’
The study examined medicines administered as monotherapy and combination, including paracetamol, nonsteroidal anti-inflammatories (NSAIDs), anticonvulsants, antidepressants, corticosteroids, opioids and muscle relaxants.
While there was limited evidence supporting their efficacy, the team found evidence that some analgesic medicines increased the risk of adverse events or side effects such as nausea, dizziness and drowsiness. These included tramadol and baclofen.
‘If analgesic medicines are required, our study shows that clinicians should take a cautious approach and importantly, make this decision in consultation with patients on their specific pain experience, severity of symptoms and their individual needs and preferences,’ Professor McAuley said.
Dr Wewege says there is some promising research into the uncommon NSAID, ketorolac.
‘We are exploring it and it has presented some promising effects,’ he said.
‘It needs to be confirmed in a high quality randomised controlled trial and we are applying for funding to test this.’
However, Dr Wewege says for the moment there is robust evidence for non-medication treatment of acute lower back pain.
‘Guidelines recommend self-managed and minimally invasive physical therapies like a heat pack and massage,’ he said.
The Handbook of Non-Drug Interventions (HANDI) has resources for managing acute low back pain.
The Australian Commission on Safety and Quality in Health Care published Low Back Pain Clinical Care Standards in 2022.
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