Guideline recommendations on the pharmacological management of non-specific low back pain in primary care – is there a need to change?

ABSTRACT

Introduction: Analgesic drugs are often prescribed to patients with non-specific low back pain (NSLBP). Recommendations for non-invasive pharmacological management of NSLBP from recent clinical practice guidelines were compared with each other and with the best available evidence on drug efficacy.

Areas covered: Recommendations concerning opioids, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, antidepressants, anticonvulsants and muscle relaxants from national primary care guidelines published within the last 3 years were included in this review. For each pharmacological treatment, the most recent systematic review was included as the best available evidence on drug efficacy and common adverse effects were summarized.

Expert opinion: Although differences exist between guidelines, publications are universally moving away from pharmacotherapy due to the limited efficacy and the risk of adverse effects. NSAIDs have replaced paracetamol as the first choice analgesics for NSLBP in many guidelines. Opioids are generally considered to be a last resort, but opioid prescriptions have been increasing over recent years. Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.

KEYWORDS:

• Non-specific low back pain
• paracetamol
• NSAIDs
• antidepressants
• anticonvulsants
• muscle relaxants
• opioids
• guideline recommendations
• pharmacotherapy

Article Highlights

• Guidelines are universally moving away from recommending pharmacotherapy, presenting the prescription of analgesics as an option that may be considered if this is required by the patient.

• Although national clinical practice guidelines for the management of LBP are based on the same body of scientific evidence, there are differences between these guidelines in terms of attitude towards pharmacotherapy, analgesics of first choice and recommendations for or against the prescription of specific pharmacological treatments.

• Although best available evidence suggests paracetamol is ineffective in paracetamol, four out of eight guidelines still recommend prescribing paracetamol for acute LBP. However, two of these guidelines immediately state that no short-term effect of this medication is to be expected. It is important to consider that the best available evidence (Cochrane review) is mainly based on one large RCT. In the other four guidelines, NSAIDs have become the first choice analgesics in LBP.

• The American guideline is the only guideline currently recommending skeletal muscle relaxants as one of two first-choice options for the treatment of LBP (together with NSAIDs); the choice between these drugs should be based on patient preferences and risk profile. Other guidelines either make no recommendations about muscle relaxants or advise against benzodiazepines; however, SMRs aren’t widely available in many European countries.

• Most guidelines recognize only limited indications for the prescription of antidepressants and anticonvulsants in LBP.

• Opioids are considered by all guidelines as a last resort option in case all other pharmacological options have failed; however, prescriptions of these medications have been increasing over recent years.

• The authors believe that upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatment options as a first choice of treatment for NSLBP. Analgesic prescriptions for NSLBP should be accompanied by the message that drugs are purely symptomatic and should only be prescribed in support of non-pharmacological measures. Patient education through mass media campaigns, patient information websites and consumer versions of guidelines could help change patients’ beliefs and behaviors to make sure patients accept the shift from pharmacotherapy to non-pharmacological treatments. Efforts to increase guideline uptake should be maximized in order to close the evidence-practice gap; this is essential for improving the quality of LBP care.

This box summarizes key points contained in the article.

Declaration of interest

M Schreijenberg was investigator on the PACE Plus trial, an investigator-initiated trial evaluating paracetamol and dic/ofenac for acute low back pain. This trial was funded by the Netherlands Organization for Health Research and Development (ZonMw; 836041009). B W Koes is investigator on the following three trials evaluating medicines for low back pain: PRECISE, an investigator-initiated trial evaluating pregabalin for sciatica. It is funded by the National Health and Medical Research Council of Australia with in kind research support from Pfizer (ACTRN12613000530729); OPAL, an investigatorinitiated trial evaluating an opioid analgesic for acute low back pain funded by the National Health and Medical Research Council of Australia (ACTRN12615000775516); PACE Plus, an investigator-initiated trial evaluating paracetamol and dic/ofenac for acute low back pain. This trial was funded by the Netherlands Organization for Health Research and Development (ZonMw; 836041009). C-WC Lin is investigator on the following three trials evaluating medicines for low back pain: PACE, an investigator-initiated trial evaluating paracetamol for acute low back pain. It was funded by the National Health and Medical Research Council ofAustralia and GlaxoSmithKline (ACTRN 12609000966291); PRECISE, an investigator initiated trial evaluating pregabafin for sciatica, It is funded by the National Health and Medical Research Council of Australia with in kind research suppott from Pfizer (ACTRN12613000530729); OPAL, an investigator-initiated trial evaluating an opioid analgesic for acute low back pain funded by the National Health and Medical Research Council of Australia (ACTRNi2615000775516). C-WCL is supported by a Career Development Fellowship from the National Health and Medical Research Council, Australia (APP1061400). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript is funded in part by a program grant of the Dutch Arthritis Foundation. The funding agency mentioned had no role in manuscript preparation, study design, data analysis, statistical input, review of drafts, writing of the article, identification of papers for inclusion or any other form of input.