Back Pain: Drug Therapy

Therapy target

Pain relief and thus improvement of the ability to move

Therapy recommendations

  • In the foreground of the therapy of non-specific low back pain is the activation of the affected person!
  • Analgesia (pain relief) according to WHO stage scheme:
    • Non-opioid analgesic
      • For acute low back pain (lumbago), no reduction in recovery time; no evidence of efficacy
    • Low-potency opioid analgesic (eg, tramadol) + non-opioid analgesic – only after unsuccessful pain therapy with non-opioid analgesics.
    • Highly potent opioid analgesic (eg, morphine) + non-opioid analgesic.

    Note: Opioid therapy should be re-evaluated regularly, in acute non-specific low back pain after no more than four weeks, in chronic low back pain after no more than three months.Opioids should be used for long-term treatment of chronic non-specific low back pain only as part of an overall therapeutic approach.

  • In the acute stage to support non-drug measures (see below “Further therapy“), so that the patient can quickly resume his usual activities In the chronic stage, if pain therapy is required for the implementation of activating measures (multimodal (psychotherapy and physiotherapy), multi- and interdisciplinary treatment / rehabilitation”).
  • Antiphlogistic analgesics (NSAIDs/nonsteroidal anti-inflammatory drugs, e.g., ibuprofen, diclofenac); according to guideline recommendations, acute low back pain should be treated with NSAIDs and/or muscle relaxants for a limited period of time; NSAIDs should be used for the treatment of nonspecific low back pain at the lowest effective dosage and for as short a duration as possible. Other treatment options include:
    • Metamizole can be used to treat nonspecific low back pain at the lowest effective dosage and for as short a duration as possible when NSAIDs are contraindicated [S3 guideline: ⇔).
    • COX-2 inhibitors can be used to treat nonspecific low back pain when NSAIDs are contraindicated or not tolerated, taking into account the warnings.
  • If appropriate, muscle relaxants (drugs that relieve muscle tension): according to the guideline: not to be used for the treatment of
    • Acute non-specific low back pain (acute low back pain); acute pain for short-term therapy (two to seven days).
    • Chronic non-specific low back pain
  • If necessary, glucocorticoids for.
    • Acute radiculopathy (irritation or damage to the nerve roots) due to lumbar (“belonging to the lumbar spine”) disc herniation (herniated disc).
    • Acute pain: neither injections nor tablets performed significantly better than placebo.
  • Tetrazepam (bezodiazepines) for chronic nonradicular pain.
  • If appropriate, local anesthetics (local anesthesia); antidepressants [note: for chronic low back pain, tricyclics and SSRIs were found to have no benefit over placebo]
  • See also under “Other therapy.”

Analgesics

Analgesics are pain relievers. There are several different subgroups, such as the NSAIDs (non-steroidal anti-inflammatory drugs) to which ibuprofen and ASA (acetylsalicylic acid) belong, or else the group around the non-acid analgesics paracetamol and metamizole. They are all widely used. Many preparations in these groups carry a risk of gastric ulcers (stomach ulcers) with prolonged use. Notice:

  • Paracetamol should not be used to treat nonspecific low back pain
  • Paracetamol was no more effective than placebo for acute low back pain at 4 weeks.

Muscle relaxants

Muscle relaxants are drugs prescribed mainly for tension. In the clinic, they are used for anesthesia. Muscle relaxants include tizanidine and tolperisone. Red Hand Letter: Tolperisone is only approved for the treatment of post-stroke spasticity in adults. Outside of this approved indication, for example, there is a risk for hypersensitivity reactions (up to and including anaphylactic shock) without proven benefit.

Antidepressants

Antidepressants are medications such as amitriptyline or venlafaxine that are used for depression. For back pain, they are used to reduce pain.

  • For chronic low back pain, there were no benefits for tricyclics and SSRIs compared with placebo
  • There is no evidence for gabapentinoids (gabapentin, pregabalin) in nonspecific low back pain

Opioids

Opioids are very strong painkillers, which include morphine. They have analgesic (pain-relieving) effects, but also sedative (fatiguing) and antiemetic (anti-nausea) effects. However, they also cause many side effects, such as constipation (constipation), nausea/vomiting, respiratory depression (decrease the stimulus to breathe). Opioids, like other narcotics, are considered narcotics, so their traffic is closely tracked and controlled.

Local anesthetics

Local anesthetics are medications administered to eliminate pain in a limited area of the body. They are usually given before minor surgical procedures.

Glucocorticoids

Glucocorticoids are drugs against inflammation. They are also used in cases of overactive immune system – for example, allergic reactions. They can lead to osteoporosis-related fractures (broken bones) when taken as long-term oral therapy (i.e., tablets), resulting in back pain.

  • Notice: Intravenous, -muscular, or subcutaneous analgesics, local anesthetics, glucocorticoids, and mixed infusions should not be used to treat nonspecific low back pain.
  • According to the S2 guideline on lumbar radiculopathy, “oral corticosteroid administration in a dose of 50-100 mg prednisolone per day can empirically lead to significant pain reduction and also functional improvement in the short term, especially in foraminal hernias.”
  • The use of oral steroids (50-100 mg prednisolone) in acute radiculopathy due to lumbar disc hernia improves function (after three weeks) but not pain.
  • Low back radicular pain: lumbosacral radiculopathy can be treated as well with oral gabapentin (anticonvulsant; 300 mg capsules, target dose 1,800-3,600 mg/day, titrated up over 15-24 -days) as with epidural steroid injections.
  • Acute pain: neither injections nor tablets performed significantly better than placebo.

Caution. Three months or longer of systemic glucocorticoid therapy increases the risk of osteoporosis by 30-50 percent. This side effect does not occur with metered-dose inhaler therapy, such as for bronchial asthma.

Antidepressants

Antiepileptic/anticonvulsants

Cannabis

In patients with chronic lumbar back pain, no studies of cannabis therapy exist to date.Small studies show little benefit compared with placebo in pain control in chronic neuropathic pain.

Phytotherapeutics (oral)

  • Willow bark can be used in combination with activating measures to treat chronic nonspecific low back pain
  • Devil’s claw (Harpagophytum procumbens) should not be used to treat non-specific low back pain.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances:

In the presence of insomnia (sleep disturbances) due to back pain: see below Insomnia/Medicinal Therapy/Supplements.