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Low back pain is the second leading cause of disability in the United States, and the fourth worldwide. It’s also one of the top five medical problems for which people see doctors.

Almost every day that I see patients, I see someone with back pain. It’s one of the top reasons for lost wages due to missed work, as well as for healthcare dollars spent. Hence, it’s a very expensive problem.

What causes the pain?

Let’s talk about the most common forms of back pain: acute (which lasts less than four weeks) and subacute (which lasts four to 12 weeks).

Most of these cases (approximately 85 percent) are due to harmless causes. We lump them into the “mechanical back pain” diagnosis, which includes muscle spasm, ligament strain and arthritis.

What the researchers found was surprising: For acute and subacute low back pain, the best and safest treatments are not medicines. The ACP made the following strong recommendation:

Most patients with acute or subacute low back pain improve over time regardless of treatment, and can avoid potentially harmful and costly treatments and tests.

First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.

Because most mechanical back pain improves no matter what, we don’t want to prescribe treatment that can cause harm. Because some medications carry significant risks, we really shouldn’t be recommending these right off the bat.

Rather, we should be providing guidance on heating pad or hot water bottle use, and recommendations or referrals to acupuncturists, massage therapists and chiropractors. These therapies were somewhat effective, and are very unlikely to cause harm.

Medicines like ibuprofen and naproxen can be helpful, but they can cause stomach inflammation and ulcers, as well as possible bleeding, and even kidney damage, especially in older adults.

Muscle relaxants can be sedating, and can interact with other common medications. Benzodiazepines and opiates not only can cause sedation, making it hard to think clearly and function normally, they are also addictive.

Basically, for acute and subacute low back pain, the risks of these medications outweigh the benefits.

Other medications, like acetaminophen, steroids, antidepressants and anti-seizure medications, were not significantly helpful for acute and subacute low back pain at all.

The study was missing a few potentially helpful low-risk medicines. Topicals such as the lidocaine patch or capsaicin ointment were not included, which is a shame, as these can provide relief for some people, and carry little risk.

I would also be interested to know if over-the-counter topical therapies containing menthol and camphor are better than placebo for low back pain.

Courtesy of Harvard Health Blog. Monique Tello, M.D., M.P.H., is a contributing editor to Harvard Health Publications.

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