ACP Guideline: Nondrug Treatments Should Be First-Line Therapy for Low Back Pain

Nondrug treatment alternatives should be considered as first-line therapy for patients with low back pain (LBP), according to an updated clinical practice guideline from the American College of Physicians (ACP).

The new guideline offered three main recommendations for treating acute (less than four weeks), subacute (four to 12 weeks) and chronic (>12 weeks) LBP:
• Nonpharmacologic treatments such as acupuncture, heat packs and massage are strongly recommended because acute or subacute LBP is expected to improve over time regardless of treatment.
• Nonpharmacologic treatment such as exercise, multidisciplinary rehabilitation, yoga and tai chi should be initially used for patient with chronic LBP.
• Only after these treatments are deemed ineffective should nonsteroidal anti-inflammatory drugs be considered as first-line therapy.

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” Nitin S. Damle, MD, MS, MACP, president of the ACP, said in a press release. “Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”

Duloxetine and tramadol showed modest effects for chronic pain and could be considered as second-line therapy, according to the guideline authors. They found moderate-quality evidence supporting the use of opioids for treating pain in this population, and noted that opioids should only be considered as an option in patients who have failed the previous recommended treatments.

“Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose,” Dr. Damle said.

The updated guidelines are based on a review of 114 studies on nonpharmacologic and 46 studies on pharmacologic treatments. The guidelines were published on Feb. 14, 2017, in Annals of Internal Medicine (doi: 10.7326/M16-2367.