ACP Guideline: Start with Nonpharmacologic Treatments for Low Back Pain

The American College of Physicians now recommends nonpharmacologic therapies — including superficial heat, massage, acupuncture, and spinal manipulation — as first-line treatment for patients with acute or subacute low back pain (lasting 12 weeks or less). The new guideline, published in the Annals of Internal Medicine, is a major change from the group’s 2007 guidance.

The ACP emphasizes that most low back pain is self-limited, with many patients showing considerable improvement within the first 4 weeks.

Among the group’s other recommendations:

• Acute or subacute pain: When drug therapy is considered, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants should be used. Acetaminophen is no longer recommended, given new evidence indicating a lack of benefit.
• Chronic pain (i.e., beyond 12 weeks): Clinicians should start with nonpharmacologic approaches, such as exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction.
• Chronic pain: If non-drug therapies aren’t sufficient, NSAIDs should be tried first, then tramadol or duloxetine. Opioids may be considered only when prior treatments fail, the potential benefits for the patient outweigh the risks, and the benefits and risks are discussed with the patient.