Key Point
Exercise therapy remains a key intervention for low back pain.
Other options. Medication options for individuals who do not respond adequately to acetaminophen and NSAIDs include short-term skeletal muscle relaxants for acute low back pain and antidepressants for chronic low back pain.6 Skeletal muscle relaxants are not considered first-line medications because of their high rate of sedation, and they have not been studied well in chronic low back pain. The serotonin norepinephrine reuptake inhibitor duloxetine was FDA approved recently for treating chronic low back pain and appears to have modest effects on pain and function.19
Complementary and alternative modalities such as spinal manipulation, acupuncture, and massage also are recommended for chronic low back pain, but not as substitutes for exercise therapy.6 Psychotherapy is another option, especially for patients with difficulty coping or comorbid psychiatric conditions. Physical modalities such as ultrasound, transcutaneous electrical nerve stimulation, and interferential therapy are not recommended because of a lack of evidence showing benefits.6 The role of interventional therapies and surgery is limited for low back pain without evidence of radiculopathy due to herniated disc or spinal stenosis.20
Opioids. In general, reserve opioids for individuals who do not respond to first-line medications and nonpharmacologic therapies. Earlier consideration of opioids may be warranted for people with severe pain and functional limitations or contraindications to first-line medications.
To manage chronic low back pain effectively, be clear with patients that opioids generally do not eliminate pain and, if used, are one part of an overall management plan. The benefits of using opioids are not likely to exceed—and might well be less than—the average 20% to 30% pain relief observed in clinical trials for general chronic pain.
Managing biopsychosocial components. For many individuals, chronic low back pain is best understood as a complex biopsychosocial condition.21 Cognitive behavioral therapy can be helpful for those with severe functional limitations related to low back pain or maladaptive coping strategies. They may exhibit fear avoidance (avoiding usual activities out of fear of harming the back) or catastrophizing (dwelling on the worst possible outcome of the back pain, such as total disability).22-24 Depression also is common with low back pain and should be appropriately evaluated and treated.16
For injured workers, opioid therapy is most likely to be effective when used in conjunction with cognitive behavioral therapy, exercise therapy, and functional restoration. Functional restoration is an intervention that includes simulated or actual work tests in a supervised environment to enhance job performance skills and improve strength, endurance, flexibility, and cardiovascular fitness.
Assess risks/benefits when considering opioids
An American Pain Society/American Academy of Pain Medicine (APS/AAPM) guideline on opioid therapy for chronic low back pain or other types of pain emphasizes the need to assess risks related to opioids’ abuse potential and to consider potential benefits and other adverse effects, such as increased respiratory depression in individuals with obstructive sleep apnea or increased risk of falls and fractures in older patients.25
Major risk factors for opioid misuse or abuse include a personal or family history of substance abuse—the latter often overlooked but critical. Formal tools such as the Opioid Risk Tool (TABLE) can help you perform and document risk assessment.26 The Opioid Risk Tool categorizes patients as low-, moderate-, or high-risk for aberrant drug-related behaviors, based on a simple point system using 5 criteria.
Risk assessment informs your decisions about whether to start opioids and how to structure follow-up and monitoring. For example, you may deem a higher-risk patient inappropriate for opioids and instead focus on functional restoration, cognitive behavioral therapy, and nonopioid analgesics. Alternatively, you might consider opioids, but only in conjunction with other therapies and with more intense monitoring and follow-up to mitigate potential risks. This plan might include more frequent clinic visits, limited-duration prescription refills (such as a 1 or 2 weeks’ supply instead of 1 month), frequent random urine drug screens,27 and close follow-up of prescription drug monitoring program data. (See “How to avoid opioid misuse”.)
TABLE
Opioid Risk Tool: Assessing opioid abuse potential
| Mark each box that applies | Female | Male | |
|---|---|---|---|
| 1. Family history of substance abuse | |||
| Alcohol | ▢ 1 | ▢ 3 | |
| Illegal drugs | ▢ 2 | ▢ 3 | |
| Prescription drugs | ▢ 4 | ▢ 4 | |
| 2. Personal history of substance abuse | |||
| Alcohol | ▢ 3 | ▢ 3 | |
| Illegal drugs | ▢ 4 | ▢ 4 | |
| Prescription drugs | ▢ 5 | ▢ 5 | |
| 3. Age (mark if between 16-45 years) | ▢ 1 | ▢ 1 | |
| 4. History of preadolescent sexual abuse | ▢ 3 | ▢ 0 | |
| 5. Psychological disease | |||
| ADD, OCD, bipolar, schizophrenia | ▢ 2 | ▢ 2 | |
| Depression | ▢ 1 | ▢ 1 | |
| Scoring totals | _______ | _______ | |
| 0–3=low risk for aberrant behaviors; 4–7=moderate risk; ≥8=high risk. | |||
| ADD, attention-deficit disorder; OCD, obsessive-compulsive disorder. From Webster LR, Webster RM. Pain Med. 2005.26 Used with permission. | |||
Start low
The APS/AAPM guideline recommends that you initiate opioids at low doses (such as hydrocodone 5-10 mg, codeine 60 mg, or oxycodone 5 mg, 2 to 3 times daily) and titrate slowly to reduce the risk of accidental overdose.25 Previously, physicians prescribed opioids with no “ceiling dose,” meaning that doses were titrated up until patients experienced pain relief or intolerable adverse effects. Recent evidence, however, indicates that the risk of overdose in patients prescribed opioids for chronic pain begins to increase at doses equivalent to morphine, 50 to 100 mg/day, and continues to rise in a dose-dependent fashion.28-30