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The clinical problem
Low back pain causes more disability worldwide than any other health condition.1 Although many people self-manage their condition without needing to seek care,2 low back pain is the second most frequent symptom to prompt attendance in general practice after the common cold.3 Most low back pain is ‘non-specific’ meaning there is no identifiable spinal pathology. While the available evidence suggests a limited role for medicines in the management of an acute episode of non-specific low back pain, medicine prescription remains almost routine.4 Many patients with persisting symptoms also continue to take medicines long-term despite the low likelihood of ongoing benefits. We suggest a different approach that emphasises selective prescribing, and discontinuing medicines that are no longer of benefit, for patients with non-specific low back pain.
The evidence for change
Recent guidelines indicate a reduced role for medicines in the management of non-specific low back pain. The 2017 Danish Guideline does not recommend any medicine.5 The 2016 UK guideline from the National Institute for Health and Care Excellence only recommends non-steroidal anti-inflammatory drugs (NSAIDs) and ‘weak’ opioids.6 The 2017 US guideline from the American College of Physicians (ACP) makes a similar recommendation and includes the addition of skeletal muscle relaxants for acute non-specific low back pain (ie, pain for <12 weeks), but explicitly states that the initial treatment of non-specific low back pain should be non-pharmacological.7 These guidelines reflect new evidence suggesting that in patients with non-specific low back pain, many pain medicines have little or no benefit over placebo, and potential for harm. For a detailed description of the evidence on benefits and harms of medicines for low back pain, we refer readers to the evidence document accompanying the ACP guideline.7 Below we focus on evidence (see box 1 for our search strategy) for medicines that …
Contributors AT contributed to the idea for the article, performed the literature search and wrote the first draft of the manuscript. He is guarantor. RB contributed to the idea for the article and to all revisions of the manuscript and approved the final version. IH contributed to the idea for the article and all revisions of the manuscript and approved the final version. OC co-ordinated patient feedback on early versions of the manuscript, contributed to revisions and approved the final version. CM contributed to the idea for the article, the literature search and all revisions of the manuscript and approved the final version.
Funding This work was supported by an Australian National Health and Medical Research Council (NHMRC) programme grant entitled ’Using healthcare wisely: reducing inappropriate use of tests and treatments' (APP1113532). AT is supported by an NHMRC Early Career Fellowship. RB is supported by an NHMRC Senior Principal Research Fellowship. CM is supported by an NHMRC Principal Research Fellowship.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.