You may have heard that doctors are getting away from prescribing opioids for chronic low back pain. New guidelines from the American College of Physicians (ACP) advise doctors to start with options that don’t involve any type of medication.
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This breaks from the World Health Organization tiered medication scale favored in the past. The scale previously focused on drugs that included opioids.
“We interpret the new guidelines as saying, ‘Try a number of non-pharmacological options before starting the use of long-term medication for low back pain.’ That’s a positive step,” says spine specialist E. Kano Mayer, MD.
While the ACP reviewed lots of studies to formulate its guidelines, he notes that it failed to look at how long each intervention was effective or at outcomes other than pain reduction.
“Cleveland Clinic spine specialists favor the active, rather than the passive, therapies recommended,” says Dr. Mayer. “We prefer that you do things actively to control pain and improve function, rather than waiting for things to be done to you.”
What to try first for your back pain
Cleveland Clinic spine experts support the following ACP recommendations, he says:
- Physical therapy
“Cleveland Clinic very much advocates active physical therapy,” says Dr. Mayer. An exercise prescription can help to ease back stiffness and strengthen muscles that support the spine.
This ancient Chinese technique involves inserting hair-thin needles at key points to ease pain. “Acupuncture is better at relieving the radiating leg pain that can accompany low back pain. We often recommend acupuncture because relieving pain allows you to exercise and be active,” says Dr. Mayer.
Individual, group or supervised exercise can make you sore at first. “But it can help improve your core strength, spine flexibility, endurance and balance,” he notes.
- Yoga and tai chi
Practicing these meditative forms of exercise from ancient India and China “has shown good benefit for those with low back pain, improving their function, endurance and symptoms,” says Dr. Mayer.
- Cognitive behavioral therapy (CBT)
“Research shows this popular form of talk therapy improves coping, lessens social isolation and decreases the social impact of pain on your life,” he says. Combining psychological therapy with physical therapy and social work support is also beneficial.
Placing electrodes at certain points allows you to control and release tension in your back muscles. “This improves function, positional tolerance and muscle pain,” says Dr. Mayer.
- Stress management and mindfulness
Relieving stress and focusing on the present help to take your mind off pain.
- Progressive relaxation
Gradually releasing tension in each part of the body can be helpful in easing pain, especially before bed.
Remedies less likely to help
Cleveland Clinic spine specialists generally do not support the use of passive treatments for low back pain.
“Chronic use of low-level laser therapy, ultrasound, transcutaneous electrical nerve stimulation (TENS) and spinal manipulation may only help in the short term,” Dr. Mayer points out. “We don’t want you to waste your money on treatments unlikely to provide more than a day of benefit.”
When you may need medicine
If non-drug interventions don’t help, the ACP recommends first trying non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen, indomethacin or meloxicam. While NSAIDs provide some pain relief, they may put you at risk for GI bleeding or kidney damage.
As second-line drugs, the ACP recommends duloxetine (an antidepressant) or tramadol (a novel opioid, but still subject to abuse).
Due to their serious side effects and addictive nature, opioid medications (morphine, oxymorphone, hydromorphone, tapentadol) should be used only as a last resort when patients fail all other therapies, the ACP advises. The rule of thumb: Use the lowest possible dose of opioid for the least amount of time.
If you’ve been suffering with long-term low back pain, it’s worth exploring these non-drug treatment options before resorting to pills. You’re likely to find your quality of life improving.