What Role Does Medication Play in Back Pain Treatment?

If you have severe back pain that lasts more than a few days, or if you have mild to moderate back pain that does not respond to self-treatment, it is important to visit your primary care physician.

Regardless of the cause of the pain, a doctor will probably recommend self-treatment techniques. In general, limiting the amount of bed rest and pain medication is the preferred approach to back pain management among primary care physicians—a strategy supported by current research.

In one study of more than 1,000 people, doctors were divided into three groups according to whether they had a low, medium, or high frequency of prescribing pain medications and bed rest. After a month, people seeing the physicians who least often prescribed drugs and bed rest improved more quickly than those in the other groups. Only 30% of these people had to make moderate to severe cutbacks in their daily activities, compared with 37 percent of people seeing doctors in the medium-frequency group and 46 percent in the high-frequency group. After a year, however, there were no differences among the three groups in pain levels or ability to function.

Many doctors feel that the successful treatment of back pain with minimal bed rest and minimal medication is a result of the self-care practices they recommend. The above study supports this belief: People whose physicians were least likely to prescribe bed rest and pain-relief medications reported being more satisfied with their personal knowledge of how to treat back pain and just as satisfied with their medical care as those whose doctors prescribed drugs and rest.

Types of Back Pain Medications

Prescription NSAIDs

When over-the-counter medications do not relieve back pain, the doctor might need to prescribe a stronger NSAID such as diflunisal or meclofenamate (available in generic form only).

Although a certain type of NSAID known as COX-2 inhibitors have been shown to treat pain and inflammation as effectively as traditional NSAIDs, they have come under scrutiny for their adverse effects, including an increased risk of heart attack and stroke in individuals with or at risk for cardiovascular disease.

As a result of these concerns, the U.S. Food and Drug Administration (FDA) has strengthened the warnings on the labels of all NSAIDs, including the COX-2 inhibitor celecoxib (Celebrex). Currently, Celebrex (and generic versions approved by the FDA in May 2014) is the only COX-2 inhibitor that remains on the market in the United States.

Muscle relaxants

Studies have shown that muscle relaxants are an effective treatment for low back pain that lasts less than four weeks. Their usefulness for chronic low back pain requires further study, however.

Muscle relaxants appear to work by depressing the activity of the nerves in the spinal cord and brain. Common muscle relaxants are baclofen (Lioresal), carisoprodol (Soma), cyclobenzaprine (Flexeril), and methocarbamol (Robaxin). The anticonvulsant gabapentin (Neurontin) also is used often. A few studies suggest that a combination of a muscle relaxant and an NSAID may be more beneficial than a muscle relaxant alone.

The use of muscle relaxants is controversial because they are potentially addictive. Therefore, you should not take them for more than one or two weeks, and people with a history of substance abuse or other mental health conditions should use them with great caution.

Possible side effects of muscle relaxants include dizziness, drowsiness, dry mouth, headache, stomachache, and nausea or vomiting.

Epidural steroid injections

Epidural steroid injections may be used to treat low back pain and sciatica. The injections usually contain an anesthetic for pain relief and a corticosteroid, which helps to reduce inflammation around irritated nerves in the epidural space. Studies have shown that epidural steroid injections can relieve back pain. Unfortunately, however, that relief is often only temporary.

Opioids

Highly addictive painkillers such as opioids (morphine, codeine, and meperidine) should also be used with a great deal of caution and only when all other treatments have failed. People who need opioids for more than a few days sometimes take controlled-release formulations of oxycodone (OxyContin) or morphine (MS Contin). These long-acting drugs provide more consistent control of back pain than standard, short-acting narcotics.

Disease-modifying antirheumatic drugs

The medication etanercept (Enbrel), a disease-modifying antirheumatic drug (DMARD), is used to treat ankylosing spondylitis. The drug works by interfering with an immune system protein known as tumor necrosis factor, which contributes to inflammation. Possible side effects of Enbrel include reactions at the injection site, respiratory infections, and tuberculosis.

Exercise

If your back pain is mild, it is safe to get back to an aerobic exercise routine as soon as treatment eases your pain. After two weeks, exercises to strengthen the back and abdominal muscles can be started slowly. Building core strength in the back and abdomen is very beneficial in preventing recurrence.

Not recommended or unproven treatments

Prolonged bed rest (more than four days) is not recommended as part of treatment. Although still used occasionally, transcutaneous electrical nerve stimulation (TENS)—the application of low-energy electrical radiation to “numb” the nerves—is declining in popularity. Support belts and back machines have not been found to be of any benefit in the treatment of back pain.

Publication Review By: Lee H. Riley III, M.D. and Suzanne M. Jan de Beur, M.D.

Published: 04 Aug 2011

Last Modified: 02 Jun 2014