pharmaceutical management in simple low back pain

Last edited 04/2021 and last reviewed 04/2021

Pharmacological treatment

• paracetamol:
  • regular paracetamol is the first option
  • if regular paracetamol alone is insufficient (and taking account of individual risk of side effects and patient preference), offer NSAIDs and/or weak opioids
• NSAIDS
  • consider risk of side effects, especially in older people and those at increased risk of side effects
  • offer treatment with a standard oral NSAID/ COX-2 inhibitor
    • co-prescribe a PPI for people over 45
• weak opioids:
  • consider risk of opioid dependence and side effects
  • examples of weak opioids are codeine and dihydrocodeine
• tricyclic antidepressants:
  • consider if other medications are insufficient
    • start at a low dose and increase up to the maximum antidepressant dosage until:
      • therapeutic effect is achieved or
      • unacceptable side effects prevent further increase
• strong opioids:
  • consider for short-term use to people in severe pain
  • consider risk of opioid dependence and side effects
  • examples of strong opioids are buprenorphine, diamorphine, fentanyl, oxycodone and tramadol (high dose)
  • consider referral for specialist assessment for people who may require prolonged use of strong opioids

For NICE guidance regarding management of chronic pain (pain that lasts for more than 3 months) then see linked item.

Reference:

• 1. NICE (May 2009).Low back pain - Early management of persistent non-specific low back pain