Low back pain is one of the most common emergency department presentations. Though diagnosis is often straightforward, pain management can be a source of frustration for both the patient and the provider, especially as we focus on limiting narcotic prescriptions given the spreading opiate crisis. In an effort to manage pain, practitioners often counsel patients on the use of over the counter medications or discharge them with a prescription, but what is the evidence behind these medications that we commonly use for back pain? For this month’s journal club, we reviewed three articles that studied the use of acetaminophen, NSAIDS plus muscle relaxers or opiates, and corticosteroids for the management of acute low back pain.

ARTICLES REVIEWED

1. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586-96.

2. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-80.

3. Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015;313(19):1915-23.

ADDITIONAL READING

4. Chou R, Deyo R, Friedly J, et al. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017

WILLIAMS, ET AL 2014

This multicentered, double-blind, randomized, controlled trial enrolled 1643 patients with low back pain across 235 primary care centers to answer the question: does paracetamol (known in the United States as acetaminophen), taken regularly or as needed, improve time to recovery in patients with low back pain? They found no significant difference in the rate of recovery (defined as a pain score 0-1 for 7 consecutive days) between the scheduled or as needed acetaminophen groups and placebo over a study period of 12 weeks. The median recovery time for all groups was 16-17 days. They also found no difference between acetaminophen and placebo in secondary outcomes, including pain intensity, disability, function, global ratio of symptom change, sleep quality, and quality of life.

Bottomline: While strong in many aspects of study design, this paper fell short on its primary outcome. Asking if acetaminophen improves time to recovery is the wrong question to be asking. Pain relievers are meant to relieve pain, not hasten time to recovery. A better primary outcome would have been difference in pain scores or difference in functional status between acetaminophen and placebo. Despite this shortcoming, the clear message from this paper is that acetaminophen doesn’t make back pain better.

FRIEDMAN, ET AL 2015

This was a single-center, randomized, double-blind clinical trial designed to determine whether cyclobenzaprine or oxycodone/acetaminophen combined with naproxen is more effective than naproxen monotherapy for nontraumaic low back pain. The primary outcome was improvement on the Roland-Morris Disability Questionnaire (RMDQ) 7 days after ED discharge.

Roland MO, Morris RW. A study of the natural history of back pain.  Part 1: Development of a reliable and sensitive measure of disability in low back pain. Spine 1983; 8: 141-144 — Roland MO, Morris RW. A study of the natural history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low back pain. Spine 1983; 8: 141-144

They enrolled 323 adults with nontraumatic, nonradicular low back pain and randomized them to naproxen + placebo, naproxen + prn cyclobenzaprine, or naproxen + prn oxycodone/acetaminophen. There was no significant difference in improvement on the RMDQ at 1 week between groups. There was also no statistically significant difference in pain frequency, pain severity, and medication use during previous 24 hours between groups. Both the oxycodone/acetaminophen and cyclobenzaprine groups experienced more adverse events than the placebo group.

Notably, only 1/3 of participants used the prn medication they were randomized to take (placebo, cyclobenzaprine, or oxycodone/acetaminophen) more than once daily and nearly 40% only used it intermittently, once, or not at all. While likely reflective of our patients’ use patterns, this is a limitation of the study, and biases results toward no effect.

Bottomline: Though limited, the takeaway from this article is that the addition of cyclobenzaprine or oxycodone/acetaminophen to naproxen does not provide better improvement in functional outcomes or better pain relief than naproxen alone.

GOLDBERG, ET AL 2015

In this study, 269 patients with radicular back pain and MRI-diagnosed disc herniation were randomized to receive either prednisone taper or placebo. The primary outcome was a change in self-reported Owestry Disability Index (ODI) score at 3 weeks. While both groups had improvement in 3 week ODI scores, the prednisone-treated group had mean 6.4-point greater improvement in scores at 3 weeks (ODI scores range 0-100). This improvement was sustained at 52 weeks, with 7.4-point greater improvement. There was no difference in 3- and 52-week pain scores between groups. Adverse events were more common in the prednisone group, with 49.2% of participants experiencing 1 or more adverse event vs 23.9% in the placebo group.

oswestry Disability index and pain figure.png

Bottomline: Though these results are hard to generalize to the ED population (primary care population, all patients had an MRI), the takeaway from this article is that for those patients that have acute radicular back pain that is likely from a herniated disc, a course of prednisone could offer modest improvement in function, though it will not improve pain and has increased rates of adverse events.

Summary:

Review of these articles solidifies one certainty: you can’t make back pain go away with a pill. Specifically, from this journal club, we learned:

Acetaminophen does not accelerate recovery time.
Adding cyclobenzaprine or oxycodone to naproxen does not improve functional outcomes or provide better pain relief.
Though corticosteroids do not improve pain, they offer modest improvements in functional outcomes but with increased adverse events.

The takeaway message from our discussion was that the cornerstone of back pain management in the emergency department should not be medication, but expectation setting and patient counseling.