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Doctors and Patients Advised to Take a Cautious Approach to Use of Analgesics for Low Back Pain, a New Study in the BMJ has concluded

  • Researchers at Neuroscience Research Australia (NeuRA), UNSW and Brunel University London have conducted the most comprehensive evaluation of the safety and efficacy of analgesic medicines for the treatment of acute low back pain.
  • Published in the BMJ, the study found that despite the ongoing popularity of medicines for low back pain treatment, considerable uncertainty remains around their overall impact on pain relief and safety.
  • Clinicians should take a cautious approach to the use of analgesic medicines and make treatment decisions in consultation with patients to address their specific cause of pain, the severity of symptoms and individual preferences.

Back pain continues to be the number one cause of disability worldwide, costing the Australian health system an estimated $4.8 billion every year. According to the Royal College of General Practitioners, musculoskeletal concerns are the second-most common reason for GP visits, after psychological concerns.

The vast majority of people who visit their doctor for acute non-specific low back pain, which is defined as low back pain that lasts fewer than six weeks, are prescribed an analgesic to manage their symptoms (61 percent of patients in Australia and 48 percent in the UK).

A new study conducted by researchers at Neuroscience Research Australia (NeuRA), UNSW Sydney and Brunel University London, published in the BMJ, has looked at 69 different medicines or combinations of analgesic medicines including non-steroidal anti-inflammatory drugs, paracetamol, opioids, anticonvulsants, antidepressants, skeletal muscle relaxants and corticosteroids to compare their effectiveness for adults with acute low back pain. Using meta-analysis, this is the most comprehensive evaluation of its kind to inform clinical decision-making.

The research revealed that despite the ongoing popularity of medicines to treat low back pain, considerable uncertainty remains around their overall impact on pain relief and safety when compared with a placebo. It was also found that some analgesic medicines could increase the risk of adverse events or side effects, which can include nausea, dizziness and drowsiness.

Professor James McAuley, Director for the Centre for Pain IMPACT at NeuRA and UNSW’s School of Health Sciences, said the study recognises the complexities in acute low back pain and treatment. “Despite over 60 years of research, we are still uncertain whether any analgesic medicine provides meaningful pain relief for people with low back pain.  We recommend that doctors and patients take a cautious approach to managing acute low back pain with analgesic medicines until higher quality trials of head-to-head comparisons are available.”

A comprehensive analysis

The study analysed 98 randomised controlled trials (involving 15,134 participants in total) published between 1964 and 2021 of adults with acute non-specific low back pain. These included trials that compared an analgesic medicine directly with another analgesic medicine, a placebo, or no treatment at all across a total of 69 different medicines or combinations.

Dr Michael Wewege, a research fellow at NeuRA and a lead author of the study said the research team looked at nearly 60 years of research involving over 15,000 participants.

“Although previous reviews have evaluated analgesic medicines compared with a placebo, very few have compared the effectiveness of these medicines as a whole. Our rigorous method ensured as much data as possible could be taken into account,” said Dr Wewege.

Dr Neil O’Connell of Brunel University London said, “it is quite shocking that the evidence base for the effectiveness and safety of some of the most commonly used drugs for such a common condition is so fragile and incomplete”. Our findings clearly indicate the need for larger, rigorous trials that can genuinely inform better clinical decisions.

Implications for clinicians

Low back pain is one of the main reasons people visit their GP. Clinical practice guidelines recommend advice, reassurance, encouragement of physical activity, and self-management of symptoms as first-line care, whilst analgesic medicines and physical therapy are second-line interventions.

“Patients should be reassured that acute low back pain is very likely to resolve by itself over time, regardless of whether or not they take medicines,” said Professor McAuley. “If analgesic medicines are required, our study shows that clinicians should take a cautious approach and importantly, make this decision in consultation with patients on their specific pain experience, the severity of symptoms and their individual needs and preferences.”

About NeuRA

Neuroscience Research Australia (NeuRA) is an independent, not-for-profit research institute based in Sydney aiming to prevent, treat and cure brain and nervous system diseases, disorders and injuries through medical research.

To learn more about NeuRA:

Key facts: About low back pain

  • Over 90 percent of all low back pain problems cannot be attributed to a serious cause (such as fracture, cancer, infection) and are termed as non-specific low back pain.
  • Low back pain is classified as acute (less than six weeks in duration) and chronic (lasting three months or longer).
  • It’s now widely accepted that changes in the nervous system including the brain, play an important role in pain persisting long after tissues have healed.
  • Pain medication such as analgesics are often prescribed for acute low back pain, but they can have side effects and do not address the root cause of the pain.

Link to study:

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