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The ACP guidelines suggest using medications when back pain is severe enough to cause functional impairment. Acetaminophen is at the top of that list, but a 2014 study of acetaminophen for low back pain, published in Lancet, found acetaminophen no better than a placebo when it comes to recovery time. The study researchers randomly assigned patients to receive regular doses of acetaminophen three times per day, acetaminophen as needed for pain relief, or a placebo for four weeks. More than 500 patients were analyzed in each group, and the study showed no difference in recovery time between any of the groups. 3

Other medications recommended in the ACP guidelines include NSAIDs, muscle relaxants, antidepressants, and opioids. “As a first choice of medication, I would go with a short course of an NSAID on a daily basis, as opposed to as needed. Some evidence suggests that naproxen is best because it is has less risk for GI, renal, or hepatic toxicity,” Mayer said.

Other medications on the list may be effective for some patients. Although antidepressants are frequently used, a recent review of studies, found that their benefit is unproven. 1 “Opioids are probably most effective for masking pain, but the dose can quickly get out of control, making both the doctor and the patient uncomfortable,” Mayer said.

Alternative Therapy

The ACP guidelines suggest considering nonpharmacologic therapy for back pain lasting longer than four weeks. Included among these are spinal manipulation, massage, acupuncture, progressive relaxation, and cognitive behavioral therapy (CBT). According to the National Institute of Neurological Disorders and Stroke, acupuncture may be moderately effective, and spinal manipulation (chiropractic care) has been shown to provide a small to moderate, short-term benefit.1

“Our long-term best results come from exercise and CBT. Alternative therapies like massage, chiropractic, and acupuncture may be as effective as medications and safer. But trials show that they are a short-term fix. Primary care doctors can do some CBT and learn some relaxation techniques. In really tough cases, you can refer to a mental health professional or a pain management clinic,” said Deyo.