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Chronic low-back pain
DAVID CLINE
n Agents
n Opioids
n NSAIDs
n Muscle relaxants
n Cyclic antidepressants
n Evidence
Therapy for low-back pain (LBP) that is chronic (CLBP) differs in many
respects from the approach to acute back pain. In the nonpharmacologic
arena, for instance, there is much better evidence supporting exercise for
CLBP than there is for its use in acute back disorders. 1 This chapter focuses
on the pharmacological approaches to CLBP (defined as back pain lasting for
at least three months). For optimal application of the evidence addressing
drug therapy of CLBP, acute care providers should adhere to the general
approach for patients with chronic pain as outlined in other chapters. One of
the most important tenets is that any therapy prescribed for CLBP should be
part of a longitudinal care plan that includes appropriate follow-up and
monitoring for both efficacy and safety.
In CLBP, one of the major issues for the ED caregiver is use of opioids. The
proportion of patients with CLBP who are prescribed opioids ranges widely –
from 3% to 66% depending on the setting. 2 As outlined in other chapters
in this text, there is a potential role for opioids in acute flares of spine pain
(e.g. spinal spondylitic syndromes), but the use of opioids for other neck and
back conditions (e.g. radicular syndromes) is not supported by available
evidence.
Meta-analysis overviewing 38 studies initially, with nine high-quality
investigations included in the final calculations, found only a very limited
role for opioids in CLBP. 2 If opioids do have a role in this condition, it is
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