Low back pain is one of the most common causes of doctor's visits in the United States -- about 80 percent of adults will experience low back pain at some point in their lives. Treatment for low back pain typically depends on whether the pain is acute or chronic. One of the most common treatments is medication, such as a nonsteroidal anti-inflammatory drug (NSAID). However, alternative pain management, such as yoga and massage, may also be beneficial for people with low back pain.
In fact, the American College of Physicians (ACP) recently released new guidelines recommending that patients try alternative pain management to treat their low back pain before turning to pharmacologic treatments. "We're seeing a fairly profound shift in the way pain is managed, especially acute pain, in this country," said Andrew Linn, MD, Director of Pain Management for Mercy Medical Group, a service of Dignity Health Medical Foundation. "[The ACP] want you to avoid using narcotic medications initially."
For patients with acute low back pain, the ACP recommends superficial heat, massage, acupuncture, or spinal manipulation. If the patient wants to use a pharmacologic treatment, the ACP recommends NSAIDs or muscle relaxants. However, acute low back pain typically resolves itself without the patient doing anything. "There is some evidence to show that heat in particular is more helpful than doing nothing," Dr. Linn said, "and there's increasing evidence that shows that spinal manipulation and maybe acupuncture are more beneficial than doing nothing."
Patients who have chronic low back pain should try exercise, acupuncture, mindfulness-based stress reduction, yoga, and tai chi, among other nonpharmacologic treatments. If those approaches don't work, then patients can try NSAIDs before moving on to opioid medications such as tramadol. The ACP recommends that clinicians only use opioids when other treatments have failed.
Part of the shift away from narcotics has to do with the opioid epidemic. According to the Department of Health and Human Services, on an average day, more than 650,000 opioid prescriptions are dispensed, and 78 people die from an opioid-related overdose. Using alternative pain management first can cut down on the number of opioids that are available for misuse.
The ACP previously recommended that clinicians use medications with proven benefits in conjunction with back care information and self-care to treat their patients' low back pain. Patients who didn't improve with self-care could then use nonpharmacologic treatments with proven benefits, such as spinal manipulation for acute pain, and exercise therapy or yoga for subacute or chronic pain.
Dr. Linn said he feels positive about the new recommendations and is in favor of trying alternative pain management first. However, he noted that it could be a difficult conversation to have with patients. "You have to have an honest conversation with your patients that, if you start narcotic medications, there's a risk that you could be taking it a year from now for the same thing even though it's not helping," he said. "So we really have to try other things that can be equally effective, potentially, but that require a little bit more effort."
Dr. Linn also said that yoga, stretching, and other alternative pain management options can provide long-term benefits such as a strong core and support muscles in the spine, which will hopefully reduce episodes of low back pain. Patients may find reassurance that their pain is generally short-lived and will get better with time. However, Dr. Linn said the important thing for patients to know is that there is "almost always another option" for treating low back pain.
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