Alexandra Stratton, MD, MSc, FRCSC,1
Dr. Darren Roffey, PhD,2
Dr. Erica Stone, MD, FRCPC,3
Mohamed M. El Koussy, BSc,4
Dr. Eugene Wai, MD,5

1Orthopaedic Spinal Surgeon, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
2University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
3Anesthesiology, PGY 6 Pain Medicine, The Ottawa Hospital, Ottawa, ON.
4Clinical Research Assistant, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
5is an orthopedic surgeon who specializes in the care of adult spinal disorders. He is also an Associate Professor in the Department of Surgery at the University of Ottawa. In addition he is the Research Chair for the Canadian Spine Society. Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.


Abstract: Opioids are drugs with pain relieving properties; however, there is evidence that opioids are no more effective than non-opioid medications in treating low back pain (LBP), and opioid use results in higher adverse events and worse surgical outcomes. First line treatment should emphasize non-pharmacological modalities including education, self-care strategies, and physical rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered an appropriate introduction into pharmacological treatment when deemed necessary. Non-opioid adjunct medications can be considered for specific features related to LBP such as neuropathic leg pain. Primary care providers should exhaust first and second line treatments before considering low-dose opioids, and only then in consultation with evidence-based clinical practice guidelines.
Key Words: Pharmacological; low back pain; radiculopathy; opioids; analgesia.

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1. First line treatment for low back and radicular leg pain is non-pharmacological.
2. Second line treatment includes NSAIDs (with or without proton pump inhibitor), and muscle relaxants (3 weeks maximum), gabapentinoids and antidepressants.
3. Exhausting non-opioid analgesics includes trialing different medications within the same class and at different doses since many of these medications have wide therapeutic dose ranges.
A "start low and go slow" approach is recommended for initiating pharmacological treatments for low back and radicular leg pain, especially when using neuroleptics and antidepressants.
When treating low back pain with neuropathic leg pain, patients who fail a trial of pregabalin may tolerate gabapentin, or vice versa.
Antidepressants have a role in managing low back pain, particularly chronic, even in the absence of mood disorder.
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