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Pharmacological Options in the Management of Low Back Pain

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

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Dr. Ted Findlay, DO, CCFP, Clinical Assistant Professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada.

Abstract
Low back pain is one of the most common conditions for which patients seek medical attention. It can be managed with lifestyle modification, or less commonly medical and surgical intervention. Appropriate selection among various pharmacological options mandates an understanding of the underlying symptomatology and the over-riding treatment plan and objectives. The range of potential medications is substantial: over-the-counter analgesics include acetaminophen and non-steroidal anti-inflammatory drugs, muscle relaxants, and weak opioid combinations including codeine or tramadol. More potent versions of many of the same components are available on prescription, commonly employing stronger opioids either singly or in a combination analgesic. When the pain involves either chronic or neuropathic features, other classes of medications, including anti-epileptic drugs and anti-depressants, may be appropriate.
Key Words: low back pain, acute, chronic, neuropathic pain, nociceptive pain, medications.

Introduction
Low back pain (LBP) has the potential to cause substantial pain, disability, and a decrease in health-related quality of life. It remains one of the most common reasons for which patients seek medical attention.1,2 Most often, the clinical course is self-limited, improving with appropriate activity modification, simple counter-irritants such as heat or ice, directed pain-limiting physical treatment and short-term pharmacological intervention. The vast majority of patients present with mechanical low back pain and respond well to uncomplicated mechanical therapy. Only very rarely does back pain represent sinister pathologies requiring more focused intervention.3

While the options guiding management of acute low back pain can be straight-forward, addressing chronic back problems is more challenging and often necessitates a multidisciplinary approach with judicious pharmacotherapy as one component of the overall treatment plan.4 This review is intended to define the options and rationale for the use of common medications employed in the management of chronic low back pain.

Specifically, this review will address only medication classes that have a Health Canada indication for the treatment of back pain or are recognized in reputable existing clinical practice guidelines for off-label use.

Low Back Pain Case #1:

Barney is a 37 year old male patient who is infrequently seen in your family practice office. He presents today, clearly uncomfortable, complaining about low back pain that he has been suffering for two weeks after falling 12 feet from a ladder onto solid ground. He was taken by ambulance to the local emergency room; the discharge note states that his examination in the ER was limited due to pain. An X-ray showed an apparent compression fracture at T10. An MRI confirmed the fracture and also found a left-sided L5/S1 herniated disc. In your office, he also describes significant left leg pain. Your examination shows a loss of the left ankle reflex, mildly diminished plantar flexion strength and difficulty with attempting to toe walk on the left side. In the emergency room, he was prescribed Oxycodone 10 mg/Acetaminophen 325 mg (Oxycocet), and has been taking two tabs every 6 hours which has reduced his pain from 9/10 in the emergency room to 5/10 at present. He is seeking a prescription refill and potentially a more potent medication as he finds the analgesia inadequate.