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

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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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^1,2Darren M. Roffey PhD; ¹Simon Dagenais DC, PhD, MSc; ³Ted Findlay DO, CCFP; ^4,5Travis E. Marion MD, MSc; ⁶Greg McIntosh MSc; ^1,2,4,5Eugene K. Wai MD, MSc, FRCSC

¹University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, ²Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,

³Department of Family Medicine, University of Calgary, Calgary, AB, ⁴Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, ⁵Department of Surgery, Faculty of Medicine, University of Ottawa, ON, ⁶CBI Health Group, Toronto, ON,

Abstract

Obesity and low back pain are equally complex medical conditions with multi-factorial etiologies. Their clinical practice guidelines both include recommendations for screening and examination that can be easily implemented. There is sufficient information to compile a framework for the primary care provider, partnering with the patient and appropriate specialists, to manage obesity and low back pain in a structured fashion. Weight loss and exercise are paramount and should be recommended as the first options. Cognitive behavioural therapy, pharmacological treatment and bariatric surgery may then be implemented sequentially depending upon the effectiveness of the initial interventions.

Key Words: Obesity, low back pain, exercise, nutrition, cognitive behavioural therapy, bariatric surgery, weight loss, pharmacological, evidence-based guideline.