Louise Chang, MD
About one in four Americans has experienced low back pain within the past three months, making it one of the most common types of pain and the most frequent cause of disability in adults under 45.
Although pain medication can’t actually heal a back injury, it can relieve pain and open a window for other treatments -- such as physical therapy -- to have a chance to work.
There are multiple categories and types of medications for back pain; depending on how severe your symptoms are, how long you’ve had them, where they’re located, and what side effects you can tolerate.
The first medication of choice for most people with back pain is an over-the-counter, nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin) or naproxen (Aleve), says Jae Jung, MD, assistant professor in the department of orthopaedics at the David Geffen School of Medicine at the University of California-Los Angeles. “These are considered milder analgesics, and would be the first tier of treatment,” he says.
Tylenol (acetaminophen), while not a nonsteroidal anti-inflammatory drug, is also a common over-the-counter pain reliever used to treat back pain.
There are also prescription-only NSAIDs, such as celecoxib (Celebrex), diclofenac (Voltaren), meloxicam (Mobic), and nabumetone (Relafen).
Although these medications are on the milder side of the pain relief spectrum, they still come with side effects -- especially if you take them at higher doses for a long time. NSAID side effects can include gastrointestinal problems, ulcers, and kidney damage, while acetaminophen can affect the liver.
Jung says he's had patients tell him they've been taking 6 to 8 ibuprofen daily for six months. “That can be a problem," he says. "In the pain world, anything more than three months is chronic pain. So, if you’ve been taking an NSAID or acetaminophen to manage back pain for three months or more, you should see a doctor to at least find out if you’re taking the right medication at the right dose.”
You can also get your anti-inflammatory medication in the form of a topical cream that can be applied directly to the back. While these technically have the potential for the same side effects as the oral medications, the risk is not the same, because they're not affecting your whole body, says Jung.
Other topical treatments that can be used for pain contain ingredients such as capsaicin, camphor, menthol, and eucalyptus oil.
If over-the-counter pain relievers or prescription NSAIDs are not relieving your back pain, your doctor may suggest adding a muscle relaxant. These medications include:
These are many brand names in the same category, says Jung. They help relieve the muscle spasms that are causing your back pain.
Muscle relaxants may be particularly useful for acute injuries (such as straining your back playing basketball), says Jung. For example, carisoprodol (Soma) significantly reduced back pain and improved function after three days of treatment, according to the results of clinical trials presented at the American Academy of Pain Medicine's 2010 annual meeting.
Most of these drugs have similar side effects, with drowsiness being the most common. "They can be quite sedating," Jung says. "If you’ve never tried them before, don’t operate heavy machinery or drive until you know how they affect you. I usually start patients on these at night to see how they react."
For some patients, NSAIDs and muscle relaxants are not enough. People with long-lasting, chronic back pain, particularly after multiple surgeries, are sometimes prescribed opioid or narcotic medications. In fact, one study showed that as many as 70% of back pain patients receive opioids, which some experts suggest is probably too many.
These drugs act on pain receptors in the brain and nerve cells to alleviate pain. Jung says there are milder, shorter-acting versions, such as Vicodin (acetaminophen and hydrocodone) and Tylenol with codeine -- which is what most people begin with -- as well as stronger drugs like morphine.
Their most common side effects include:
There’s also a step between NSAIDs and muscle relaxants and a more classic opioid or narcotic drugs. Tramadol (brand names Rybix, Ryzolt or Ultram) also acts on the opioid receptors in the brain, but it is weaker compared to morphine or hydrocodone, so it’s not regulated like a controlled substance, says Jung. “So it’s a milder approach and patients who don’t want to move on to narcotics often think that’s a good option, he says.
In some cases, however, narcotics can be necessary. “I’ve seen patients who’ve had multiple back surgeries and have been on morphine for 10 years, and that’s the only way they can mange their pain,” Jung says.
But caution is warranted. In fact, long-term opioid use may make back pain worse. “There’s data coming out now that being on these medications for long periods, at high enough doses, can change the nervous system so that you actually perceive pain more. I try not to encourage chronic use, although some people just can’t come off those medications enough to function.”
Like anti-inflammatory drugs, corticosteroids can also relieve inflammation and alleviate back pain. They can be taken either orally or via injection into your back.
“Steroids are the most powerful anti-inflammatory that we have in our arsenal,” says Jung. A short course of oral steroids might even be tried before opioids when someone has had serious back pain for a few weeks, without relief from NSAIDs and muscle relaxants. This could calm inflammation down before it becomes chronic.
To achieve this goal, Jung says, he frequently prescribes a dose pack of Medrol (methylprednisolone). A patient takes 24 mg the first day, then decreases the dose by 4 mg every day for a total of five or six days. "This can short-circuit the pain cycle,” says Jung.
Corticosteroid medication can also be injected into the space around the nerve roots of the spine or into the facet joints, which are spinal joints that can develop arthritis. “This delivers a powerful medication directly to the source of the pain, as locally as possible, and minimizes the side effects of taking a systemic pill,” Jung says.
How safe are steroid injections? “The consensus in the medical community is that it’s safe to get about three injections per year,” Jung says. Side effects of excessive steroid use include bone loss, weight gain, and damage to the body’s ability to process blood sugar. “I’ll see patients who will tell me they’ve done an injection every other month. That’s too much, in my opinion.”
Why would you take an antidepressant or an anti-seizure drug for your back pain? Because they can be very effective for a specific type of pain -- the kind induced by nerve problems.
“Certain antidepressants, like Cymbalta [duloxetine], and anti-seizure medications, like Lyrica [pregabalin] or Neurontin [gabapentin] have been shown to be beneficial for nerve symptoms,” explains Jung. Another class of antidepressants, known as tricyclics -- including amitriptyline (Elavil) and nortriptyline (Pamelor) -- also may be prescribed to manage chronic back pain. “So if you have a pinched nerve in the back, with pain that radiates down your leg, one of these medications can be very effective to quiet the nerve irritation and relieve the burning pain, numbness and tingling that are often involved.”
Although they vary somewhat, the antidepressants and anti-seizure medications used to treat back pain have a fairly similar lists of side effects. The more common side effects of these medications include:
Call your doctor if you experience any of these more serious side effects:
No matter which medications you take for your back pain, Jung says that they should not be your only mode of relief.
“If a patient has only had pain for a few days, I don’t want to blast them with chemicals -- they may just recover on their own. With pain that’s lasted three months or more, we try to use more than one medication to alleviate their pain,” he says. “We have to get patients involved in their care. Physical therapy should be used early on. Teaching the patient to exercise, in combination with your other therapies, is a lot better than just giving them pills to take.”
SOURCES:National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.Jae Jung, MD, assistant professor of orthopaedics, David Geffen School of Medicine at UCLA, Los Angeles.Simon S. Results of clinical trials presented to the American Academy of Pain Medicine, February 2010, San Antonio.Starz, T. Duration of narcotic usage by patients with low back pain. American College of Rheumatology 2004 meeting; San Antonio; Oct. 16-21, 2004; presentation 1863.University of Maryland Medical Center: "Low Back Pain."Medscape Today: "Opioid use more common than expected in lower-back pain patients."
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