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In people with acute or chronic low back pain that has not responded to non-drug treatments, medications can provide small to moderate improvement in pain and functioning

Chou R, Deyo R, Friedly J, et al. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166:480-92.

Review question

In people with low back pain, do drug treatments improve pain and functioning?


Low back pain is very common and may be experienced as dull or sharp and can be specific to one area or over a larger area, usually between the ribs and legs. It may also cause leg symptoms. There are many causes of low back pain, including injury or strain, aging, illness, fractures, and problems existing since birth.

Low back pain often lasts less than 4 weeks (acute), though it may be subacute (4 to 12 weeks) or chronic (lasting longer than 12 weeks).

Treatment of low back pain is difficult and often not very effective at improving pain or functioning.

How the review was done

The researchers did a systematic review based on studies available up to November 2016.

They found more than 70 randomized controlled trials.

The key features of the studies were:

  • participants were adults who had acute, subacute, or chronic low back pain not caused by cancer, neurologic deficits, infection, fracture, or trauma;
  • treatments were drugs, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, tramadol, tapentadol, antidepressants, skeletal muscle relaxants, benzodiazepines, antidepressants, corticosteroids, and antiseizure medications; and
  • treatments were compared with placebo, no treatment, or other treatments.

What the researchers found

Based on the results of this review, the American College of Physicians made 1 strong recommendation (the benefits of treatment clearly outweigh the risk or burden of treatment) and 1 weak recommendation (the benefits of treatment are finely balanced with the risk or burden of treatment).

In adults with acute or subacute low back pain who want drug treatment, use NSAIDs or skeletal muscle relaxants for a small improvement (strong recommendation).

In adults with chronic back pain that has not responded to non-drug treatment, first use NSAIDs or use tramadol or duloxetine as second choices for small to moderate improvement. If NSAIDs, tramadol, and duloxetine are not effective, and if the potential benefits outweigh the risks for the individual patient, opioids may be considered for a small improvement (weak recommendation).


In people with acute and subacute low back pain, NSAIDs or skeletal muscle relaxants can provide small improvements in pain and functioning. For chronic low back pain, NSAIDs, tramadol or duloxetine, or opioids may provide small to moderate improvement.

Recommendations from the American College of Physicians for drug treatment in adults with low back pain



Evidence (effect size)

Low back pain for up to 12 weeks (acute or subacute)

(Strong recommendation*)

For people who want drug treatment, use NSAIDs or skeletal muscle relaxants.

NSAIDs improved pain and function (small).

Skeletal muscle relaxants improved pain (small).

Low back pain for more than 12 weeks (chronic)

(Weak recommendation†)

For chronic low back pain that has not adequately responded to non-drug treatment, consider drug treatment with NSAIDs or tramadol or duloxetine.

If NSAIDs or tramadol or duloxetine have failed, and if the potential benefits outweigh the risks for the individual person, opioids may be considered.

NSAIDS improved pain (small to moderate).

Tramadol improved pain (moderate) and function (small).

Duloxetine improved pain and function (small).

Strong opioids (tapentadol, morphine, hydromorphone, oxymorphone) reduced pain and function short-term (small).

*The benefits of treatment clearly outweigh the risk or burden of treatment.

†The benefits of treatment are finely balanced with the risk or burden of treatment.


Related Topics


A harmless, inactive, and simulated treatment.
Randomized controlled trials
Studies where people are assigned to one of the treatments purely by chance.
Systematic review
A comprehensive evaluation of the available research evidence on a particular topic.

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