GPs should be cautious about painkillers in treating lower back pain until more evidence is collected on their use, say researchers.
A team of UK and Australian scientists reviewed the data on 69 different analgesic medicines or drug combinations and found little evidence on the comparative effectiveness in acute low back pain.
In all they studied 98 randomised controlled trials of more than 15,000 people done over 60 years looking at medicines that included non-steroidal anti-inflammatory drugs, paracetamol, opioids, anticonvulsants, antidepressants, skeletal muscle relaxants and corticosteroids.
It included trials that compared an analgesic medicine directly with another analgesic medicine, a placebo, or no treatment at all.
Yet there remains uncertainty on the best options because there have been so few head-to-head comparisons, they concluded in a study in the BMJ.
They also concluded there was moderate to low confidence around the evidence for adverse events.
‘It is quite shocking that the evidence base for the effectiveness and safety of some of the most commonly used drugs for such a common condition is so fragile and incomplete,’ said co-author Dr Neil O’Connell from Brunel University London.
‘For people with acute low back pain, it is important to recognise that the evidence for these medications is really uncertain. As a result, it would be sensible to approach their use cautiously.’
For clinicians this also means taking a cautious approach and making decisions about analgesics in consultation with patients based on their individual needs and preferences, he added.
‘It would seem sensible to only use analgesics at the lowest effective dose for the shortest period of time necessary and not to persist with their use if they are not found to be offering benefit.’
In its 2016 guidelines if drastically curbed drug options for treating the condition, advising GPs instead to focus on exercise and psychological therapies.
It does not advise using paracetamol alone and recommends using an over-the-counter NSAID such as ibuprofen first-line, if there are no contraindications, at the lowest effective dose for the shortest possible time.
Where an NSAID is contraindicated, not tolerated, or ineffective, NICE say consider the short-term use of codeine with or without paracetamol.
But the use of benzodiazepines, opioids, or gabapentinoids are not advised.