Pharmacists should take notice of new back pain guidelines
Wednesday, August 30, 2017
Pharmacists — particularly those working on the front lines of community pharmacy — may want to think about the latest guidelines for treating lower back pain (LBP). These guidelines were developed by the American College of Physicians (ACP) and published in the most recent edition of the Journal of the American Medical Association (JAMA).
While specifically focused on helping physicians guide their patients to optimal treatment, other healthcare professionals should consider these recommendations and incorporate them, as needed, into their counseling.
Familiarity with these guidelines might be especially valuable for pharmacists who sometimes see patients suffering from lower back pain before they ever see their doctor. According to research, about 60 percent of patients today will self-treat prior to seeking the advice of a medical professional.
And that isn’t necessarily a bad thing. Many conditions are adequately treated at home with available OTC or nonpharmacological approaches. In fact, the authors of the guidelines specifically state that "nonevidence-based management of LBP is associated with medical overuse and high healthcare expenditures."
Treating LBP is a high priority for many people. Nearly 30 percent of American adults over 18 years of age admit to having some type of lower back pain in the previous three months. Research suggests that LBP is actually the leading cause of disability around the world.
The expense of this condition reflects how widespread it is. In the U.S., treating back pain costs us about $50 billion per year. Thus, these ACP recommendations are timely and valuable.
The guidelines group patients with LBP into three groups: acute (0-4 weeks), subacute (4-12 weeks) and chronic (>12 weeks).
For the purpose of recommendations, the advice for acute and subacute LBP is the same. Both nonpharmacologic and pharmacologic (Rx or OTC) approaches received equally strong recommendations. At the same time, such approaches are admittedly (according to the studies reviewed) not dramatically better than placebo in some cases.
The nonpharmacologic recommendations for treating acute or subacute (less than 12 weeks total) LBP include things like applying superficial heat (i.e. a heating pad, hot water bottle), massage therapy, acupuncture or spinal manipulation (chiropractic therapy). There was no specific advice given suggesting that one of these approaches was better than another.
As pharmacists we recognize the potential for drug side effects and interactions, and as such leading patients toward a nonpharmacologic approach may be the right advice. This could be especially true for patients with a history of GI disease or have concomitant drug therapy for which NSAIDs would be inappropriate.
The pharmacologic recommendations that could be offered to patients who are inclined that way included NSAIDs and muscle relaxants. For pharmacists counseling such patients who want OTC options, we can therefore recommend (to the appropriate patient) things like ibuprofen or naproxen. A visit to their family physician or even an urgent medical clinic might additionally provide a patient with a prescription muscle relaxant like cyclobenzaprine or baclofen.
When it comes to treating chronic (>12 weeks) LBP, the recommendations lean more strongly to trying nonpharmacologic approaches first. Then, if this fails, the patient should consider NSAIDs (first line), followed by tramadol or duloxetine (second line). Finally, there was a reasonable consensus that doctors should prescribe "opioids only when the aforementioned treatments have failed and after consideration of their risks and benefits."
These recommendations are not provided to deter patients from seeking medical advice for treating LBP. Rather, they exist to help direct practitioners make evidence-based decisions for treating LBP when other causes have been ruled out.
Pharmacists can help support these recommendations by educating the public and directing patients to the appropriate level of care.
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