05/04/2023
Which medication is best for back pain?
When we get back pain, many peoples first reaction is to head to the bathroom cabinet and take some medication. But what is the best medication to take? Ibuprofen? Paracetamol? muscle relaxants, anticonvulsants? The list is seemingly endless. Even if we don’t have medication in our bathroom cabinet, many of us will have something prescribed by our GP [1].
There are so many options about what to take that GPs need guidance about what to prescribe, and this needs to be based on high quality research. One such piece of research was published just the other week in the BMJ [2]. The paper was a meta-analysis, drawing together the data from 98 different pieces of research, based on over 15000 patients. Statistically, it’s a very powerful study!
So, what did the study find? Which is the best medication for back pain? Unfortunately, the data did not find one medication to be any more effective than any other. Most of the medications have side effects too.
Why did such a powerful piece of research not find the answer? Personally, I feel it was because they were researching ‘acute non-specific low back pain’. The assumption is made that this is essentially one condition, with all the patients being homogenous (similar). My opinion is that this is simply not the case. Back pain is caused by lots of different conditions. It’s heterogenous. It might be caused by a kidney stone, rheumatoid arthritis, or may be mechanical. These different conditions may well respond to a medication, but they won’t all respond well the same one. The muscle spasm of a kidney stone may respond well to a muscle relaxant. The pain of rheumatoid arthritis may respond well to a strong anti-inflammatory drug. Mechanical back pain might be helped a little by a less powerful anti-inflammatory medication.
Of course, the authors of this recent paper cannot be criticised for not examining the patients. They were pulling together the data from different studies. The different medications being studied will have helped subgroups of patients within the overall patient group. In my opinion, a study that is seeking to find the single best treatment of a symptom that can be the result of a heterogenous mixture of conditions is unlikely to find a clear winner. All credit to the authors for trying, however!
So, what should back pain patients do in the meantime? The guidelines published by NICE [3] in 2016 suggest that keeping active is better than rest , that exercise is helpful, and that manual therapy should be considered. Now, where could you go for that?
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1. Ndlovu, M., et al., Pain medication management of musculoskeletal conditions at first presentation in primary care: analysis of routinely collected medical record data. BMC Musculoskelet Disord, 2014. 15: p. 418.
2. Wewege, M.A., et al., Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis. BMJ, 2023. 380: p. e072962.
3. (UK), N.G.C., Low Back Pain and Sciatica in Over 16s: Assessment and Management. 2016.
