How to Assess and Manage Acute and Chronic Low Back Pain

Using a multimodal approach could be a better method for managing acute or chronic back pain than prescribing opioids for a patient, especially if that patient will require lifelong treatment. 

Unlike acute low back pain, chronic low back pain will typically last for more than 3 months. As for affecting the workforce, chronic low back pain is the most common cause of disability in people younger than 45 years, said Russell Bell, MD.¹ It is also one of the top reasons why individuals visit a primary care physician.¹

Back pain is the most expensive benign medical condition in United States, reports Dr. Bell said.¹ Nearly 19% of all workers’ compensation claims are related to back pain, and 2% of all US workers sustain back injuries each year.¹

Individuals at risk for back pain have not been clearly identified in the past. Gender, race or ethnicity, and genetics are not considered factors that contribute to back pain. However, some studies have shown that extreme height, extreme weight, and cigarette smoking may contribute to signs of back pain. 

Typical low back pain generators include muscle (often relieved by trigger point injections), bone (lumbar facet joint and sacroiliac joint) and articulations, nerve, ligament, and disc. 

One common misconception about back pain is that acute back pain will turn into chronic back pain, but that is not always the case. 

“On average, acute low back pain will resolve with time, typically within a 6-week period,” said Peter Pryzbylkowski, MD. “It is important for front-line providers to classify acute low back pain into low axial vs radicular as the treatment paradigm is distinct for each.” 

Another misconception with chronic low back pain is that opioid treatment is an effective method for the management of the disease process. 

“In fact, even patients with chronic back pain can gain benefit from interventional procedures, appropriate physical therapy modalities, and appropriate medication selection. The treatment goal for patients with chronic low back pain is not curative but rather to restore functionality.”

Opioid treatment does have its place, however. That being said, there are still a variety of precautions clinicians should take before prescribing painkillers to patients, Dr. Pryzbylkowski said.

“While opioid medications can help with back pain, especially an acute episode of back pain, these medications play a lesser role in chronic back pain,” he said. “Physicians should be aware of the potential for adverse reactions from opioids—sedation, respiratory depression, nausea, mental status changes—as well as risk of addiction or misuse.”

There are potential adverse effects to consider when prescribing opioids for long-term pain, which is why clinicians do not typically prescribe them to this patient group. “There is minimal evidence that long-term opioid use for chronic back pain improves overall pain or function,” he said. “Opioids should be prescribed with caution and used for short-term, finite periods of time.”

Alternative medications used for both acute and chronic low back pain fall into several categories: muscle relaxants, neuropathic agents, and anti-inflammatory agents. Other treatments include physical therapy, appropriate interventional pain procedures, acupuncture, yoga, and cognitive behavior modalities, Dr. Pryzbylkowski noted. 

“It is important to treat chronic low back as a chronic medical condition that will require lifelong treatment,” he said. 

Reference

1. National Institute of Health. Low back pain fact sheet: National Institute of Neurological Disorders and Stroke (NINDS). http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm. Updated August 3, 2015. Accessed September 2, 2015.