Are NSAIDs Really Better Than Placebo for Chronic Low Back Pain?

A recent Cochrane review has shown that non-steroidal anti-inflammatory drugs (NSAIDs) were more effective than placebo regarding pain intensity and disability in chronic back pain but the magnitude of the effects was small.

NSAIDs are commonly used to treat low back pain especially in patients with acute back pain. Short-term NSAID use is also recommended for pain relief in patients with chronic back pain. A Cochrane review in 2008 showed a small but significant effect from NSAIDs vs. placebo in patients with chronic back pain.

For this updated review, researchers focused on patients with chronic low back pain to determine if NSAIDs were more effective than various comparator treatments for non-specific chronic low back pain and if so, which NSAID type was most effective. The team included single- and double-blinded, randomized controlled trials of NSAIDs that were used to treat chronic low back pain. A total of 13 trials were included in the review with 10 of the trials having a low risk of bias.

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Researchers found a “low” quality of evidence that NSAIDs were more effective than placebo regarding pain intensity, with a mean difference in score from baseline of -3.30 (95% CI: -5.33 to -1.27) on a 0 to 100 visual analogue scale (VAS) with a median follow-up of 56 days. There was also a “low” quality of evidence that NSAIDs were more effective than placebo regarding disability, with a mean difference from baseline of -0.85 (95% CI: -1.3 to -0.4) with a median follow-up of 84 days.

Two studies that compared different non-selective NSAIDs—ibuprofen vs. diclofenac and piroxicam vs. indomethacin—did not show any differences though both had small sample sizes. Another trial showed no differences in pain intensity between selective vs. non-selective NSAIDs. Further, another trial compared diflunisal vs. paracetamol and no differences were seen in improvement from baseline in pain intensity score. An improvement in global improvement was seen with celecoxib vs. tramadol in one study.

Out of the 13 total trials included in the review, 6 demonstrated NSAIDs were more effective than placebo on pain intensity. Study authors noted that the level of evidence was low and the magnitude of effects small for these findings. The differences in effect between NSAIDs and placebo were even less when the review only included trials with low risk of bias. In addition, no differences in efficacy were found between the various types of NSAIDs, including selective vs. non-selective NSAIDs.

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