Patient-centred, pragmatic prescribing for acute non-specific low back pain

Guidelines recommend that medicines, despite their underwhelming efficacy, can play a supporting role in the management of acute non-specific low back pain.^4,12,13

This involves ensuring that first-line non-pharmacological therapy has been implemented before considering medicines. And if medicines are required, the aim of taking them should be to reduce pain, rather than to completely stop it, so that the patient can maintain function and stay active.⁴

‘I say to patients to just take your medicines when you know it’s hurting or when you know you’re going to do some activity that’s going to hurt. That’s a much more appropriate way of taking medicines rather than routinely taking them’, says Dr McCallum.

Geoff, a 64-year-old retired management consultant from Perth, says he finds his GP’s advice on medicines helpful when he has an episode of acute low back pain.

‘There’s an acknowledgement that there’s nothing wrong with taking them, but it needs to be controlled, which means short doses and according to need, particularly to help me do activities that I like such as play golf. It helps to keep my pain manageable, though it hasn’t helped my golf score,’ he says with a laugh.

The pinnacle of patient-centred care is shared decision making.¹⁵ It involves familiarising patients with the treatment options available, including their advantages and disadvantages, and helping them to explore their preferences to inform their final decisions.¹⁶

The philosophy behind shared decision making is that patients will have more autonomy in decisions about their personal health if the doctor-patient relationship shifts from paternalistic to a more equal relationship.¹⁷

But while it’s based on each patient’s right to make decisions about their own health, shared decision making is a continuum. The amount of information provided and responsibility for decision making can vary according to the context in which the decision is occurring.¹⁸

With medicines for acute non-specific low back pain, for example, less detailed discussion is required when choosing between paracetamol or an NSAID if the medicine is going to be taken short term by a low-risk patient, than is needed if an opioid is being considered.

Including a physical examination as part of the consultation can be reassuring for patients, even when no specific findings are made, and also centres the patient, says Dr McCallum.

‘I recall a patient, where I had finished taking his history and I said to him “right, now let’s look at you”. He said, “you’re the first person to do that in two years.” I thought, “oh my god” and it really stuck with me’.

‘Patients often come to see you because the pain is incredible, they’ve not slept for three or four nights, they’re worried, thinking “has a disc slipped or something like that?” It’s reassurance about what it’s not, rather than what it is, that they want,’ he says.

Being pragmatic helps to put the evidence and guideline recommendations on medicines into practice in a realistic manner, says Dr McCallum.

‘The reality is that patients with acute non-specific low back pain are usually already taking an over-the-counter medicine on their own initiative when they first see a GP,’ he says.

‘The first thing I ask the patient is “are these medicines helping your pain?” If they are, sure there are studies that say paracetamol doesn’t help with low back pain. But if a patient says it helps, then crack on, continue taking it, I’m not going to tell them that they’re wrong.’

Of course, at the same time, GPs need to ensure that patients aren’t causing themselves harm, says Dr McCallum. ‘So the second thing I ask is “are they taking too much paracetamol or ibuprofen?” If you’ve got a 50-year-old patient, for example, and he’s taking 400 mg of ibuprofen three times a day for two weeks and starting to get a bit of stomach pain, then I say, “you have to take it less, have some days off”.’

It’s also essential to check for contraindications. ‘If you’ve got someone with acute non-specific low back pain, whatever you do or don’t do, it’s probably going to get significantly better in a period of weeks,’ says Dr McCallum.

‘Exposing a patient to a risk of a GI bleed or a stroke when taking an NSAID is not acceptable. You can just keep it simple and instead prescribe them paracetamol or recommend they trial not taking a medicine at all,’ he says.

In 2015 the first studies reported that medicines for acute non-specific low back pain have little or no effect.^8-11 Before these findings, guidelines endorsed the World Health Organisation (WHO) analgesic ladder.³

However, if the patient answers ‘no’ to the question ‘are these medicines helping your pain?’, Dr McCallum’s advice is more like the children’s game of Snakes and Ladders than like climbing the analgesic ladder.

‘The analgesic ladder had you taking paracetamol and building on it with second- and third-line medicines. But because we know from the evidence that these medicines aren’t very good, if a medicine is not helping, there’s no need to continue taking it,’ says Dr McCallum. 

‘My advice to this patient is to stop taking it and see if the pain gets worse. If it doesn’t, then clearly it wasn’t helping in the first place.’ In other words, rather than going further up the ladder, go back down the snake.

The 2017 Therapeutic Guidelines (TG) for low back pain recommend that if a medicine is required, an oral NSAID should be trialled first, after ensuring the potential benefits have been weighed against potential harm.⁴

If NSAIDs are contraindicated or not tolerated, the guidelines state that even though paracetamol is ineffective, individual patients may experience a benefit and, because of its favourable safety profile, a trial of paracetamol may be considered.⁴

But how can an ineffective medicine have a benefit? Dr McCallum says one explanation is that efficacy statistics are based on population data which includes those who respond well and those who don’t. A small improvement in pain may not be statistically significant, but may be appreciated by patients, particularly those with intolerable pain.

‘Statistics that come from a population should be treated in a different context to the response a patient has to a treatment. The most important factor is the patient in front of you and not the population averages,’ he says. Dr McCallum says another possible explanation for the benefit is that the evidence shows paracetamol has no benefit compared to placebo. It’s possible that a patient with acute non-specific low back pain may experience a benefit that is due to the placebo effect.

The 2017 TG for low back pain also recommend that opioids may be considered for patients with severe pain that is not adequately relieved with other measures and is interfering with their ability to function.¹⁹

Whichever medicine is prescribed, it should be at the lowest effective dose for the shortest time. In addition, clear stopping goals should be established with the patient and timely review is essential to assess individual benefits and harm of the medicine, as well as progress towards satisfactory recovery.^7,13,19

When assessing recovery, however, the limited effectiveness of medicines and the impact of simple non-pharmacological treatments as part of first-line therapy should be kept in mind and given due acknowledgement. This can help ensure that expectations of medicines are not too high.