How to manage

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CLINICAL FEATURE : A disease overview, with a focus on treatment

HTM

Low back pain

Acute low back pain is commonly encountered in community pharmacy, and can range from an ache to shooting pains or spasms. Jenny Gowan (teaching associate at Monash University, Melbourne and consultant pharmacist) discusses warning signs for urgent referral, medications, and the type of tests used in the investigation of low back pain. Rather than prolonged bed rest, current guidelines promote the need to keep active and use non-medical treatments, where possible
In New Zealand, low back pain has the highest incidence of
all work-related diseases, with the Accident Compensation
Corporation (ACC) spending more than $350 million annually on claims for lumbar spine injuries.1
Pain is the key symptom in most back problems. Like
many other work-related musculoskeletal conditions, the
connection between symptoms, disability and demonstrable
pathology is often unclear. A wide range of occupations,
work tasks, workplace factors and psychological factors have
been associated with low back pain, which most commonly
occurs with the task of heavy lifting.2 People of working age
with back problems are less likely to be employed full-time
than people without back problems. One study showed that
14% of people with long-term back problems experience
persistent pain and 86% experience pain one day per week.3
Low back pain is the highestcontributor to disability in
the world, according to a pivotal international study published by The Lancet in the Global Burden of Disease Study
in 2012.2 The study found low back pain and osteoarthritis
are now ranked second only to cancer as a leading cause of
disease burden in Australasia.4
Recent Australian studies have shown 50% of individuals
with low back pain have not sought medical care and use the
pharmacy as the first point of contact for regular large quantities of analgesics.5 Studies of individuals self-managing their
back pain and those managed in primary care have revealed
that usual care is often not evidence-based.6,7 Similar results
would be expected in New Zealand.

pain, acute low back pain does

not cause prolonged loss of
function.

Chronic back pain lasts longer than three months

Chronic back pain is
defined as pain lasting more
than three months. It may
cause severe disability and
delayed recovery. Patients
with symptoms lasting more
than eight weeks have a rapidly reducing rate of return
to usual activity. They are
likely to experience difficulties returning to work and
consequently experience loss
of work. Latest terminology
encourages the use of persistent pain rather than chronic
pain. Many pain-management
specialists believe the term
persistent pain is a more
Imaging is of no benefit in most cases of acute back pain, which usually gets better after a month
accurate description, as it
includes the impact of pain on
reason for pain.
functioning, wellbeing and quality of life.
Learning objectives
Provide adequate
analgesia, usually starting
A number of warning signs indicate a serious cause
New Zealand guidelines for managing low back pain
with regular paracetamol
There are a number of warning signs of serious causes of
Identify serious cases
of acute back pain and
are available from ACC
low back pain that the pharmacist may uncover with targeted for short-term symptom
refer to a GP, when
The New Zealand Acute Low Back Pain Guide provides a
relief.
questions. A single red flag is common, but serious disease is
necessary.
best practice approach, taking into account relevant evidence
Advise patients to stay
uncommon in those presenting to primary care with acute
for the effectiveness of treatment of acute low back pain for
active, avoid bed rest and
back pain.7
Warning signs are listed in Table 1. If there are no red
the prevention of chronic pain and disability. It follows an
continue as normally as
Describe pharmacological treatments for the
extensive review of the international literature and wide con- flags and the person is in good general health, then advice
possible.14,15
management of low
and simple analgesia, such as therapeutic doses of paracetasultation with professional groups in New Zealand.8,9
back pain.
The Guide to Assessing Psychosocial Yellow Flags in
Pharmacists role in
mol, may be appropriate. If the pain is persistent, then referAcute Low Back Pain provides an overview of risk factors for
low back pain
ral to a general practitioner is recommended for diagnosis
long-term disability and work loss.
Low back pain can be
and management.
Screen patients for
possibility of adverse
These two guides should be used together. They are
debilitating and people
The main cause of back pain presenting to the general
events with common
freely available on the ACC website and endorsed by
often want to know what
practitioner is vertebral dysfunction or mechanical
analgesics.
the New Zealand Guidelines Group.8,9
is causing it but, in about
pain. Degenerative changes in the lumbar spine
These guidelines are very comprehensive, but the
85% of cases, the pain
(lumbar spondylosis) are commonly found in older
ACC website notes: Please be aware that, due to the
is non-specific with no
individuals. This may lead to spinal canal stenosis.
Reinforce key mesGROUP 2
sages used by GPs and
age of this guideline, some sections may have been
identifiable cause.15 The
The New Zealand guidelines also include yellow
allied health workers
superseded by more recent evidence.9
flags as listed in Table 2. Yellow Flags indicate psycho- NPS MedicineWise has
in pain management.
The Low Back Pain Guide deals with the management
developed downloadable
social barriers to recovery which are an integral part of
of acute low back pain and recurrent episodes not chronic
tools, such as a pain-manpain-management strategies.9
The key messages for health professionals, provided by
pain.
agement diary and a painSource resources
available to support
the National Prescribing Service (NPS) in Australia for genmanagement plan, to assist
pharmacists in pain
eral practitioners and to be reinforced by pharmacists and
Acute low back pain is common
help health professionals
management.
other allied health professionals follow.
Acute low back pain is common, and episodes, by defiprovide advice to patients.
Take a thorough history and examination to assess for the
nition, last less than three months. In a few cases, there is
presence of serious clinical conditions (red flags).
a serious cause, but generally the pain is non-specific and
Key points for manag Use lower lumbar imaging in patients found to have a
a precise diagnosis is not possible. After an acute episode,
ing low back pain
serious condition or if the patient has radiculopathy or spinal
there may be persistent or fluctuating pain for a few weeks
Key points for managing low back pain are:
stenosis and is a candidate for surgery.
or months. Even severe pain that significantly limits activity
imaging tests are not always necessary
Reassure patients low back pain is rarely serious, most
at first, tends to improve, although there can be recurring
use a step up approach to provide adequate analgesia
Continued on page 33
episodes and occasional pain afterwards. Unlike chronic back pain settles quickly and imaging usually does not explain the

PharmacyToday.co.nz

July 2014 | 31

LOW BACK PAIN : how to manage

From page 31
keep active
use non-medical treatments.15
Imaging tests are not always necessary
The investigation of low back pain is dependent on triaging patients into those who require immediate imaging and
those where imaging can be deferred until after a trial of
conservative therapy. The choice of imaging modality will
depend on the suspected underlying pathology. Initial diagnostic screening should be undertaken for the evaluation of
the following red flags:13
osteoporosis
significant trauma (any age)
age over 70 years.
If the radiographic findings are abnormal or inconclusive,
or the cause of pain remains uncertain, further imaging
(MRI or CT) is indicated, (or if there is any indication of
malignancy or infection). MRIs are commonly used for radiating pain (sciatica, radiculopathy), cauda equina syndrome,
spinal stenosis, neurogenic claudication, suspected cases of
infection or malignancy, and in postoperative assessments.
CT is widely accepted as the criterion standard for the evaluation of osseous structures (eg, fractures, spondylosis, scoliosis) and surgery.13
The 2004 New Zealand guidelines recommend investigations in the first four to six weeks do not provide clinical
benefit unless red flags are present.9 This is reinforced by
the NPS guidelines.14,15
Imaging tests (eg, x-rays, CT scans, MRIs) are not recommended for acute low back pain because:
most people with low back pain feel better after about a
month, whether they have an imaging scan or not
x-rays may show spinal changes that are often completely
unrelated to the pain and do not need any treatment; this can
cause anxiety and stress, and potentially unnecessary followup tests and procedures (eg, spinal injections, surgery).
X-rays expose the patient to radiation, so should only be
used when there is a clear benefit. Back x-rays deliver around
65 times more radiation than a chest x-ray.15
Persistent pain requires holistic treatment
Pain medicine needs to be clear about what can and cannot be achieved.16
In a world that expects quick fixes for everything, and
where medicine has promised much, expectations and capacity for medical amelioration of pain often far exceed reality, to
say nothing of the economic realities of increasing access to
specialist services. Pain clinics can only see a small fraction
of patients who have pain; medication and procedures often
do not cure the pain; and increasingly disgruntled patients
shop around, often favouring medication over other harder
but ultimately more rewarding strategies.16
Many patients with persistent low back pain, which does
not respond to multiple drugs and procedures, require a
holistic non-medical approach. These are challenging patients
for the pharmacist as they can involve overuse of OTC analgesics, or doctor-shopping for prescription medicines.
Patients have to be encouraged to wean themselves off
drugs, especially opioids, and to recognise that yet another
operation or procedure is unlikely to help where others have
failed.
The use of physiotherapists and psychologists has been
shown to be beneficial to improve movement and activity,
and restore confidence that life is possible without pain being
a barrier.
Community participation projects involving art, music,
gardening and physical therapies can achieve surprising
results for patients with persistent pain.
Step-up approach best with analgesic medication
The Australian Therapeutic Guidelines: Analgesics for
Management of Low Back Pain recommends regular use of
paracetamol as the first choice.12 When paracetamolprovides
insufficient pain relief, regular use of NSAIDs is recommended. The Australian guideline notes oral opioids may be
necessary to relieve severe back pain.12 This contrasts with
the New Zealand 2004 guidelines, which state the use of opioids (and diazepam) shows evidence of harm to the patient.9
Before recommending or dispensing analgesic pain
relief, the patients medication history should be checked
for possible drug interactions or doubling up of analgesics,
particularly paracetamol combinations and other products
prescribed by general practitioners noting many of those
with low back pain may attend multiple doctors.
PharmacyToday.co.nz

Analgesics and NSAIDs

in acute low back pain flares
can be useful to facilitate
maintenance of activity rather
than simply to relieve pain.
Paracetamol may be used to
reduce the overall daily doses
of NSAIDs, and thus the risk
of their adverse effects. For
persistent pain, it is important
to consider regular dosing
rather than as needed dosing, with additional alternate
analgesia for breakthrough
pain if needed. Time taken to
specify the actual times the
medication should be taken
will aid adherence, particularly with paracetamol dosing.
There are many barriers to
taking paracetamol 500mg
two tablets four times a day,
but fewer when using the
extended-release formulations (paracetamol 665mg
two tablets three times a day).
Extended-release paracetamol
is not subsidised by Pharmac.

Table 1. Red flags are warning signs of serious causes of back pain812
Cauda equina syndrome (features include some or all of the following: urinary retention, faecal
incontinence, widespread neurological symptoms, and signs in the lower limbs, including gait
abnormality, saddle area numbness and a lax anal sphincter)
Age >50 years or <20 years
History of cancer
Temperature >37.8 degrees
Constant pain day and night, especially severe night pain
History of osteoporosis or prolonged corticosteroid or immunosuppressant use
Unexplained weight loss
Symptoms in other systems (eg, cough, breast mass)
Significant trauma (eg, fall)
Features of spondylarthropathy (eg, peripheral arthritis, night-time waking with pain)
Neurological deficit
Drug and/or alcohol abuse
Use of anticoagulants
Back pain for over a month and no improvement
Bowel and bladder retention
Pain in back of thighs and legs

Paracetamol doses recommendations changed

There have been recent changes to the recommended
use of paracetamol in the US and the UK, with dose reductions in adults and children. The new recommendations
for adults are a decrease in dose from 4g to 3g per 24 hours
using 375mg tablets. In Australia, the Therapeutic Goods
Administration (TGA) has considered these changes and recommends there should be no change to recommended paracetamol dosing regimens in Australia, ie, 500mg to 1000mg
up to four times a day.13
For the pharmacological treatment of low back pain, the
New Zealand guidelines9 and the Australian Therapeutic
Guidelines analgesic12 options include:
paracetamol 1g orally, four- to six-hourly up to a maximum dose of 4g daily or paracetamol modified-release 1.33g
orally, eight-hourly (not subsidised)
and/or
an NSAID orally.
The potential benefits of NSAIDs should be weighed up
against their potential harm, particularly in high-risk and
older patients. In older people, with increasing comorbidities and frailty, an age-related increase in the prevalence of
back pain, and an increase in pain threshold, coupled with an
age-related decline in the ability to tolerate severe pain, the
emphasis changes to symptom control.18
Paracetamol, ibuprofen combinations
Products containing a combination of ibuprofen 150mg
and paracetamol 500mg have been shown to be of benefit
in people with dental pain. They may also be useful for low
back pain.19,20
Concentrations of both ibuprofen and paracetamol
reach levels required for therapeutic effect when the fixedcombination formulation is administered either in the fed or
fasted state. Taking ibuprofen with food is reported to give
slower and lower levels, which may result in additional doses
being taken.21 Fast-acting formulations of ibuprofen demonstrated more rapid absorption, faster initial pain reduction,
good overall analgesia in more patients at the same dose, and
longer-lasting analgesia but with no higher rate of patients
reporting adverse events.22
Paracetamol, caffeine combination
A meta-analysis to determine the analgesic effect of the
combined dosage of paracetamol (1000mg) and caffeine
(130mg) versus paracetamol (1000mg) showed that the use
of paracetamol plus caffeine provided increased analgesia
over paracetamol alone in acute pain states.23,24
Gastrointestinal toxicity is a concern with NSAIDs
Generally, the adverse effect profile for all NSAIDs is
similar and is summarised in Table 3.24,25
The main exception is gastrointestinal toxicity; however,
all NSAIDs can cause serious ulcers depending on patient
susceptibility, dose and duration. Although selective COX-2
inhibitors (eg celecoxib, etoricoxib, meloxicam low dose)

Table 2. Yellow flags indicate psychosocial

barriers to recovery9
Belief that pain and activity are harmful
Sickness behaviours (like extended rest)
Low or negative moods, social withdrawal
Treatment that does not fit best practice
Problems with claim and compensation
History of back pain, time off, other claims
Problems at work, poor job satisfaction
Heavy work, unsociable hours
Overprotective family or lack of support

may have less harmful effects on the gastrointestinal tract,

they are not without risk and the concomitant use of lowdose aspirin eliminates the protective gastrointestinal effect.
They are also not subsidised by Pharmac. The risk of a serious gastrointestinal adverse event varies between NSAIDs
and is dose-related.24
NSAIDs with shorter plasma half-lives (eg, ibuprofen,
diclofenac) appear to be less gastrotoxic than those with long
half-lives (eg, indomethacin).12,24
The combination of Helicobacter pylori infection and
NSAID use increases the risk of ulcer 60-fold and of bleeding
six-fold over patients who have neither risk factor. Other risk
factors include concomitant use of antiplatelet drugs, anticoagulants, selective serotonin reuptake inhibitors (SSRIs),
corticosteroids, cigarette smoking, and excessive alcohol
intake.12 The use of a proton pump inhibitor (eg, omeprazole,
pantoprazole) with an NSAID may reduce gastrointestinal
risk.
Potential adverse CV effects a concern with NSAIDs
There is evidence cardiovascular harm is a general adverse
effect of all NSAIDs, other than low-dose aspirin.24,25
It is therefore recommended to use the lowest possible
dose of NSAID for the shortest possible duration.
If long-term use of NSAIDs is proposed for persistent low
back pain, an appropriate dose of fish oil (greater than 2.7g/
day of omega-3 fatty acids) can be used as an NSAID-sparing
drug.12
Low-dose aspirin may reduce the increased cardiovascular risk associated with NSAIDs, but it will also increase
gastrointestinal adverse effects.25 NSAIDS must be avoided
in people with heart failure and are contraindicated in those
with severe heart failure.24 Data from a population-based
follow-up study, the Rotterdam Study (n = 8423, mean age
68.5 years), showed that the use of NSAIDs was associated
with an increased risk of atrial fibrillation. Further studies
are needed to investigate the underlying mechanisms behind
this association.29
Continued on page 34
July 2014 | 33

how to manage : LOW BACK PAIN

From page 33

Table 3. Adverse effects of NSAIDs8,2429

All NSAIDs can cause renal impairment

High-risk factors include congestive heart failure, cirrhosis, sodium restriction and co-administration with diuretics,
ACE inhibitors, angiotensin II receptor blockers (ARB), aspirin or other nephrotoxic drugs.8
The combination of an NSAID, with an ACE inhibitor
or an ARB and a diuretic, may lead to the triple whammy
effect responsible for many cases of drug-induced renal failure.26
For acute low back pain, it is recommended NSAIDs
be used for only up to three weeks.12 Ongoing NSAID use
requires continual reassessment of the harm-to-benefit ratio.
A topical NSAID is an option, but offers only short-term
relief for acute injuries.

System

Adverse effect

Cardiovascular/
cerebrovascular

Rise in blood pressure, fluid retention, myocardial infarction, stroke, atrial fibrillation

Gastrointestinal

Nausea, vomiting, dyspepsia, diarrhoea, constipation, gastric mucosal irritation, superficial erosions, peptic
ulceration, oesophagitis, oesophageal strictures, faecal blood loss, major gastrointestinal haemorrhage, ulcers,
small bowel erosions

Haematological

Anaemia, bone marrow depression, decreased platelet aggregation

Hepatic

Hepatotoxicity, fulminant hepatic failure

Neurological

Headaches, confusion, CNS toxicity with systemic lupus erythromatosus , hallucinations, depersonalisation reactions, depression, tremor, aseptic meningitis, tinnitus, vertigo, neuropathy, toxic amblyopia, transient transparent
corneal deposits

Opioids may be initiated if pain relief is suboptimal

The goal of treatment is reduction of pain. If there is
insufficient pain relief, and pain is interfering with the
patients ability to function and/or to exercise, Australian
Guidelines consider the addition of one of the following for a
fixed period of time (ie, up to threeweeks only):12
codeine 30mg to 60mg orally, six-hourly as necessary
or
tramadol immediate-release 50mg to 100mg orally, up to
four times daily as necessary
or
oxycodone immediate-release 5mg to 10mg orally, fourhourly as necessary.
Due to safety concerns of accumulation and overdose toxicity, all products containing dextropropoxyphene have been
withdrawn from the market in Europe, the US, Canada and
New Zealand. They are still available in Australia.
Care should be taken with tramadol to avoid drug interactions with other serotonergic medicines.24

Renal

Glomerulopathy, interstitial nephritis, decreased glomerular filtration rate, alterations in tubular function, reduction in diuretic-induced natriuresis, inhibition of renin release, oedema

Other

Precipitation of asthma in patients with nasal polyps (3% to 11% incidence), allergic reactions, angioedema, skin rashes

Modified-released opioids option for persistent pain

For severe pain that persists beyond twoto threeweeks,
despite regular use of an immediate-release opioid, the use of
an equivalent dose of a modified-release opioid preparation
for up to 12weeks may be considered.12
There is no evidence that treating these patients with opioids beyond a 12-week period is of any clear benefit. Patients
should be monitored on a regular basis to determine treatment response and titrate the dose up or down as appropriate. There must be an active treatment plan with a set time
frame.11,12
Psychosocial and occupational factors may increase the
risk of persistence in individuals presenting with acute back
pain.6,12
Assessment using yellow flags (Table 2) will be of value
in assessing the need for counselling and/or medication for
depression or anxiety.
Few data support codeine in combination t herapy
Paracetamol or an NSAID given with a strong opioid,
such as morphine, for acute pain, reduces the amount of
opioid used, improves analgesia and reduces the duration of
patient-controlled analgesia.11
However, data supporting products which combine a
weak opioid, such as codeine in doses of 8mg15mg, with
paracetamol or an NSAID, are limited.11
There is evidence that a dose of codeine, less than
30mg six-hourly, is no more effective than paracetamol
alone. Codeine is a prodrug and requires conversion by the
cytochrome P450 (CYP) 2D6 isoenzyme to morphine. About
10% of the codeine is converted to morphine in the normal
metaboliser by CYP2D6. This conversion is dependent on
the patients individual pharmacogenetics, which are unpredictable.
Approximately 6% to 10% of Caucasians and 1% to 2% of
Asians lack the CYP2D6 isoenzyme and derive no analgesic
benefit from codeine.
Conversely, some people (up to 10% of Caucasians and up
to 30% of North Africans) are ultra-rapid metabolisers and
are at higher risk of morphine toxicity.12,24,25
Misuse of combination products is a current concern
Current concerns are the potential for misuse leading
to dependence and over-use of OTC codeine-combination
products. This has resulted in toxicity from the non-opioid
analgesic, (eg, acute renal failure and gastrointestinal perforation from ibuprofen), as well as dependence on codeine. This
results in larger doses of the combination product being used.
34 | July 2014

The patient with low back pain believes that they derive benefit until they experience adverse events.
Since 2013, warning labels have been applied to the combination product Nurofen Plus. The labels warn customers
that codeine painkillers should only be used for three days at
a time and that codeine can cause addiction.
Many consumers are surprised when alerted to this information as they have no idea that the product was addictive,
and will then seek further medical advice.
Bed rest no longer advised for low back pain
Prolonged bed rest is not recommended for acute low
back pain.5,612 Advise patients to stay active, even if moving
about is painful.
It is important to resume normal activities as soon as possible as this increases the rate of recovery, reduces time spent
off work and is not associated with recurrent pain.
Encourage regular stretching and moving and avoiding
long periods in one position. The New Zealand guidelines are
particularly useful at reinforcing rehabilitation with a nondrug emphasis.9
Non-medical management plays a key role
There are many non-medicine treatments for acute low
back pain (eg, heat, cold and manual therapies such as
massage, spinal mobilisation or spinal manipulation). The
Cochrane Back Review Group offers extensive literature
reviews but evidence is variable.30 Transient application of hot
or cold packs may be helpful in the short term.69,12
An extensive review by the Cochrane Back Review Group
of 12 studies, involving 2887 participants, showed combined
chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute
low back pain.
However, there is currently no evidence that supports or
refutes that these interventions provide a clinically meaningful difference for pain or disability in people with low back
pain when compared with other interventions. Further
research is required.31
Exercise interventions may be useful for preventing
recurrence of low back pain. Referral to a physiotherapist
with regular attendance helps the patient to feel that they are
being active in their treatment rehabilitation.
Written consumer resources can be sourced from reputable websites (eg, NPS,32 Health Navigator33) and the Ministry
of Health.34
Reinforce key messages regarding low back pain
There are effective ways to relieve acute low back pain
and help your recovery.
Stay active start with gentle activity, keep moving.
Be positive do not allow the pain to take over.
Control the pain use a simple pain reliever to help you
stay active.32 n
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