Lower Back Pain Part 2: Treatment and Follow up

Last month, we started a two-part series on the evaluation and treatment of acute lower back pain (LBP) in the ED. This month, we are going to get into treatment options and how to help arrange follow-up care.

You just finished your exam, and all is well. No red flags are flying, but your patient is in significant pain. Let’s look at our resources to get the patient some real relief.

First-line treatment: NSAIDs

NSAIDs are widely considered to be the most effective first-line therapy for acute lower back pain. They are cheap and effective, though recent studies have found no significant difference in pain relief between patients who received 400 mg of Ibuprofen and those who received 600 mg or 800 mg, suggesting a likely therapeutic ceiling for Ibuprofen. Take the time to explain to your patients that more is not always more, and that taking 400 mg instead of 800 mg may also decrease the risk of unwanted GI or renal side effects. The same appears to apply to IV Ketorolac, with no discernible difference in pain relief when comparing 15- and 30-mg doses.

Also, take the time to explain that the patient needs to avoid taking additional NSAIDs other than what you are prescribing, and if possible, take a quick glance over their medication list. The last thing you want to do is stack days of Ibuprofen on top of a large dose of time-released NSAIDs that your patient was already on for their arthritis.

It's very easy to forget that what we consider the most elementary level of pharmacology is still special knowledge that not everyone has. When I worked on a rapid response team, I cannot tell you the number of times we were called to the GI suite for a hypertensive crisis because the patient had confused their antihypertensives with blood thinners and stopped taking them both for their upcoming scope. If you are reading this, I guarantee you’ve had a patient describe their home meds by color and shape, with no idea of the name or dose.

What if my patient can’t tolerate oral NSAIDs?

For patients with CKD, oral NSAIDs are a no-go. In this population, topical NSAIDs such as Diclofenac gel are a great option. A systematic review of topical NSAIDs for acute pain relief found them to be very effective, with an overall number needed to treat of 4 or less.

Multiple publications support topical NSAIDs for patients with CKD, as the minimal systemic absorption is believed to be safe for most CKD patients in short courses, though it is reasonable to avoid all forms of NSAIDs for patients in ESRD or stage 4+ CKD, given their greatly increased risk of decompensation.

Now, patients on blood thinners are a different story. While the science is strong that topical NSAIDs have far less systemic absorption than their oral counterparts, there is still an inherent risk that the small amount of systemic absorption could potentiate unwanted bleeding. Given that there is no good research evaluating the safety of topical NSAIDs for patients on blood thinners, this should be avoided.

Might help, might be placebo: Muscle relaxers

The benefits of skeletal muscle relaxants are much debated in Emergency Medicine. For some, it is a safe and effective non-narcotic option for a variety of issues. For others, it is seen as little more than a CNS depressant with a mostly placebo effect.

So what does the evidence tell us? There’s actually a lot of evidence out there on the effects of muscle relaxers for lower back pain, including this systematic review, this meta-analysis, and this other meta-analysis.

TL;DR: They provide mild to moderate pain relief, but side effects are common. The most common side effects are CNS depression, drowsiness, and increased risk for falls. These were mostly associated with the elderly and patients with polypharmacy.

Hot take on muscle relaxers: They are a cheap, non-addictive medication option for patients in the appropriate population. Even if their primary mechanism of action is to make the patient drowsy so they sleep through their pain, I’ll take that as a win.

Key takeaways for muscle relaxers:

• Use the lowest dose necessary for relief

• Keep the duration <7 days; these are not medications for long-term use

• It may be reasonable to give a single dose to a high-functioning elderly patient while in the ED, but given the fall risks and incidence of polypharmacy, avoid the prescription.

• Soma (carisoprodol) = hard pass. It's highly addictive, it's a Schedule IV controlled substance, and it's basically the tramadol of muscle relaxers. If your patient is asking for it by name, just say no.

Useful for some, but greatly overused: Steroids

Steroids are probably the most overutilized medication for acute lower back pain. There is good evidence that short-term steroids provide relief of symptoms in patients with radicular back pain. There is also solid evidence that steroids provide little to no benefit in the setting of non-radicular musculoskeletal back pain.

We also tend to underestimate the significant side effects of even short-term steroid use. Hyperglycemia, infection risk, sleep disturbances, the list goes on. Take the time to look over your patient's current medication list to make sure they aren’t currently taking or recently finished a course of steroids.

Lidocaine patches: Slightly superior to “thoughts and prayers”

Topical lidocaine patches are a common treatment option in the ED for patients with lower back pain, especially in populations with contraindications to other treatment options. They are quick, easy to apply, and generally considered safe.

The evidence, however, is very limited. Most of the studies touting its effectiveness are nonrandomized and noncontrolled. One comprehensive review did address the potential effectiveness of lidocaine patches, however the results were minimal and suggested a strong likelihood of a placebo effect (as evidenced by functional MRIs if you really want to take a deep dive).

The biggest barrier for patients is often cost. 5% lidocaine patches are notoriously expensive, even for patients with insurance. In contrast, 4% lidocaine patches are available over the counter for a fraction of the cost.

Opioids and back pain: The smoking gun of an epidemic

A cross-sectional study of over 10,000 physicians from 2009 - 2017 found that opioids were prescribed during 21.6% of office visits for new onset lower back pain. Back pain is a leading cause of opioid prescriptions worldwide and is a major contributing factor to the current opioid epidemic.

We are getting better at avoiding opioids for things like back pain, but sometimes it's your only viable option. Patients may have significant contraindications to other therapy options, and there may be no alternative but a short course of opioids. In these cases, a policy statement from ACEP, SEMPA, and AAENP offers some guidance:

• In the ED, titrate opioids incrementally with a goal of relative comfort and function, and recognize that complete pain relief is often an unreasonable goal.

• Prescriptions for opioids should be for immediate-release medications only, for the lowest effective dose, for the shortest reasonable time.

• EM providers should avoid starting patients on long-acting or extended-release opioid medications.
  

The most important (and usually the most difficult) part: Follow-up care

For me, this is often the hardest part. Many of my patients don’t have insurance, or have some semblance of insurance but no PCP. Both of these common scenarios result in patients being caught in an endless “catch-22” loop of frustration:

PCPs don’t have any new patient openings for at least 90 days; the orthopedic surgeon who fixed their meniscus tear doesn’t see back pain, and the spinal surgeon won’t see any new patients without an MRI. This is a scenario we all see far too often, patients generally either getting better on their own, or continuing to present to the ED with worsening symptoms until they qualify for an emergent MRI.

While follow-up care is a major challenge, most EDs have social workers or case managers who can help educate, advocate, and provide resources for patients. Engage with whatever resources you have at your disposal, and look for opportunities to make sure everyone in the department knows what resources are available and how to use them.