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Pain Management: Opioids and Alternatives


Summary of Key Points

  • Many medication options exist for the management of chronic spinal and back pain disorders, including nonsteroidal antiinflammatories, acetaminophen, oral steroids, antidepressants, anticonvulsants, opioids, cannabinoids, and topical ointments.

  • Muscle relaxants, oral steroids, opioids, and nonsteroidal antiinflammatories can be used effectively in such certain acute situations, such as sprains, strains, and herniated discs.

  • Muscle relaxants, oral steroids, nonsteroidal antiinflammatories, and opioids are not known to be beneficial in chronic pain management.

  • Acetaminophen, antidepressants, anticonvulsants, and/or topical ointments are preferentially recommended for chronic conditions, given their collective efficacy and safety profiles.

  • All medications should be used as adjuncts to physical rehabilitation, interventional care, and surgery.

Back and spinal pain disorders are common, debilitating, and costly. Pain is a common feature of many such disorders, and patients seek relief for pain by the millions. As alternatives to surgical, interventional, and rehabilitation techniques, patients turn to medications often, and it is thus important for practitioners to be aware of analgesic options. Traditional analgesics include opioids, acetaminophen, and nonsteroidal antiinflammatory agents, although other classes are used often in chronic pain disorders, including but not limited to steroids, antidepressants, anticonvulsants, muscle relaxants, topical ointments, and cannabinoids. This chapter reviews these agents, particularly for use in management of uncomplicated chronic low back pain.

Acetaminophen

Acetaminophen (acetyl-para-aminophenol) is a commonly used analgesic, antipyretic, and antiinflammatory drug. Although avidly prescribed for a number of pain disorders, acetaminophen has not been found to be superior to placebo for low back pain. It is still recommended if alternatives pose significant side effects or other limitations. Standard doses range from 325 mg to 1000 mg every 4 to 6 hours, not to exceed 4000 mg per day. Acetaminophen possesses an excellent safety profile outside of hepatotoxicity in excess use or overdose (>5 g). Such hepatotoxic injury from acetaminophen is more frequently encountered in existing liver disease, alcohol abuse, or severe fasting states.

Nonsteroidal Antiinflammatory Drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) are common first-line choices for control of acute low back or neck pain, lacking risk factors for adverse effects. A comprehensive review of 65 studies totaling over 11,000 patients showed that NSAIDs are modestly effective for short-term relief of chronic low back pain without radiculopathy. However, no difference was noted between NSAIDs and placebo for radicular symptoms, and no difference was identified between different types of NSAIDs and between NSAIDs and other commonly used pharmacotherapies, including opioids and muscle relaxants. As such, choosing a specific NSAID should be guided by side-effect profile. Gastrointestinal toxicity is the most common serious side effect, with serious ulcer complications seen in about 1.5% of patients. Other potential adverse effects include cardiovascular events, renal failure, tinnitus, fluid retention, and hypertension. Clinical and laboratory monitoring for adverse renal or gastrointestinal reactions is imperative with NSAID use. Risk factors for such side effects from NSAIDs include advanced age (>65 years), cardiovascular disease including congestive heart failure, gastrointestinal bleed, or ulcer, renal disease, and liver cirrhosis.

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