Oral Presentation Sydney Spinal Symposium 2023

Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews (#2)

Aidan G Cashin 1 2 , Benedict M Wand 3 , Neil E O'Connell 4 , Hopin Lee 5 , Rodrigo RN Rizzo 1 2 , Matthew K Bagg 1 3 , Edel O'Hagan 1 , Christopher G Maher 6 7 , Andrea D Furlan 8 , Maurits W van Tulder 9 , James H McAuley 1 2
  1. Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, Australia
  2. School of Health Sciences, University of New South Wales, Sydney, Australia
  3. School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
  4. Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University, London, UK
  5. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
  6. Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
  7. Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
  8. Institute for Work & Health, Toronto, Canada
  9. Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands

Aims

To summarise the evidence from Cochrane Reviews of the efficacy, effectiveness, and safety of systemic pharmacological interventions for adults with non‐specific low back pain (LBP).

Methods

The Cochrane Database of Systematic Reviews was searched from inception to 3 June 2021, to identify reviews of randomised controlled trials (RCTs) that investigated systemic pharmacological interventions for adults with non‐specific LBP. Two authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools. The review focused on placebo comparisons and the main outcomes were pain intensity, function, and safety.

Results

Seven Cochrane Reviews that included 103 studies (22,238 participants) were included. The reviews reported data on six medicines or medicine classes: paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, opioids, and antidepressants. 

We found no high‐ or moderate‐certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate‐certainty evidence that NSAIDs and muscle relaxants may provide a small effect on pain, and high‐certainty evidence for no evidence of difference between paracetamol and placebo. For safety, we found very low‐ and high‐certainty evidence for no evidence of difference with NSAIDs and paracetamol compared to placebo for the risk of adverse events, and moderate‐certainty evidence that muscle relaxants may increase the risk of adverse events. For chronic LBP, we found low‐certainty evidence that NSAIDs and very low‐ to high‐certainty evidence that opioids may provide a small effect on pain. For safety, we found low‐certainty evidence for no evidence of difference between NSAIDs and placebo for the risk of adverse events, and low‐certainty evidence that opioids may increase the risk of adverse events. 

Conclusions

The available evidence suggests that pharmacological interventions for adults with non‐specific LBP appear to be ineffective or only marginally effective, and carry an increased risk of adverse events. There is a clear need to prioritise new effective and cost‐effective treatment strategies to improve care for people with LBP.