Pharmacological management of back pain syndromes

The symptom of back pain may be the result of many different pathologies. As such, patients with back pain require careful assessment to determine whether the cause is from the spine or other systems. For acute mechanical back pain, treatment is often symptomatic. Symptomatic treatment may include analgesics, anti-inflammatories and/or muscle relaxants. Patients may also need hypnotics in the short term to help them sleep at night. However, drug therapy should be reduced and stopped as soon as possible. Furthermore, too much bedrest may be counterproductive. Paracetamol (acetaminophen) is the standard treatment for transient back pain. More severe pain may require the addition of an opioid, such as codeine or dextropropoxyphene. Morphine and pethidine (meperidine) may be necessary in patients with back pain due to neoplastic disease or osteoporotic fracture. However, the opioid analgesics are associated with dependence, tolerance and adverse effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic efficacy comparable with paracetamol. Individual patients respond differently to different NSAIDs, and several agents may have to be tried. Long term therapy with NSAIDs is necessary in diseases with an inflammatory component such as ankylosing spondylitis. Calcitonin reduces bone resorption and bone blood flow, and has been suggested to have central analgesic effects. As such, it has been used successfully in patients with Paget's disease, osteolytic bone disease and osteoporosis. Bisphosphonates also inhibit osteoclastic bone resorption and may be useful in Paget's disease, osteolytic metastases and osteoporotic fractures. Other drugs which may be useful in relieving back pain associated with specific circumstances include the tricyclic antidepressants, anxiolytics, antiepileptic agents, corticosteroids, colchicine and chymopapain.