First Line Medications for Acute Back Pain

First Line Pain Medications for Acute Back Pain

An athlete ices his back injury.
An athlete ices his back injury.. Nadia Richie Studio/Imagezoo/Getty Images

First Line Pain Medications for Acute Back Pain

Most of us don't get up in the morning expecting to injure our backs.  So when it does happen, we may not know exactly what to do about it.

A number of first line defense pain killers exist for acute low back pain, but they don't all work equally well. And many of these have not exactly proven themselves when medical research put them to the test.  

Just the same, your doctor may suggest or prescribe some of these drugs, so it's up to you to know how effective each is for the problem you are trying to solve (in this case acute low back pain and/or injury.)

In the pages that follow, you'll get the facts about some of the most commonly prescribed pain meds for acute low back pain.  The 2nd to last page in this series explains what to do to get your physical prowess back.  Well, at least to get back to work and your household chores, anyway.

Non-Steroidal Anti-Inflammatory Medications (NSAIDs)

Aspirin and a glass of water
Aspirin and a glass of water. Stephen Swintek/Stone/Getty Images

Non-Steroidal Anti-Inflammatory Medications (NSAIDs)

Doctors often recommend NSAIDs, which is an acronym for non-steroidal anti-inflammatory medication.  NSAIDs are used to decrease inflammation that almost invariable occurs after an injury.  They are also used to relieve pain.  This class of drug is different from Tylenol, which is a pain reliever only.  

A 2016 comparative effectiveness review published by the Agency for Healthcare Research and Quality (AHRQ) found that taking NSAIDs may give better pain relief than taking a placebo.   And a review by the Cochrane Database* found that NSAIDs may yield about the same degree of pain relief as Tylenol.  Keep in mind, though, the studies reviewed were all of low, or at best, of moderate quality.

The Cochrane review also found (again, low quality evidence) that taking NSAIDs resulted in more gastrointestinal complications than taking Tylenol.

Related: Over the Counter Pain Medications for Neck and Back Pain

* Disclosure:  I am a consumer reviewer for the Cochrane Back and Neck Group.

Skeletal Muscle Relaxers

cylobenzaprine - Flexeril
cylobenzaprine - Flexeril. LAGUNA DESIGN/Collection:Science Photo Library/Getty Images

Skeletal Muscle Relaxers

Many times after an injury, muscles seize up and go into spasm.  Spasms can be very painful; they can also interfere with your regular activities because they make it difficult to move.  

Your doctor may prescribe skeletal muscle relaxers in conjunction with a course of physical therapy to help you participate fully in your exercise program.  (Skeletal muscle relaxers are only available by prescription.)

The AHRQ review mentioned earlier found moderate evidence that skeletal muscle relaxers were better than placebos for achieving pain relief.

Related: How to Get Rid of Back Muscle Spasms

Opioids and Acute Low Back Pain

Close up of oval white pill, Vicodin
Vicodin. GIPhotoStock / Getty Images

Opioids and Acute Low Back Pain

Many doctors prescribe opioid medication as a first line treatment for acute back or neck pain, but the World Health Organization (WHO) and others advise against it.  

Instead, WHO advises taking a stepped approach to pain relief, beginning with a non-opioid pain reliever such as aspirin or paracetamol, and possibly an adjuvant (for example, skeletal muscle relaxers.)  Adjuvants, they say may, help calm anxiety.  

If the pain persists or gets worse, WHO then recommends mild opioids like codeine.  And if that doesn't work, WHO recommends taking strong opioids such as morphine until you are pain free.

An article in American Family Physician that summarizes research based recommendations on pain relievers says that before turning to opioids only, taking this class of drug in combination with a non-opioid pain reliever is advisable. But even before that, they recommend taking acetaminophen (Tylenol) first, then ibuprofen or naproxen (i.e., NSAIDs) and next, CoX-2 selective NSAIDs.  If you still need help, at that point, they recommend taking the opioid/non-opioid combination.

Why all the Restrictions on Opioids?

Opioid medications are narcotics, which means by taking them, you run the risk of becoming addicted.

At least to some extent, this is a "buyer beware"  situation. The British Medical Journal  reports that over half of all regular opioid users report having back pain.  The article also says that opioids are now the most commonly prescribed drug class in the U.S.  In fact, they are prescribed 2 - 3 times more in North America than they are in Europe, the authors inform us.

Read the Book Review: The Painful Truth by Dr. Lyn Webster.

Although the AHRQ review found that taking opioids will likely give better pain relief than taking a placebo medication, the strength of this evidence was rated "low."  

Not only that, but the medication may not be all that effective.  The British Medical Journal article notes that taking opioids doesn't seem to speed patients' return to work nor improve functioning in workers who have acute back pain.

And a 2015 study published in the Journal of Family Practice found taking opioids for chronic low back pain gave modest relief in the short-term (<4 months) but only minimal improvement in patients' ability to function, when compared to placebo.

Related: What to Do for Mild Back Pain

Following a Back Or Neck Injury - How to Become Functional Again

Physical therapy treatment
Physical therapy treatment. sylv1rob1

Following a Back Or Neck Injury - How to Become Functional Again

The medications you've read about are all meant to relieve pain.  None are particularly good at helping patients improve their physical functioning after injury.

For improving your ability to function, the story is a bit different.  In general, a multidisciplinary approach yields the best results. It's likely that the combined effects of a physical therapy program will be what gets you back in commission.

According to a 2015 study published in the journal Orvosi Hetilap, personalized and guided physiotherapy, cognitive behavioral therapy and short training programs are the preferred first-line treatments for restoring physical functioning.

And don't think you need to automatically turn to surgery after an acute neck or back injury - certainly not before trying therapy and exercise, at least. Surgery is reserved for degeneration, and only after the failure of conservative therapy, the study authors conclude.

Article Sources

Architectural view of a big library with lots of books.
Architectural view of a big library with lots of books.. Carl Bruemmer / Design Pics/Perspective/Getty Images



Berland, D., M.D., et. al. Rational Use of Opioids for Management of Chronic Nonterminal Pain. American Family Physician. August 2012.

Berthelot J., Darrieutort-Lafitte C., Le Goff B., Maugars Y. Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. Joint Bone Spine. Dec 2015 Accessed: March 2016.

Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive Treatments for Low Back Pain [Internet]. AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Feb. Report No.: 16-EHC004-EF.

Deyo, R., Von Korff, M., Duhrkoop, D. Opioids for low back pain. BMJ. Jan 2015. Accessed: March 2016.

Chapparo, L., Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. Aug. 2013.

Illés S., Low back pain: when and what to do. Orv Hetil. Aug 2015 Accessed: March 2016.

Jones P., Dalziel S., Lamdin R., Miles-Chan J., Frampton C. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. July 2015. Accessed March 2016.

World Health Organization. Treatment Guidelines on Pain. WHO website.

Continue Reading