Treatment of Chronic Low Back Pain

Full update May 2021

Treatment of back pain that lasts beyond twelve weeks can be challenging. The chart below reviews evidence-based nondrug and drug therapy options in the treatment of chronic back pain. See our chart, Treatment of Acute Low Back Pain, to review drug and nondrug options for acute low back pain.

Medication or Intervention


NONDRUG THERAPY: Nondrug therapy is recommended first-line for chronic low back pain.17 A variety of options exist, and different patients may prefer or benefit from different techniques or interventions.

General considerations for all patients with chronic low back pain

Remain active9,17,19

Avoid bedrest.2,6,9,16

Continue normal activities to the extent possible.5

Evidence-based educational materials1,9


Supplements/reinforces verbal information from prescriber.1

Medium-firm mattress1

Firm mattress less likely to help.1

Weight loss6

Obesity is associated with low back pain.6,12

Efficacy of weight loss for chronic low back pain unknown.6

Smoking cessation11

Smokers have a higher pain intensity score and higher risk of back pain.11

Evidence is conflicting,6 but some data show that quitting smoking is associated with improved pain [Evidence Level B-3].11

Evaluate psychosocial factors2,9

Use regular follow-up to evaluate, and provide an expectation of return to work and normal activities.2,5

First-line interventions


Exercise may provide small improvements in pain and function.17,19

  • Type of exercise is likely not important, as no difference between regimens has been shown.17
  • Consider patient capabilities and preferences in determining the type of exercise.5

If unsupervised exercise worsens pain, therapist involvement may be necessary.6

Water exercise (e.g., aqua-jogging) may relieve pressure and provides a low-impact option for exercise.


May provide moderate improvement in pain and function, when added to usual care.19,32

  • May improve short-term function more than pain, especially immediately after treatment.33

May provide better pain relief compared to NSAIDs [Evidence level B-2].17

Multidisciplinary rehabilitation (includes physical therapy as part of rehabilitation)1,17,19

May provide moderate improvements in pain and small improvements in function.19

May be beneficial for significant functional impairment/work refusal.1,6

May reduce the need for short-term disability and increase likelihood of returning to work.19

Mindfulness-based stress reduction (e.g., meditation)17,19

Helps patients with awareness and to develop techniques to more effectively handle stress and pain.26

May provide small improvements in pain and function.17

Other interventions to consider

Spinal manipulation (e.g., chiropractic adjustments)17,19

May provide small improvements in pain (not enough data to evaluate impact on function).19

Combine with exercise or psychological therapies (e.g., cognitive behavioral therapy, biofeedback).5

  • Combining with other treatment options may improve effectiveness (e.g., exercise, massage, yoga).17


May provide small to moderate improvements in pain and function.19,32,34

More effective for short-term relief (e.g., 12 to 24 weeks) compared to long-term (e.g., 52 weeks).19

Most data support Vini yoga or Iyengar yoga types.6

Instructor with experience working with patients with low back pain may prevent further injury.6

Progressive muscle relaxation1,17

May provide moderate improvements in pain and function.17


May provide small improvements in pain and function.19

More effective for short-term relief (e.g., 12 weeks), compared to long-term (e.g., 52 weeks).19

Combine with education and exercise to improve effectiveness.2

Tai Chi17,19

May provide moderate improvement in pain and small improvements in function.17

May decrease pain more than some other forms of exercise (e.g., jogging).17

Cognitive-behavioral therapy and/or Biofeedback9,17

Use in combination with exercise therapy.5

May provide moderate improvements in pain, but no effect on function.17.

Laser therapy17

May provide small improvements in pain and function.17

Operant therapy17

(e.g., behavioral exercises)

May provide small improvements in pain, but no effect on function.17

Don’t rely on the following for relief

Kinesiology tape

Data are conflicting. Some studies find no difference in pain control compared to placebo in adults with chronic low back pain.24 Other reviews find improved pain relief with kinesiology taping compared to other physical techniques (e.g., physical therapy, acupuncture).35

May consider for pregnancy-related low back pain, when oral medications are limited.23

Lidocaine (topical)

Data are lacking for low back pain, WITHOUT a neuropathic component.

  • Most data supporting use are in neuropathic pain for patients unable to take oral medications.22

See our chart, Topicals for Pain Relief, for more on lidocaine and other topical pain products.

Transcutaneous electrical nerve stimulation (TENS) devices

No difference in pain control comparing an active TENS device to an inactive sham TENS device.19


First-line (Newer guidelines NO longer recommend acetaminophen first-line.5,9,17)

(e.g., ibuprofen, naproxen)

NSAIDs are more effective than acetaminophen (3,000 mg total daily dose) for back pain (e.g., ibuprofen up to 800 mg three times daily).1,6,9,18

  • Acetaminophen may be no more effective than placebo [Evidence Level B-1].5,17, However it may be worth a try in patients unable to take chronic NSIADS, due to its safety profile.

Avoid NSAIDs in chronic renal disease, hypertension, heart failure, high GI or CV risk.2-4

Use lowest NSAID dose for shortest time necessary to minimize side effects.1,5

Current data do not support the use of topical NSAIDs in chronic low back pain.28

Consider using a PPI (e.g., omeprazole, lansoprazole) with NSAIDs to reduce GI risk.1,5,6



Selective norepinephrine reuptake inhibitors (SNRIs)

  • Consider duloxetine 30 to 60 mg once daily for patients who fail or can’t take NSAIDs:7,13,27
    • Especially patients with comorbid depression or anxiety.
    • Even for patients without a neuropathic pain component.
  • Limited data support venlafaxine 150 mg/day in patients with depression AND chronic low back pain.10
  • Other SNRIs have not been studied in low back pain (e.g., desvenlafaxine, levomilnacipran).

The following are NOT recommended due to lack of efficacy:5,6,17

  • Tricyclic antidepressants ([TCAs], e.g., amitriptyline).
  • However, may be recommended if back pain has neuropathic involvement.6,25
  • Selective serotonin reuptake inhibitors ([SSRIs], e.g., fluoxetine, sertraline).


Gabapentin or pregabalin

Guidelines do not support the use of gabapentin or pregabalin for most patients with low back pain.5,6,21

  • May be considered with concomitant neuropathic pain or involvement.6,14
    • Gabapentin: 100 mg at bedtime, increased to 300 to 1,200 mg three times daily.6,14
    • Pregabalin: 25 mg at bedtime, increased to 75 to 300 mg twice daily.6

Skeletal muscle relaxants
(e.g., cyclobenzaprine)

Not recommended for most patients with chronic low back pain due to lack of evidence.9,21

May be considered only “as-needed,” for acute flare-ups.6,9

No proof they are more effective than NSAIDs.15

High incidence of central nervous system adverse effects (e.g., sedation).15

Avoid in patients at risk of falls (e.g., elderly).2

Avoid benzodiazepines due to risk of abuse, dependence, and tolerance.1

Opioids, including tramadol

Avoid in most patients with chronic back pain.5,6,9

  • No difference in pain control between opioids and NSAIDs.21

May be considered for severe, disabling pain uncontrolled with an NSAID.1

Weigh the risks of adverse effects (e.g., nausea, constipation, sedation), abuse, and misuse against benefit.

  • Recovery from chronic pain may be four times less likely in patients receiving opioids, compared to nonusers.31

Watch for diversion and abuse; consider chronic pain contract.2

Principles of good prescribing suggest using the lowest effective dose for the shortest time needed.

  • Up to 50% of patients taking opioids for at least three months are still taking them five years later.8

Tramadol: titrate dose up slowly, max dose of 400 mg/day (300 mg/day elderly).6,29,30

  • Conversion to long-acting product can be considered once an effective dose has been established.6
  • Use caution combining with duloxetine, due to risk of serotonin syndrome.29,30


Epidural steroid injections

Data are inconclusive about the true benefit of epidural steroid injections for back pain.6,20

  • Avoid in patients without associated radiculopathy or sciatica.6,20
  • Can be considered for some patients with a neuropathic component to their pain (e.g., radiculopathy [weakness, numbness, difficulty controlling specific muscles], sciatica [pain or numbness runs down the leg]), as benefit is typically acute and not sustained.6,20
    • These may be patients who are unable to take (or do not benefit from) other options or who need to avoid use of opioids.6,20
  • Data do not support use in patients with spinal stenosis.6,20

Most common adverse events include: bleeding, local hematoma, pain.20

  • Serious adverse events are rare (e.g., infection, nerve damage).20

Abbreviations: CV = cardiovascular; GI = gastrointestinal NSAID = nonsteroidal anti-inflammatory drug; PPI = proton pump inhibitor.

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.



Study Quality


Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study


Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study


Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56.]


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Cite this document as follows: Clinical Resource, Treatment of Chronic Low Back Pain. Pharmacist’s Letter/Prescriber’s Letter. May 2021. [370535]