The Australian Pain Society is proudly multidisciplinary and encourages respectful debate. Please refer to our recent ‘Letter to the Editor’ by Dr Stephanie Davies MBBS, FANZCA, FFPMANZCA and Dr Gregory Parkin-Smith MTech(Chiro), MBBS, MSc, DrHC, CertEM.
We would like to provide some additional background information to the article “Pain Management and Pharmacy” with reference to the discussion of back pain. We would like to share the link to the CostB13 guidelines[i] for acute and chronic back pain in primary care http://www.backpaineurope.org/ and their two summary statements copied below, with updates in italics.
Summary of recommendations for treatment of acute non-specific low back pain in primary care:
- Give adequate information and reassure the patient
- Do not prescribe bed rest as a treatment
- Advise patients to stay active and continue normal daily activities including work if possible
- Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs,
- Consider adding a short course (no more than 4-5 days) of stronger analgesics and/or muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
- Consider (referral for) spinal manipulation and exercise programme for patients who are failing to return to normal activities at or after 2-weeks of initial treatment
- Re-Triage, Assessment and multidisciplinary treatment programmes in occupational settings may be an option for workers with sub-acute low back pain and sick leave for more than 4 – 8 weeks
Summary of the concepts of treatment of chronic low back pain (CLBP) in primary care:
- Conservative treatments: Cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, and multidisciplinary (bio-psycho-social) treatment can each be recommended for non-specific CLBP. Back schools (for short-term improvement), and short courses of manipulation/mobilisation can also be considered. The use of physical therapies (heat/cold, traction, laser, ultrasound, short wave, interferential, massage, corsets) cannot be recommended. We do not recommend TENS.
- Pharmacological treatments: The short term use of NSAIDs and weak opioids can be recommended for pain relief. Noradrenergic or noradrenergic-serotoninergic antidepressants, muscle relaxants and capsicum plasters can be considered for pain relief. We cannot recommend the use of Gabapentin.
- Invasive treatments: Acupuncture, epidural corticosteroids, intra-articular (facet) steroid injections, local facet nerve blocks, trigger point injections, botulinum toxin, radiofrequency facet denervation, intradiscal radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency lesioning of the dorsal root ganglion, and spinal cord stimulation cannot be recommended for non-specific CLBP. Intradiscal injections and prolotherapy are not recommended. Percutaneous electrical nerve stimulation (PENS) and neuroreflexotherapy can be considered where available.
Surgery for non-specific CLBP cannot be recommended unless 2 years of all other recommended conservative treatments — including multidisciplinary approaches with combined programs of cognitive intervention and exercises — have failed, or such combined programs are not available, and only then in carefully selected patients with maximum 2-level degenerative disc disease.
These guidelines also highlight the need for the treatment of both acute and chronic low back pain to include, triage, diagnosis (based on examination, history, appropriate investigations including an emphasis that imaging is not usually necessary) through to evidence-based treatments. Arguably, these summary statements are now outdated and in need of an update including the combination of Paracetamol and NSAIDS is likely to be better due to the synergistic effect. Also, there is some doubt about Paracetamol on its own[ii].
More recent publications support the ongoing implementation of the Cost B13 guidelines, published in 2006, including patient education, staying active, exercise including a daily walk, lifestyle modification, spinal manipulative therapy[iii],[iv],[v] and if necessary, simple analgesia, is likely to yield the best-possible outcomes[vi].
The CostB13 guidelines support the use of paracetamol, non-steroidal anti-inflammatory drugs (less than 3 months), and weak opioids, such as tramadol, in combination with paracetamol. The use of strong opioids for acute back pain isn’t mentioned, whilst the guidelines for chronic back pain advocate the limited use of strong opioids as the evidence of effectiveness is low (Level C)1, whilst the potential for harm is real.
Neuropathic pain can contribute to spinal pain[vii], and if a strong opioid is considered for neuropathic pain, then buprenorphine (S8) could be considered the least harmful effective option[viii],[ix] as it is the only strong opioid not associated with rapid tolerance, opioid-induced hyperalgesia[x], lowering of the person’s sex hormones[xi], or a negative impact on the patient’s immune system via inhibiting their natural killer cells. In addition, buprenorphine has both an analgesic and anti-hyperalgesic effect which is relevant in neuropathic pain, which can be a contributor in some people with spinal pain7.
We believe this is a key area for undergraduate and post-graduate training of health care professionals so that they do not overlook behavioural non-pharmacological clinical guideline recommendations for non-malignant pain[xii].
The aim is to increase guideline-concordant treatment to benefit the patient and the health care systems.
Yours sincerely,
Dr Stephanie Davies MBBS, FANZCA, FFPMANZCA
Dr Gregory Parkin-Smith MTech(Chiro), MBBS, MSc, DrHC, CertEM
[i] Airaksinen O, Brox J, Cedraschi C, et al. COST B13 European guidelines for the management of chronic non-specific low back pain. Eur Spine J. 2006;15:S192 – S300.
[ii] Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. The Lancet. 2014, 384/9954, 1586-96.
[iii] Parkin-Smith GF, Norman IJ, Briggs E, Angier E, Wood TG, Brantingham JW. A structured protocol of evidence-based conservative care compared with usual care for acute nonspecific low back pain: a randomized clinical trial. Archives of Physical Medicine and Rehabilitation. 2012;93(1):11-20
[iv] Shnayderman I, Katz-Leurer M. An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clin Rehabil. March 1, 2013 2013;27(3):207-214.
[v] Sitthipornvorakul E, Janwantanakul P, Lohsoonthorn V. The effect of daily walking steps on preventing neck and low back pain in sedentary workers: a 1-year prospective cohort study. Eur Spine J. 2015;24(3):417-424.
[vi] Goertz CM, Long CR, Hondras MA, Petri R, Delgado R, Lawrence DJ, et al. Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study. Spine. 2013;38(8):627-34
[vii] Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006;22(10):1911-1920.
[viii] Gordon A, Callaghan D, Spink D, et al. Buprenorphine transdermal system in adults with chronic low back pain: A randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase. J Clin Ther. 2010;32(5):844-860.
[ix] Hans G. Buprenorphine–a review of its role in neuropathic pain. J Opioid Manag. 2007;3(4):195-206.
[x] Koppert W, Ihmsen H, Körber N, et al. Different profiles of buprenorphine-induced analgesia and antihyperalgesia in a human pain model. Pain. 2005;118(1-2):15-22.
[xi] Bliesener N, Albrecht S, Schwager A, Weckbecker K, Lichtermann D, Klingmuller D. Plasma testosterone and sexual function in men receiving buprenorphine maintenance for opioid dependence. J Clin Endocrinol Metab. 2005;90(1):203-206.
[xii] Holliday S, Magin P, Dunbabin J, Oldmeadow C, Henry J-M, Lintzeris N, et al. An evaluation of the prescription of Opioids for chronic nonmalignant pain by Australian General Practitioners. Pain Medicine. 2013;14(1):62-74
Australian Pain Society 
Steph and Greg, I must apologise for attributing the recommendation for “neuroreflexotherapy” to you. On re-reading your letter, I discovered that it is attributable to those who wrote the Cost B13 European Guidelines.
Steph and Greg, your recommendation for “neuroreflexotherapy” (where available) was news to me. To my dismay, I found that neuroreflexotherapy is characterised by temporary implantation of a number of epidermal devices into trigger points in the back and into referred tender points in the ear. As you know, myofascial “trigger points” have never been shown to exist as distinct pathological entities. A 2011 Cochrane Review lent cautious support to this form of “alternative” therapy, which originated in Spain, but concluded: “However, until research duplicates these results in different settings, there is no strong evidence that it will work as well outside the specialty clinics in Spain.” Have further trials been conducted outside Spain? Do they lend support to this form of passive therapy?
PS This sentence does not make sense to me: “Neuropathic pain can contribute to spinal pain.” Did you mean to say that descriptors associated with the pain of neuropathy can be used by those with spinal pain?