Low back pain is one of the most common reasons for doctor visits and workers compensation claims in the United States. It is associated with increased healthcare costs as well as lost wages and decreased work productivity.

Acute back pain generally lasts less than 4 weeks and usually resolves on its own. Subacute low back pain is defined as lasting 4 to 12 weeks, while chronic back pain lasts over 12 weeks. Up to 30% of patients report persistent low back pain up to 1 year after experiencing an acute episode. One in five report substantial limitations in activity, according to background information in the article.

The American College of Physicians offers new guidelines for how physicians should treat low back pain, in an article published this month in Annals of Internal Medicine.

The guidelines are based on randomized controlled trials and systematic reviews on noninvasive pharmacological and non-pharmacological treatments of nonradicular low back pain. To develop the guideline, the ACP reviewed randomized controlled trials and systematic reviews of studies evaluating noninvasive, nondrug, and drug therapy for low back pain in adults. To be included, studies had to be published in English between January 2008 and November 2016. The authors identified earlier studies using the 2007 ACP/American Pain Society systematic reviews. The guidelines and evidence reviews also underwent peer review and a public comment period.

Here are five key points:

1. The evidence-based clinical practice guideline, “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain,” recommends treatment of acute or subacute low back pain with non-drug therapies.

2. Some of these non-drug therapies include superficial heat, massage, acupuncture or spinal manipulation.

3. The society recommends providers prescribe anti-inflammatory drugs or skeletal muscle relaxants if pursuing a drug therapy.

4. American College of Physicians suggests patients with chronic low back pain first try non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy or spinal manipulation. While no therapy was clearly better than any other, new evidence supports mindfulness-based stress reduction and tai chi in chronic low back pain and acupuncture in acute low back pain.

5. Those chronic low back pain patients who have experienced no response to non-drug therapies should then take NSAIDs first, and then tramadol or duloxetine as second line therapy.

“Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose,” said Nitin S. Damle, MD, MS, MACP, president, American College of Physicians.

McCormick Law Office, Milwaukee, Wisconsin.