Back pain is increasingly becoming one of the most common complaint of people. Eight out of ten people get affected by it at some point of their lives. The range of pain varies from dull, constant ache to a sudden, sharp pain.
Our back consists of a large, complex structure having bones, nerves, muscles, tendons, ligaments and blood vessels emerging from below the neck. This highly complex anatomy of our back provides the required flexibility to our head and allows movement of arms, head and legs. It also protects internal organs, and houses the spinal cord. The vertebral column consists of 33 small bones called vertebrae, which are supported by muscles, tendons and ligaments, and are cushioned by shock absorbing disks. A number of problems in the vertebral column can result in back pain.
Pain in back which develops suddenly and goes away on its own after a few days is called acute back pain. If the pain lasts for three or more months then it is called chronic pain.
In the last 20 years, there has been an increase in the prevalence of lower back pain. It has been found to be slightly more common in women than men. Back pain is a leading factor responsible for affecting the daily work of people. Studies indicate increasing sedentary work as the main cause for increase in the problems of back, resulting in back pain.
Symptoms
Back pain generally presents itself as a combination of following symptoms:
- Dull, aching pain
- Pain traveling to buttocks, legs and feet
- Pain becoming worse after prolonged sitting
- Pain becoming better after changing positions
- Inability to stand straight without having pain
- Sharp localized pain in the back after strenuous activity
Treatment
Although medicines used for managing back pain cannot treat the underlying cause of pain, they can still provide temporary relief from the discomfort. NSAIDs, narcotic analgesics, corticosteroids, skeletal muscle relaxants and serotonin nor-epinephrine re-uptake inhibitors are some of the drugs that are used for managing back pain and their descriptions are given below:
1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs are the medicines that are used to relieve pain, decrease inflammation and reduce increased body temperature.
Prostaglandins are naturally occurring chemicals that produce inflammation and the associated pain. These are produced in our cells by the enzyme cyclo-oxygenase (COX), which is of two types, COX-1 and COX-2. NSAIDs block both COX enzymes and reduce the production of prostaglandins throughout the body which in turn results in decreased inflammation and pain.
a. Non-selective COX Inhibitors:
They inhibit both types of COX enzymes. Following are the classes of non-selective COX inhibitors:
(I) Salicylates:
Drug: aspirin
Brand Name: Aspirin
The U.S. FDA Status: Approved
Availability: OTC
Dosage Form: Capsule
Indicated in Pregnancy: No. Avoid using during third trimester due to chances of ductus arteriosus. During first and second trimester, lowest dose for shortest duration should be used.
Alcohol Content: No
Side Effects: Abdominal pain, black stools, change in consciousness, chest pain, confusion, constipation, diarrhea, drowsiness, fainting, fever, headache, heartburn, indigestion, irregular heartbeat and skin rash
(ii) Propionic Acid Derivatives:
Drug: ibuprofen
Brand Names: Advil
The U.S. FDA Status: Approved
Availability: OTC
Dosage Form: Tablet
Indicated in Pregnancy: No. Avoid using during third trimester due to chances of ductus arteriosus. During first and second trimester, lowest dose for shortest duration should be used.
Alcohol Content: No
Side Effects: Hemorrhage, anemia, vomiting, eosinophilia, hypertension, upper gastrointestinal hemorrhage, peptic ulcer, dyspepsia, dizziness, abdominal pain, belching, bloating, diarrhea, indigestion, itching, nausea and unusual tiredness
Drug: naproxen sodium
Brand Names: Aleve
The U.S. FDA Status: Approved
Availability: OTC
Dosage Form: Tablet
Indicated in Pregnancy: No. Avoid using during third trimester due to chances of ductus arteriosus. During first and second trimester, lowest dose for shortest duration should be used.
Alcohol Content: No
Side Effects: Belching, bruising, labored breathing, indigestion, headache, itching, skin eruptions, stomach pain, swelling, tightness in chest and constipation
Drug: ketoprofen
Brand Names: Ketoprofen
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Capsule
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Dyspepsia, constipation, abdominal pain, edema, headache, nausea, renal insufficiency, flatulence, increased blood urea nitrogen, loss of appetite, troubled breathing and fatigue
Drug: flurbiprofen
Brand Names: Flurbiprofen
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No. Avoid using during third trimester due to chances of ductus arteriosus. During first and second trimester, lowest dose for shortest duration should be used.
Alcohol Content: No
Side Effects: Abdominal pain, bladder pain, cloudy urine, constipation, lower back pain, rash, swelling and vomiting of blood
(iii) Aryl Acetic Acid Derivatives:
Drug: Diclophenac, Aceclophenac
Brand Names: Voltaren
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Topical gel
Indicated in Pregnancy: Yes, under continuous monitoring
Alcohol Content: No
Side Effects: Skin rash, pain and burning sensation at the site of application, flu like symptoms, itching skin, eye pain, nasal congestion, redness of skin, tightness in chest and scaly skin
(iv) Indole Derivatives:
Drug: indomethacin
Brand Names: Indocin
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injection
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Mild headache, anxiety, bloating, lightheadedness, nausea, constipation, diarrhea, indigestion, heartburn, epigastric pain, decreased appetite, headache, dizziness and hot flushes
b. Preferential COX-2 Inhibitors :
These are the drugs that have more selectivity for COX-2 enzymes. They display their anti-inflammatory effect through other mechanisms as well.
Drug: nabumetone
Brand Name: Nabumetone
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Headache, itching skin, nausea, rash, stomach pain, swelling, indigestion, vomiting and chills
c. Selective COX-2 Inhibitors:
These are the drugs which display selective selection for COX-2 enzyme, without affecting COX-1 enzyme. Due to selective inhibition of COX-2 enzyme, they do not irritate the gastric lining and cause minimal damage to it. It should only be prescribed in patients who are at high risk of developing peptic ulcer, perforations and bleeds.
Drug: celecoxib
Brand Names: Celebrex
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Capsule
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Hypertension, diarrhea, abnormal liver function tests, dyspepsia, GERD, abdominal pain, peripheral edema, increased liver enzyme, cough, fever, sneezing, sore throat, swelling and vomiting
d. Analgesic -Antipyretics with poor anti-inflammatory action:
Drugs belonging to this class have weak peripheral anti-inflammatory action and an additive analgesic action. They poorly inhibit prostaglandins but have more action on COX present in brain. They too, do not produce gastric irritation. Drugs belonging to this class are:
(I) Para aminophenol derivatives:
Drug: acetaminophen
Brand Names: Acetaminophen
The U.S. FDA Status: Approved
Availability: OTC
Dosage Form: Extended release tablet
Indicated in Pregnancy: Yes, under continuous monitoring
Alcohol Content: No
Side Effects: Skin rash, sore throat, mouth ulcers, yellow eyes, diarrhea, increased sweating, loss of appetite, nausea and stomach cramps
2. Narcotic Analgesics:
Narcotic refers medically to any psychoactive compound which has sleep inducing properties. Narcotic analgesics refer to medicines of opioid origin that are used for treating moderate to severe pain. These drug molecules attach themselves to the opioid nerve receptors. These increase pain threshold and decrease pain perception. Some people take narcotic analgesics for short period of time till the pain goes away. Others, suffering from chronic pain who require proper pain management, use narcotics for long periods of time. These drugs have a high risk of being abused and misused.
a. Natural Opium Alkaloids:
These drugs are obtained naturally.
Drug: morphine sulphate
Brand Names: Arymo ER
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Abdominal pain, blurred vision, numbness, chest pain, confusion, cough, decreased urination, dizziness, fainting, severe constipation and slow heartbeat
Drug: codeine sulphate
Brand Names: Codeine sulphate
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Blurred vision, chest pain, fever, confusion, cough, decreased urination, dizziness, fainting, severe constipation and slow heartbeat
b. Semi-Synthetic Opiates:
These are made synthetically by modifying naturally occurring opiates.
Drug: hydromorphone
Brand Names: Dilaudid
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injectable
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Agitation, blurred vision, behavioral change, dry mouth, irregular heartbeat, lightheadedness, mood changes, rapid breathing, abdominal pain, vomiting, wrinkled skin, stiff neck, sunken eyes and unusual tiredness
Drug: hydrocodone
Brand name: Hysingla ER
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Extended release tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Bloating, body pain, chills, cough, depression, fever, headache, rapid weight gain, sore throat, tightness in chest and tingling in hands or feet
Drug: oxycodone
Brand Name: OxyContin
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Extended release tablet
Indicated in Pregnancy: Yes, under continuous monitoring
Alcohol Content: No
Side Effects: Chills, cold sweat, confusion, fever, twitching, tightness in chest, abdominal pain, cough, decreased frequency of urination, dry mouth, fainting and flushing
c. Synthetic Opioids:
These drugs are synthesized chemically and do not possess any resemblance to morphine structurally but bind to opioid receptors and show effects similar to that of morphine.
Drug: fentanyl
Brand Names: Duragesic
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Transdermal film
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Fever, nausea, diaphoresis, vomiting, hyperventilation, black stools, blurred vision, chest pain, confusion, dry mouth,
Drug: methadone hydrochloride
Brand Names: Dolophine Hydrochloride
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Black stools, bleeding gums, blurred vision, chest pain, cough, confusion, troubled breathing, dizziness, difficulty swallowing, extreme fatigue, headache, skin rash, loss of appetite, muscle pain and sweating
Drug: tramadol hydrochloride
Brand Name: Ultram
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Agitation, diarrhea, hallucination, nausea, tremor, vomiting, constipation, pruritis, diaphoresis, abnormal touch sensation, bloating, blood in urine, chest pain, chills and fast heartbeat
Drug: meperidine hydrochloride (pethidine)
Brand Names: Demerol
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Blurred vision, chest discomfort, confusion, cough, dizziness, skin rash, irregular heartbeat, pale lips, muscle twitching, sweating and upper abdominal pain
3. Centrally Acting Skeletal Muscle Relaxants:
These are the drugs which decrease tension in muscles by selectively acting on central nervous system, without altering consciousness. All of these drugs, however, have minor sleep inducing properties.
a. Mephenesin Congeners:
These are generally prescribes for treating muscle spasms.
Drug: chlorzoxazone
Brand Names: Chlorzoxazone
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: No
Side Effects: Drowsiness, headache, sedation, black stools, chills, confusion, cough, cold sweats, dizziness, fever, sore throat, unusual bleeding and fatigue
Drug: carisoprodol
Brand Names: Soma
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: No
Side Effects: Black stools, chest pain, chills, cols sweats, confusion, cough, dizziness, fever, loss of bladder control, muscle spasm, sore throat, unusual bruising and fatigue
Drug: methocarbamol
Brand Names: Robaxin
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: No
Side Effects: Black stools, change in skin color, chest pain, chills, diarrhea, dizziness, fast heartbeat, dark urine, headache, muscle pain, loss of appetite and nausea
b. Benzodiazepines:
These act in the brain by increasing the concentration of a neurotransmitter, gamma amino butyric acid (GABA), which acts as a muscle relaxant and help in relieving anxiety.
Drug: diazepam
Brand Names: Valium
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: Yes, under continuous monitoring
Alcohol Content: No
Side Effects: Unusual sense of well being, fear, mood changes, labored breathing, appetite loss, memory loss, nightmares and weight loss.
c. GABA Derivatives:
These drugs act in the brain by increasing concentration of a neurotransmitter, gamma amino butyric acid (GABA). This helps in relaxing the muscles and makes you calm.
Drug: baclofen
Brand Names: Lioresal
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injectable
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: No
Side Effects: Bloody dark urine, chest pain, fainting, skin rash, mental depression, hallucinations, depression, blurred vision, vomiting and shortness of breath
d. Central Alpha-2 Agonist:
These are the drugs acting on the alpha-2 receptors found on neuromuscular junctions. They have pain reducing effect.
Drug: trizanidine
Brand Name: Zanaflex
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: No
Side Effects: Dizziness, bradycardia, hypotension, drowsiness, asthenia, xerostomia, fatigue, constipation, fever, unusual tiredness and chest pain
4. Peripherally Acting Muscle Relaxants:
These drugs help in relaxing your muscles by relieving the tension in the muscles. It shows its effect on fast acting ‘twitch’ muscle, which help you in running and other powerful activities.
Directly Acting Agents: These drugs directly alter muscle contraction and help in controlling chronic spasms, including those occurring in spinal injuries.
Drug: dantrolene
Brand Name: Dantrium
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Capsule
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: No
Side Effects: Black stools, changes in speech, bluish skin, chest pain, confusion, decreased frequency of urine, joint pain, muscle cramps, nausea, skin rash and troubled breathing
5. Corticosteroids:
Drugs belonging to this class mimic the action of hormones produced in the body naturally by the adrenal gland. When they are prescribed in doses such that it increases the usual levels of adrenal hormones in the body, they curb inflammation. They also suppress immune system and prevent immune cells from attacking body’s own cells.
Drug: hydrocortisone
Brand Names: Anusol -HC
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Topical cream
Indicated in Pregnancy: No, unless benefits outweigh risk
Alcohol Content: Yes
Side Effects: Blistering, burning, crusting, drying or flaking of skin at the point of application, itching, redness of skin, acne, increased hair growth and lightening of skin color
Drug: prednisolone
Brand Names: Rayos
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Aggression, anxiety, agitation, dizziness, headache, irritability, nervousness, mood changes, noisy breathing, irregular heartbeat, weight gain and swelling of fingers, feet and hands
Drug: methylprednisolone
Brand Names: Medrol
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Aggression, anxiety, agitation, dizziness, headache, irritability, nervousness, mood changes, noisy breathing, irregular heartbeat, weight gain and swelling of fingers, feet and hands
Drug: dexamethasone
Brand Names: Decadron
The U.S. FDA Status: Discontinued
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Aggression, anxiety, agitation, dizziness, headache, irritability, nervousness, mood changes, noisy breathing, irregular heartbeat, weight gain and swelling of fingers, feet and hands
Drug: betamethasone
Brand Names: Celestone Soluspan
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injectable
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Weight gain, fluid accumulation, glucose intolerance, hypokalemia, ulcers, mood changes, insomnia, hypertension, impotence, menstrual irregularities, nausea, esophagitis ans dyspepsia
6. Serotonin nor-epinephrine re-uptake inhibitors:
These are the drugs which are generally used for treating depression but can also be used for managing chronic pain as well. They act by affecting the chemical messengers present in the brain. They block the re-absorption of the neurotransmitters, serotonin and norepinephrine present in the brain. However, their exact mechanism for alleviating pain is still not understood completely.
Drug: duloxetine
Brand Names: Cymbalta
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Capsule
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Constipation, diarrhea, dizziness, asthenia, fatigue, insomnia, nausea, sedation, xerostomia headache, erectile dysfunction, nervousness, psychomotor agitation, tension, decreased libido, anorexia, decreased appetite and restlessness
OTC Drugs Available
Over-the-counter pain revilers available in different countries as follows:
| Country | OTC Drugs Available for Back Pain |
| France | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| The USA | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone (in doses 0.5-1.0 %, topical) |
| Spain | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| China | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Italy | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| UK | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Germany | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone Diclofenac sodium |
| Mexico | Aspirin Ibuprofen Paracetamol Naproxen |
| Austria | Naproxen Paracetamol Ibuprofen Aspirin |
| Singapore | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Greece | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Ireland | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Denmark | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone Diclofenac |
| Hungary | Aspirin Ibuprofen Paracetamol Naproxen |
| Switzerland | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Czech Republic | Aspirin Ibuprofen Paracetamol |
| Croatia | Aspirin Ibuprofen Paracetamol |
| Japan | Aspirin Ibuprofen Paracetamol Naproxen Diclofenac |
| The Netherlands | Aspirin Ibuprofen Paracetamol Naproxen |
| Canada | Aspirin Ibuprofen Paracetamol Naproxen |
| Malaysia | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortison |
| Philippines | Propyphenazone Aspirin Ibuprofen Paracetamol Naproxen |
| Russia | Aspirin Ibuprofen Paracetamol Naproxen Diclofenac |
| India | Aspirin Ibuprofen Paracetamol Naproxen Ketoprofen Diclofenac (Topical) |
| South Africa | Aspirin Ibuprofen Paracetamol Naproxen Diclofenac |
| South Korea | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
| Argentina | Aspirin Ibuprofen Paracetamol Naproxen |
| Australia | Aspirin Ibuprofen Paracetamol Naproxen Hydrocortisone |
