SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky

Date: October 9th, 2020 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED. Reference: Friedman et al. Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study. AEM 2020. Case: A 41-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started 48 hours prior to the ED visits after attempting to move a couch in his house. He describes the pain as sharp, constant, non-radiating, and 6/10 in intensity. Pain gets worse with movement and minimal bending. The pain is limiting his usual activities included his ability to go to work. He denies weakness or numbness of the legs as well as bowel or bladder dysfunctions. You perform a physical exam and note prominent tender area to palpation at the right lumbar region. You explain to the patient the most likely diagnosis is a muscle strain. Your usual approach is to treat this type of case scenario with Ibuprofen. The patient asked you if Ibuprofen alone will be strong enough to control his pain. Background: Pain is one of the most frequent reasons to attend an ED. Low back pain (LBP) is responsible for 2.3% of all ED visits resulting in 2.6 million visits each year in the USA (Friedman et al Spine 2010). We have covered back pain a number of times on the SGEM. * SGEM#87: Let Your Back Bone Slide (Paracetamol for Low-Back Pain) * SGEM#173: Diazepam Won’t Get Back Pain Down * SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain The SGEM bottom line from SGEM#240 was: There appears to be no long-term analgesics benefits from prescribing opioids for chronic non-cancer pain (nociceptive and neuropathic). However, their use is associated with increased adverse events. The American College of Emergency Physicians (ACEP) has updated their clinical policy on prescribing opioids for adult ED patients. There are no Level A recommendations, one Level B recommendation and multiple Level C recommendations (ACEP June 2020) * In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? * Level B Recommendations: When possible, treat opioid withdrawal in the emergency department with buprenorphine or methadone as a more effective option compared with nonopioid-based management strategies such as the combination of α2-adrenergic agonists and antiemetics Many other pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success. These include: acetaminophen (Williams et al Lancet 2014), muscle relaxants (Friedman et al JAMA 2015), NSAIDs (Machado et al