Podcast: OTC management of acute low back pain

With the ever-changing landscape of over-the-counter (OTC) pain management in recent years, it’s important to revisit guideline recommendations to optimally assess and manage patients with acute pain.

Unrelieved acute pain can negatively impact patient well-being, affecting their sleep, physical functioning, and overall quality of life, and increases the risk of transition to chronic pain.¹ Applying appropriate evidence-based interventions throughout an acute pain consultation can help pharmacists minimise the risk of inadequate pain management.^2,3

In this CPD-accredited podcast, pharmacist John Bell discusses reducing risk in the management of acute low back pain (LBP), alongside a real patient for a first-hand perspective on how pharmacists can apply guideline recommendations to enhance care.

The first step to reduce risk in acute LBP is thorough assessment and history taking to ascertain the impact of the pain.³ This is critical for identifying ‘red flags’ that suggest a serious pathology requiring referral, or ‘yellow flags’ that suggest risk factors for chronicity and may need further attention.³ For patients with acute, mild episodes, this also provides an opportunity to reassure on the benign nature of the pain and favourable prognosis.³

Secondly, educating patients on the importance of staying active and correcting any misconceptions about pain management is key to encourage self-management and prevent setbacks in recovery.³ Finally, pharmacists play a key role in optimising use of OTC pharmacotherapy to mitigate risk. Pharmacotherapy should not be used alone but alongside non-pharmacological interventions to facilitate physical activity, and should be evidence-based – guidelines recommend oral NSAIDs first-line, while multimodal analgesia may be an option for patients presenting with moderate-to severe acute pain.^2,3 Reinforcing correct dosing instructions is another fundamental step to minimise the risk of harm, ensuring that OTC medicines are not used for more than a few days at a time.²

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Transcript

John Bell 00:09
Hello, welcome to this Australian Pharmacist podcast on acute pain management. I’m John Bell. I’m a community pharmacist and I work as a practitioner teacher at the School of Pharmacy at the University of Technology in Sydney. Pain is something I’m really interested in, I guess we all are, aren’t we? Because it’s something we’ve all suffered from time to time, but it’s something that I’ve taken an interest in for many years. I work at a hospital where I’m mainly involved in post-surgical pain management.
This CPD activity is sponsored by Reckitt. All the content is true, accurate, and it’s the independent opinion of myself. And of course, our guest, who you’ll meet a little bit later.
So today we’re speaking about acute pain. What’s acute pain? Well, it’s something that comes into our pharmacy with our patients grimacing or holding their heads or their arms or the legs or whatever. It’s musculoskeletal pain, it’s a headache, it’s migraine, it’s period pain, it’s a flare-up of osteoarthritis, or its low back pain and low back pain is specifically what we’re going to be talking about today. And I’m going to be helped in a little while by a special guest here in the studio. Louie is one of our real-life patients suffering with low back pain.
Now, non-prescription or OTC pain relievers, OTC as we generally calling them, they’re an important component of self-management of acute pain. However, the OTC pain landscape has gone through so many changes in recent years. I’m sure you can remember the upscheduling if you like of codeine products back in 2018.
More recently, of course, modified-released paracetamol, was rescheduled, there’ll be a reduction in pack sizes and accessibility as well of the immediate-release paracetamol, and that’s due to be implemented in early 2025.
The role of pharmacotherapy in acute pain, of course, continues to be a really important topic for pharmacists, and something we need to stay up to date with to, to make sure our patients are being provided with the most appropriate, the optimal therapy, a combination perhaps of interventions to ensure that the therapy is best for them.
Now to this end, in this discussion we’re looking specifically as I mentioned, at I think one of the most common presentations in primary health care, that’s low back pain. As well as affecting patient wellbeing, sleep, physical functioning and overall quality of life, we know that inadequate acute pain management can also increase the risk of transition to chronic pain. So, so important.
In one US study that involved over 5000 patients, almost a third of those patients with acute low back pain transition to chronic pain at six months. And it was found that deviations from guideline-recommended processes of care within the first 21 days were associated with a greater likelihood of developing chronic low back pain.
Of course, chronic low back pain can be very severe and disabling and this underlies not only the importance of early intervention of acute low back pain, but that these interventions are aligned with guideline recommendations. And we’re going to be exploring this today, with help from Louie, our real-life patient. Louie, maybe you should introduce yourself to our audience today.

Louie Tan 04:20
So I’m Louie, I’m 34. I work as an accountant, I’m the father of two young boys, a four-year-old and a one year old. My back pain started back in high school when I was playing tennis and basketball for the school. I also started going to the gym around that time. A lot of my time now I spend sitting in front of a screen. Obviously as an accountant, and particularly during COVID, I didn’t get to walk around as much as I used to, being stuck at home. A lot of my back pain now sort of stems from lifting and carrying the kids and doing sports still.

John 04:53
Thanks for that background. Look. I know from my own experience, trying to carry around a couple of young boys under five is a bit of a bit of a challenge even more so than sitting in front of a computer screen. So it’s great that you can provide us with this firsthand perspective in regard to the needs of a patient with acute low back pain. But tell me what does like back pain typically feel like for you?
What’s your experience in discussing your pain with health professionals, whether it’s your doctor or your pharmacist?

Louie 05:22
Yeah, when I get the back pain, it’s usually a really sharp pain, or a pinching pain on either left or right side. Usually I get the best responses from the physio. I’ll usually tend to go to them when it gets quite bad. If it doesn’t go away after a couple of days, I will go to the doctor as well, just to make sure that everything is okay. But I don’t have much experience talking to the pharmacist about it.

John 06:00
I hope we can fix that, Louie. I hope that we can make you feel really comfortable in talking with your pharmacist and you get some really good advice. And I hope all of our patients will be able to get the very best advice from their pharmacy maybe after listening to our experience together here Louie. It’s great that you’ve got that positive experience with your physio. Thorough assessment and history taking is such an important step to ascertain the impact of pain. Low back pain often manifests as a sharp pain, as you’ve said, an ache or a spasm felt in the midline or on either side of the back. It may also involve stiffness that that causes difficulty turning or bending or accompanying pain in one or both legs. I mean, from my experience, I’ve found that I’ve had a little bit of sacroiliac joint problems from time to time. So getting out of bed is a problem for me once until I get moving. But for us pharmacists, you know, asking the patient questions about how their pain has affected their range of movement and daily activities can help ascertain their pain intensity. I guess from time to time, physical examination may also be warranted. Maybe not so far as we’re concerned as pharmacists, but being able to know when to refer on to the doctor, or the physio is really important for us to identify those red flags that might suggest serious pathology. Because these include things like signs of infection, history of trauma or malignancy, maybe unexplained weight loss, and indeed pain at various multiple sites. The other things I guess we need to be concerned about altered bladder or bowel functions, or altered reflex. So these are the things as pharmacists we need to just look out for. There are also, I guess, what I like to call yellow flags, not just red flags, but yellow flags. Risk factors associated with chronicity that may need further attention and influence our management approaches. As I mentioned earlier, chronicity is such a major, major issue and so much more difficult to treat. We need to treat that pain at the first available opportunity to prevent chronicity occurring. So leg pain, older age, poor general health, these are all things that are the yellow flags, social factors, of course, such as mental stress, anxiety and depression. So red flags, yellow flags, wait for those lights to turn green, and then we can proceed with our management strategies. So when there are no red or yellow flags symptoms, then it’s almost always indicative of simple, nonspecific low back pain, most likely due to muscular strain and we can move on to a management plan. Louie, maybe you can tell us a little bit more about perhaps a specific back pain occasion you’ve had might be for the first time or perhaps even the most recent one that was quite significant. How did you go about managing that?

Louie 09:47
Yeah, actually, in the last couple of weeks, my youngest was crying in the cot next to us in the middle of the night. I tried to go and pick him up. I must have picked him up in a really awkward position. I immediately felt some pain on both sides of my lower back and ended up falling down on the bed immediately. Couldn’t get up and needed to get some medication in order to just numb the pain and try to get through the night. Even tried a heat pack, but wasn’t really that successful with it. Over the next couple of days, I went to the doctor because it just wasn’t going away. And it was just weird having pain on both sides. Ended up being not very serious from the GP’s point of view. And yeah, just kept taking some medication until it went away. Also went to the physio just to get a tune-up just to make sure that everything was in, you know, everything was in the right place.

John 10:39
I think you’ve done exactly the right thing and your GP was spot on. For most patients, minimal intervention is all that’s required. The symptoms resolve with appropriate patient education and reassurance. Of course, this should include, from our point of view too as pharmacists, explaining that most back pain is caused by simple strain – it’s unlikely to be due to a serious underlying cause. Most importantly, we need to recommend that our patients avoid bed rest. They must stay active like you’ve been doing, Louie, and continue to work.
We need to correct misconceptions about addressing fear avoidance behaviour, I think that’s what we could call it. People are afraid to move, afraid to work, afraid to be active, because these are the things that cause setbacks. People think that maybe I shouldn’t move if there’s still pain. Well, of course, that’s so wrong. I believe the most important pain management principle with low back pain is that pharmacotherapy should not be used alone. Pharmacotherapy is intended to facilitate physical activity and staying active, not to completely eliminate the pain. So we must give our patients realistic expectations. Manage their expectations, discuss reducing pain versus being pain-free. This will help avoid unnecessary escalation of pharmacotherapy as well.
Passive non-pharmacological interventions, like as you’ve mentioned, Louie, using a heat pack, sometimes a cold pack, depending on the issue or the condition, may also be recommended and is very, very useful. Louie, I’ve got another question for you. What influences your choice of medicine for your low back pain? Do you feel like you understand the difference between the different available pain relievers?

Louie 12:44
Yeah, I usually just take some ibuprofen. And you know, also take some paracetamol as well, if needed. My decisions in the past, up till now, they’ve really been driven by the pharmacist and recommendations from friends. But over the years, I’ve come to know what sort of best works for me and I tend to stick with those ones. I have asked the pharmacist before for the differences between the different medications, but gotten really vague answers for the most part. But that might be mostly because I may have been speaking to an assistant rather than an actual pharmacist. I mean, I would be interested to move to a medicine that does specifically target what I’m feeling at the time, but otherwise, I’ll just stick to what I know.

John 13:27
Louie, there’s some great messages there for us pharmacists really. I think it’s important that we, as pharmacists, train our staff to refer people like yourself to us to the pharmacist, you know. The medications that we can provide particularly in our Schedule three category, the Pharmacist Only category are very often so much more appropriate than what can be self-selected. So communication is so so important. The use of medicines should be aligned with guideline recommendations.
Of course, we know that low back pain is associated with inflammation, in this particular instance of the surrounding muscle layers. The therapeutic guidelines for nonspecific low back pain, recommend oral NSAIDs, such as ibuprofen, for instance, to be trialed first. Of course, NSAIDs work by inhibiting prostaglandin synthesis, thereby exhibiting both analgesic and anti-inflammatory effects. We know NSAIDs are contraindicated in some patients. This includes those with severe heart failure, severe hepatic impairment or active peptic ulcer disease, and gastrointestinal bleeding. So potential benefits need to be weighed against potential harms always when recommending any medication and when deciding what to recommend.
Differentiating between non-prescription and prescription doses of NSAIDs and the various types of NSAIDs, for example, is important. And non-prescription doses of ibuprofen, we should remember, have the same low-risk GI side effects as paracetamol when taken by patients without contraindications or precautions. I always remind my staff and particularly the pharmacy assistants, that ibuprofen taken in non-prescription doses for the appropriate duration – that’s a few days – need not be taken with food.
Now of course, we know that NSAIDs are not always appropriate. Paracetamol may be the way to go if the NSAIDs are not suitable, but paracetamol of course has negligible anti-inflammatory effects.
It can be offered when NSAIDs are contraindicated, but evidence does suggest that it’s ineffective for nonspecific low back pain. So NSAIDs, first choice. Of course, importantly, opioids have been found to have little benefit in acute nonspecific low back pain, and therefore have a very, very limited role in management.
While not explicitly mentioned by the therapeutic guidelines for nonspecific low back pain, another option I think we should consider for appropriate patients presenting with moderate to severe acute pain is multimodal analgesia. That’s as you know, combining analgesics with different mechanisms of action to have a synergistic effect, while of course allowing for lower doses of the individual medicines. That’s, for instance, the combination ibuprofen and paracetamol. We’ve got some available options in Australia, which include ibuprofen 200 mg and paracetamol 500 mg, and the 150 ibuprofen 500 paracetamol. I think these are worthwhile considering for mild to moderate low back pain as well.
Of course, if pain relief is insufficient, then patients can be referred to their GP, perhaps for add-on therapy if he or she deems it appropriate. Regardless of what pharmacotherapy is recommended, it’s important for our patients to understand, for us to communicate to our patients, the correct dosing instructions, dose, frequency, duration. Louie, we talked about what you were using for your low back pain. Is there anything that would make you think about deviating from dosing instructions? That is, taking more or less than recommended? I mean, we know there are risk factors here. What do you know about the potential consequences of inappropriate or prolonged use, perhaps of pain relievers?

Louie 18:37
Yeah, at the moment, especially with two young kids, I try to not take too much medication anyway. And definitely don’t want to be overdosing just because I don’t want to be ever out of action to be, you know, just to be there for the family. I’ve also been told in the past that taking pain relievers too often cause them not to be as effective over time, so I kind of tend to stay away from them and only use them when I really need them.

John 18:59
It’s a good point to make, Louie. Of course, toxicity is also always a potential problem. I guess with any medication, and we should be warning patients, I think specifically about paracetamol, which is kind of ubiquitous, isn’t it? I mean, paracetamol is not only in non-prescription preparations, but prescription medicines as well, Schedule 3 medicines, it’s in cold and flu products. So that’s something we need to be aware of and concerned about, that if people are taking more than one paracetamol product, they may be inadvertently taking more than they should. So we need of course, always to reinforce those dosing instructions, and that non-prescription medicines should not be used for more than a few days at a time. Of course, If symptoms persist, you’ve heard the line, patients should see their doctor.

Louie, thank you so much for your participation today. Your insights have been very valuable. Now there are some takeaway messages for us pharmacists, I very strongly believe. With regard to low back pain, and in the absence of red or yellow flags, our primary recommendation is to keep moving, avoid bedrest, maintain mobility, just keep active. Of course, patients need help, guidance, when it comes to the use of pain relievers. We need to select the most appropriate. Key areas to counsel on include how different medications work, and how that influences the most appropriate option for us. Low back pain is associated with inflammation, as with most acute pain conditions, therefore NSAIDs are recommended first line for short-term relief. Again, correct dosing instructions, dose, frequency, duration, and wherever possible, provide your patient with printed educational material.
Meanwhile, check out the guidelines with other pain education resources, familiarise yourself with recommendations for other specific indications. And remember to earn CPD points. We all want them, don’t we from this podcast? Don’t forget to visit psa-ph.osky.dev and complete the assessment questions. Thank you so much. See you next time.

References:

1. Sinatra R. Pain Medicine 2010;11:1859–1871.
2. Using analgesics to manage acute pain [published December 2020; amended August 2022]. In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; accessed August 2023. https://www.tg.org.au.
3. Low back pain [published March 2017]. In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; accessed August 2023. https://www.tg.org.au.

Our speakers

John Bell AM (he/him) BPharm, FPS, FRPharmS, FACPP, MSHP, FFIP, FCPA.
Mr Bell is a practitioner/teacher at the Graduate School of Health, University of Technology Sydney, and has a community pharmacy practice.

Louie Tan (he/him).

CONFLICT OF INTEREST DECLARATIONS:
Mr Bell has been a member of advisory boards for, or provided advice to: Astellas, Astra Zeneca, Bayer, GSK, Mylan, Novartis, Nutricia, Pfizer, Procter & Gamble and Reckitt Benckiser. He is currently a member of the international multidisciplinary Global Pain Faculty.

Mr Tan has no conflicts of interest to declare.