Low back pain is the leading cause of disability worldwide and the problem is growing in frequency. In response, the World Health Organization (WHO) recently released its first-ever guidelines for the non-surgical management of chronic primary low back pain (LBP) in adults. These guidelines focus on evidence-based, non-surgical care recommendations to improve health and well-being outcomes related to chronic primary LBP, particularly in adults and older people.

Based on a review of research evidence worldwide on the benefits and risks of commonly used treatments for low back pain, the WHO recommended against using the following interventions:

1. Muscle Relaxants: The WHO guidelines take a dim view of muscle relaxants for low back pain, as they may not be effective and could have side effects.
2. Anticonvulsants: These are also not recommended for the treatment of chronic low back pain due to lack of efficacy and potential side effects. Anticonvulsants used for chronic pain include gabapentin, pregabalin (Lyrica) and Topiramate, among others.
3. Steroids: The use of glucocorticoids (steroids) is not advised for low back pain management.
4. Opioids: WHO strongly advises against the use of opioids as a stand-alone treatment for chronic low back pain. If used, they should be in the lowest dose and for the shortest duration, alongside other therapies.
5. Transcutaneous Electrical Nerve Stimulation (TENS): The WHO guidelines do not recommend TENS for chronic low back pain.
6. Injectable Anesthetics: Treatments involving injectable anesthetics like lidocaine or bupivacaine are not recommended.
7. Other Pharmaceuticals: This includes antidepressants, weight loss drugs, and certain other pharmaceuticals which are advised against for routine use in treating chronic low back pain.

The World Health Organization (WHO) recommends the following nonpharmacological therapies for chronic primary low back pain:

1. Education Programs: These are designed to support knowledge and self-care strategies for individuals suffering from low back pain.
2. Exercise Programs: Exercise is suggested as a key non-surgical intervention for managing chronic low back pain.
3. Physical Therapies: This includes spinal manipulative therapy and massage, which are recommended as part of the non-surgical approach.
4. Acupuncture or Dry Needling: This traditional therapy is recommended for its potential benefits in managing chronic low back pain.
   
   

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5. Cognitive Behavioral Therapy or Mindfulness: These psychological therapies are suggested for their role in managing pain and improving quality of life.
6. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): These are recommended for pain management, although they are pharmacological, their use is suggested in conjunction with nonpharmacological therapies.
7. Topical Cayenne Pepper: It is the only herbal remedy recommended by WHO for low back pain.
   
   

Due to what it cites as a lack of evidence or potentially harmful side effects, no recommendations are made regarding these substances for chronic low back pain:

1. Benzodiazepines 
2. Cannabis
3. Acetaminophen

Overall, the guideline advocates for an integrated, person-centered approach to LBP care, considering each person's unique situation and factors influencing their pain experience. The WHO's guidelines emphasize a holistic and non-surgical approach to managing chronic low back pain, recommending nonpharmacologic therapies primarily and advising against certain pharmacological treatments that are either ineffective or carry significant risks. For more details, you can refer to the WHO's chronic low back pain guidelines.

The WHO’s recommendations largely overlap with other guidelines developed in the United States over the last seven years for chronic pain management, including:

CDC’s Opioid Prescribing Guidelines (first issued in 2016, updated in 2022) recommend a range of nonpharmacological therapies for the management of subacute and chronic pain. These recommendations emphasize the use of nonpharmacologic approaches as they do not carry the same risks as opioids and can be equally effective for many types of pain. Some of the noninvasive, nonpharmacologic approaches recommended by the CDC include:

1. Exercise and exercise therapy, including aerobic, aquatic, and resistance exercises.
2. Mind-body practices such as yoga, tai chi, and qigong.
3. Psychological therapy, particularly cognitive behavioral therapy.
4. Manual therapies, mindfulness-based stress reduction, and low-level laser therapy.
5. Acupuncture, massage, and spinal manipulation.

These therapies are favored for their positive benefit-to-risk profile, encouraging active patient participation in the care plan and addressing the effects of pain in a patient's life.

National Pain Strategy (2016)  offers a comprehensive approaches to chronic pain management. The overall emphasis is on evidence-based strategies that address the biopsychosocial nature  of chronic pain, while addressing various aspects including opioid prescription, but also focusing on multidisciplinary approached that include physical therapy, psychological interventions, and other non-pharmacological strategies.

Additionally, the National Pain Strategy emphasizes the importance of comparative effectiveness research for nonpharmacological therapies and integrative care approaches. This approach is aligned with initiatives like the NIH Back Pain Consortium (BACPAC) and the Pain Management Effectiveness Research Network, which support research and trials on nonpharmacological approaches embedded in various health systems.

While specific nonpharmacological therapies are not listed, the National Pain Strategy clearly supports a diverse and integrative approach to chronic pain management, prioritizing noninvasive and nonpharmacological methods where appropriate and effective.

The American Academy of Family Physicians (AAFP) clinical practice guideline for the diagnosis and treatment of low back pain (2017) recommends various nonpharmacologic treatments. These recommendations, developed by the American College of Physicians and endorsed by the AAFP, include:

1. For Acute or Subacute Low Back Pain:
   • Initial nonpharmacologic treatment should include superficial heat, massage, acupuncture, or spinal manipulation.
2. For Chronic Low Back Pain:
   • Initial nonpharmacologic treatment should include exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation.
   • If there is an inadequate response to nonpharmacologic therapy, NSAIDs are recommended as the first-line pharmacologic treatment, followed by consideration of tramadol or duloxetine. Opioids should only be considered if other treatments are unsuccessful and after careful consideration of the benefits and risks.
     
     

Other therapies not mentioned in any of the guidelines

There are even more therapies that were not reviewed for any of the guidelines that are helpful for low back pain and other chronic pain conditions, including kratom, CBD, nutritional supplements (especially Vitamin D, magnesium, Omega 3 fatty acids, B12), pulsed electronic frequency (PEMF), microcurrent therapy, neurofeedback, homeopathy, essential oils, herbal supplements (especially turmeric), pain processing therapy and more. A closer look at cannabis (marijuana) would yield extensive evidence of efficacy in treating chronic pain, though there might not be many studies focusing specifically on low back pain.

Most Pain Patients Want Access to Alternative Pain Treatments
 

A 2021 Harris Poll found that:

• 83% of chronic pain patients did not want to use opioids to manage their pain
• 80% were interested in using a nutritional approach
• 71% were interested in using exercise
• 68% were interested in using massage therapy
• 62% were interested in using physical therapy

It’s time for a change in U.S. Healthcare Policy

Over the last two decades, over a million people have died of opioid overdoses, most after being prescribed opioids for the management of LBP and other acute and chronic pain conditions. Millions more have become addicted and many, many millions more have continued to suffer without adequate treatment. These sufferers include chronic pain patients who became dependent on opioids for chronic  pain management and then were abruptly tapered or discontinued from opioids while being offered other dangerous and ineffective drugs or nothing at all. Most are prevented from accessing beneficial nonpharmacological pain treatments because health insurance companies almost universally refuse to cover any of them.

Besides the human cost, the annual cost of chronic pain in the U.S., including medical care and lost productivity, is over $600 billion and the cost of the opioid epidemic is over $1 trillion a year.

It's way past time for a change in U.S. healthcare policy to require health insurance, including Medicaid and Medicare, to cover nonpharmacological treatments for pain. Please sign my petition on Change.org to ask Congress and President Biden to require insurance companies to cover these treatments.

The author, Cindy Perlin, is a Licensed Clinical Social Worker, certified biofeedback practitioner and chronic pain survivor. She is the founder and CEO of the Alternative Pain Treatment Directory and the author of  The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. She's located in the Albany, NY area, where she has been helping people improve their health and emotional well-being for over 27 years. See her provider profile HERE.  She is also available for phone and zoom consultations, Find more information HERE  

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