Why those back pain pills won’t work — but here’s what WILL

Thousands of people are prescribed muscle-relaxant drugs each year. Now, surprising evidence shows . . .

WHeTHer it’s the result of a small, innocuous movement, lifting heavy luggage or playing sport, lower back pain is an all too familiar problem.

In the UK, around one in six is affected by it at any time, and it is the leading cause of disability globally.

A common treatment is a musclerelaxant drug, such as diazepam or baclofen, with 1.3 million prescriptions issued on the NHS each year.

But new research has found that they have little impact on tackling the pain — which is a concern as diazepam, for instance, has potentially serious side-effects, including drowsiness, dizziness and addiction.

Muscle relaxants cover a broad range of medications used in lower back problems to target pain radiating out from the muscles and spasming around the lower spine and pelvis.

Spasms are the body’s way of protecting itself, ensuring that the injured area is kept still. In the UK, by far the most commonly prescribed muscle relaxant for back pain is the anti-anxiety medication diazepam (previously available as Valium), which is a type of benzodiazepine and is thought to slow down the transmission of messages between nerve cells in the spinal cord.

More than 350,000 prescriptions for diazepam are written every month by gPs in england and around 100,000 for baclofen (an antispasticity medication to help painful spasms in neurological conditions). Not all will be for back pain — diazepam is also used for anxiety and seizures, and baclofen for multiple sclerosis, cerebral palsy and end-of-life care.

THe new research, published in The BMJ last month, looked at the results of 31 studies, involving 6,500 patients. The researchers said some evidence from ‘poor quality’ studies showed that antispasmodic drugs might reduce pain intensity for two weeks or less for patients with acute lower back pain compared with patients not given any treatment.

But this effect is so small (less than eight points on a zero to 100 point scale), it would probably not be noticed by a patient, according to the Australian researchers. They noted there is also the risk of side-effects.

This work contradicts earlier research, including an influential Cochrane review in 2003, which found muscle relaxants brought some relief. Another study, from the University of

Sydney in 2017, also found they were effective in easing shortterm back pain.

The lead researcher on the new review, Professor James McAuley, a psychologist at the University of New South Wales, Sydney, says the results were a surprise.

He told good Health: ‘The muscle relaxants definitely had less of an effect than we thought, and any small benefits have to be weighed against the side-effects.’

The findings follow other research over the past few years showing that standard treatments including paracetamol and non-steroidal anti-inflammatory drugs, such as ibuprofren also don’t tackle the pain.

‘After finding that paracetamol and ibuprofen were less effective than placebos, the muscle relaxants were really the last drug option available for the many people with lower back pain,’ says Professor McAuley.

‘Now we have found they don’t work, we wanted to find something that would work for patients who want to take the edge off their back pain and return to usual activities, but these aren’t the answer.’ Under guidelines from the National Institute for Health and Care excellence (NICe), diazepam should not be used for back pain, as there is no evidence it works. Yet as Stephen Ward, a consultant in pain medicine at guy’s and St Thomas’ NHS Foundation Trust in london, explains, diazepam is nonetheless commonly prescribed by gPs for back pain.

He said: ‘The use of diazepam has not gone down much since then and I suspect that the majority of these prescriptions are for lower back pain.

‘But we know there is really no evidence that it does any good and it shouldn’t be used. It is unusual for me to see a patient with long-term back pain who has not been on this medication, and it is generally offered after anti-inflammatory painkillers such as ibuprofen have not worked. The problem is that gPs only have about five minutes, so it is understandable that prescribing tablets takes preference over more time-consuming discussions around reassurance and exercise.’

Dr Ward, who helped draw up the NICe guidelines on lower back pain, suggests the medication may, however, have some positive impact on patients’ mood, as many will be very anxious due to their back pain. ‘Being in pain is stressful so taking the edge off that anxiety can make people feel less worried about the pain,’ he says.

‘But they should only be on these drugs in the very short term as they have considerable side-effects. However, I have seen people on them for years and even decades.’

As benzodiazepines can be addictive, some patients struggle to come off them, as highlighted by good Health’s Save the Prescription Pill Victims campaign.

HOWeVer, some doctors argue that very shortterm use of diazepam for people experiencing an agonising acute episode of back pain can be helpful.

Paul Thorpe, a consultant spinal and trauma surgeon at Somerset NHS Foundation Trust and Nuffield Health Taunton Hospital, says that when someone’s back muscles go into a very strong spasm — the kind that leaves them unable to move and may force them to A&e — a short, preferably just one, dose of diazepam may help.

‘Someone can be completely poleaxed by this pain and while muscle relaxants are not to be used in the long term for chronic back pain, keeping a small dose of 5mg to 10mg of diazepam to occasionally take in a crisis is not unreasonable,’ he says.

‘Treatment options are very limited for people with back pain and they need an approach during a crisis.’

Professor Martin Marshall, chairman of the royal College of gPs, agrees: ‘gPs have long been aware that muscle relaxants prescribed for short periods of time can sometimes be an effective treatment for patients suffering with acute back pain spasms...when combined with self-treatment such as applying heat and ice to the affected area, as well as moderate exercise.’

However, according to back pain experts and NICe, the only approach proven to work is to stay as physically active as possible. As Professor McAuley explains: ‘Don’t stay in bed — get up, do your normal activities — although rest during the day if you need to. I know that it is hard, but we know that people who lie in bed take much longer to recover.’ Dr Ward says reassurance from gPs is also crucial to help reduce patients’ anxiety.

‘explaining that lower back pain is rarely caused by something sinister, and it will resolve by itself, generally within a few weeks, is really helpful,’ he says.