For managing non-specific low back pain, NICE guidance NG59 says non-steroidal anti-inflammatory drugs (NSAIDs) can be considered. Any recommendation should reflect aspects such as the potential for gastrointestinal, liver and cardio-renal toxicity as well as risk factors such as the patient’s age. Oral NSAIDs for low back pain should be prescribed at the lowest effective dose for the shortest possible period of time.15

Only if NSAIDs are contraindicated, are not tolerated or are ineffective should a weak opioid (with or without paracetamol) be considered. Opioids should not be offered routinely or be used for chronic low back pain, and paracetamol should not be offered on its own.

Other drugs that NICE says should not be offered for low back pain include selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants or anticonvulsants.15

A muscle relaxant such as a benzodiazepine may be necessary if the patient is experiencing muscle spasms. NICE suggests a short course such as diazepam 2mg up to three times a day for up to 5 days if not contraindicated. However, NICE currently states that “the evidence base to support use of this particular medicine [diazepam as a muscle relaxant in the treatment of lower back pain] is extremely small.”11,18

NG59 does not refer to the use of topical analgesics in back pain with no sciatica. However, several topical medicines, are licensed for use in musculoskeletal conditions including backache.19