Medication for back pain.
Detailed overview.
Medication
Based on NHG · WHO · NICE
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Medication plays a limited role in treating back pain. No medication cures back pain; they can only temporarily relieve symptoms while your body heals. Here is a detailed overview based on WHO (2023), NICE (2016) and recent trials.
NSAIDs
First choiceHow do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Of all the painkillers used for back pain, NSAIDs have the best evidence. In a review of 301 placebo-controlled trials they were the only treatment shown to be effective for acute low back pain (Cashin et al., BMJ EBM 2025), and Cochrane (2020) points the same way. Be realistic about the size: the effect is small, and a network meta-analysis of all analgesics found considerable uncertainty, with no medicine proven effective with high confidence (Wewege et al., BMJ 2023).
Examples
Ibuprofen, naproxen, diclofenac
Dosage
Ibuprofen 400mg max 3x/day; naproxen 250-500mg max 2x/day. Max 7-14 days.
Caution
Take with food. Use caution with stomach issues, kidney disease, heart failure, high blood pressure. Do not combine with blood thinners. Do not use during pregnancy, especially not in the third trimester.
Paracetamol (acetaminophen)
Guidelines disagreeHow do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
The PACE trial (Williams et al., Lancet 2014) showed that paracetamol is no better than placebo for acute low back pain, and Cochrane (2016) confirmed it. On that basis WHO (2023) and NICE do not recommend it.
Your Dutch GP will probably still suggest it first, and that is not an oversight. The NHG standard for non-specific low back pain names no drugs itself; it refers on to the stepladder in the NHG standard on pain, where paracetamol is step one, on the stated principle of the lightest sufficiently effective treatment with the fewest side effects. Thuisarts.nl puts that to patients as: “start with paracetamol, it has the fewest side effects”. The reasoning is different, not the evidence: the standard itself says the effect of painkillers on non-specific back pain is probably limited, and then picks the one that does the least harm. NSAIDs are probably not more effective than paracetamol, only riskier.
Why guidelines disagreeOpioids
Not recommendedHow do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
The OPAL trial (Jones et al., Lancet 2023) showed that opioids are no better than placebo for acute low back pain, but cause more side effects. The WHO (2023) does not recommend opioids. The risk of dependence, misuse and overdose is significant and increasing.
Muscle relaxants
LimitedHow do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Limited evidence for short-term pain relief in acute muscle spasm (BMJ 2021); little to no effect on function. Significant side effects (drowsiness, dizziness). Risk of dependence with benzodiazepines. No longer than 1-2 weeks.
Antidepressants (duloxetine)
Some evidenceHow do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Duloxetine (SNRI) has some evidence for chronic back pain (ACP 2017). Works via the pain-inhibiting pathway, not via antidepressive action. Only consider for chronic pain, not acute back pain. Must be tapered gradually.
How long do you use painkillers?
Day 1–3
Start if needed
NSAID with food; check with pharmacist or GP if unsure.
Day 3–14
Keep it short
As short as possible, and keep moving in the meantime.
After 2 weeks
Stop, or see your GP
Still in a lot of pain? Do not keep taking them on your own.
Sources
- WHO Guideline on management of chronic primary low back pain (2023)
- Williams CM, et al. Efficacy of paracetamol for acute low back pain. Lancet (2014)
- Jones CMP, et al. Opioid analgesia for acute low back pain. Lancet (2023)
- NICE Guideline NG59 (2016)
- NHG-Standaard Aspecifieke lagerugpijn (2017, laatst gewijzigd 2024)
- NHG-Standaard Pijn (2018), tabel 1: het medicamenteuze stappenplan
- Qaseem A, et al. ACP Clinical Practice Guideline (2017)
- Cashin AG, et al. Muscle relaxants for non-specific low back pain. BMJ (2021)
- Cashin AG, et al. Analgesic effects of non-surgical and non-interventional treatments for low back pain. BMJ Evid Based Med (2025)
- Wewege MA, et al. Comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain. BMJ (2023)
- Thuisarts.nl. Ik heb lage rugpijn (NHG)
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