A new evidence-based clinical guideline for treating low back pain emphasizes nonpharmacological approaches and says drug treatments should be used only when other methods are unsuccessful. The American College of Physicians (ACP) guideline, an update to the ACP's 2007 guideline on the topic, also notes that acute and subacute low back pain usually resolves by itself in time. Recommended treatments include superficial heat (which the ACP says is supported by moderate-quality evidence) and massage, acupuncture, and spinal manipulation (low-quality evidence). When drugs are called for, the guideline says there is moderate-quality evidence for nonsteroidal antiinflammatory drugs (NSAIDs) and skeletal muscle relaxants.

For chronic low back pain, the ACP advises initial use of "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence)."

In chronic low back pain unresponsive to these approaches, the ACP guideline says the following can be tried: NSAIDs as first-line therapy, or tramadol or duloxetine as second-line therapy. Opioids should be considered afterward only on a case-by-case basis and only if the potential benefits outweigh the risks and there has been a discussion with patients of the known risks and "realistic" benefits. There was no or insufficient evidence to determine treatments for radicular low back pain, the ACP concluded.

The ACP guidelines committee reviewed the relevant literature published through April 2015, and then performed updated searches through November 2016. The ACP notes that low back pain is one of the most common reasons for physician visits in the United States and is associated with high costs, both direct and indirect.-Serena Stockwell

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