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For patients with low back pain, providers should consider alternatives to drugs as first-line therapy, according to an updated clinical practice guideline from the American College of Physicians (ACP).

Moderate-quality evidence in the literature shows that chronic pain can be eased with exercise, multidisciplinary rehabilitation, acupuncture, and mindful stress reduction, according to , and colleagues on the ACP's Clinical Guidelines Committee, writing ..

Similar results have been observed in lower-quality studies with tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, laser therapy, operant therapy, cognitive behavioral therapy, and spinal manipulation, the panel determined.

If these fail to ease chronic pain, nonsteroidal anti-inflammatory drugs (NSAIDs) may then be a reasonable choice.

Qaseem and colleagues reviewed as well as .

In a change from the ACP's previous recommendations from 2007, acetaminophen (Tylenol) was no longer deemed effective for acute pain due to new evidence.

Duloxetine (Cymbalta) had modest effects for chronic pain and could be considered in the case of an inadequate response to NSAIDs; the opioid tramadol (Ultram) was yet another option.

However, "clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients," according to the guideline.

Acute or subacute low back pain is expected to improve over time regardless of treatment, Qaseem's group wrote, again strongly recommending non-pharmacologic treatments such as acupuncture, heat packs, and massage. When it comes to drugs, the ACP committee added, NSAIDs and skeletal muscle relaxants should be the go-to therapies.

The updated guideline was welcomed by , of University of Pittsburgh School of Medicine, who was not involved in the review.

"It is practice-changing in that clinicians do not routinely refer to complementary and integrative therapies such as mindfulness because up to now there were no studies to base their recommendations on," she told 番茄社区 in an email.

"With these updated guidelines, clinicians now have a menu of evidence-based non-pharmacologic treatments to offer their patients. Hopefully, insurance providers will now pay for effective therapies such as acupuncture and mindfulness-based therapies."

In line with that sentiment, an accompanying the updated ACP guideline highlighted two problems with prioritizing alternative treatments for low back pain: their limited availability and affordability.

"Moreover, these updated reviews and recommendations do not focus on diagnostic tests, such as magnetic resonance imaging, and invasive therapies, such as injections and surgery, which are major drivers of healthcare spending for low back pain," wrote , of Boston's Massachusetts General Hospital.

In fact, despite the large number of studies included in the reviews, Atlas argued that the evidence base for all treatments remains shaky.

"Likely what is needed is an 'all of the above' approach," he wrote. He called for "more pragmatic trials to evaluate proven therapies and their combinations in real-world settings; efforts to reduce the use of low-value services, such as payer coverage policies based on guideline recommendations; patient engagement through shared decision making; and pressure on insurers to cover non-pharmacologic, non-invasive therapies that have shown benefit."