If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (eg, one week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion.

Finally, it is important to be supportive of patients with acute low back pain while at the same time setting realistic expectations. They need to know that their pain may not be 100 percent relieved in the emergency department and that symptoms could persist for weeks or even months.^4–6

Clinical Question

In patients with acute nontruamatic, nonradicular low back pain, will a short course of diazepam added to naproxen improve functional outcomes at one week?

Reference

Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain (published online ahead of print Jan. 19, 2017). Ann Emerg Med. pii:S0196-0644(16)31214-8.

• Population: Adult patients presenting to the emergency department with acute low back pain ≤2 weeks of duration that caused functional impairment (score >5 on the Roland-Morris Disability Questionnaire [RMDQ]) and discharged home.
• Exclusions: Radicular pain, pain >2 weeks or a baseline low pain frequency of at least once per month, absence of other non-musculoskeletal causes of pain, no direct trauma to the back, unavailable for follow-up, pregnant or breastfeeding, those with chronic pain syndrome, and those allergic or intolerant to the use of the investigational medications.
• Intervention: Educational session, naproxen 500 mg PO every 12 hours as needed, plus diazepam 5–10 mg PO every 12 hours as needed.
• Comparison: Educational session, naproxen 500 mg PO every 12 hours as needed, plus 1–2 placebo every 12 hours as needed.
• Outcome:
  • • Primary: Improvement in the RMDQ score between ED discharge and one week follow-up.
    • Secondary: Pain intensity at one week and three months measured on a four-point descriptive scale and adverse events

  .

Authors’ Conclusions

“Among ED patients with acute, nontraumatic, nonradicular low back pain, naproxen plus diazepam did not improve functional outcomes or pain compared with naproxen plus placebo one week and three months after ED discharge.”

Key Results

The study enrolled 114 patients (mean age mid-30s and about 55 percent men).

Primary Outcome: No improvement in functional outcome at one week when diazepam was added to naproxen. Both groups improved by 11 points on the RMDQ.

Secondary Outcome: Pain intensity at one week and three months was comparable between the two groups. Adverse events were infrequent and comparable between the two groups, with no serious unexpected adverse events reported.

Evidence-Based Medicine Commentary

Inclusion/Exclusion: Only 21 percent (114 of 545) of the patients screened were included in the study. This limits the results to only a specific subset of patients presenting to the emergency department with back pain.