An honest look at medications for chronic low back pain: what each one is good for, what research shows, and what every patient should know about risks.
With chronic low back pain, medication alone rarely takes the pain away; the basis is combining it with exercise and changes in daily life. Medications are a support that makes it easier to move.
An important note:
This page is meant to help you understand your medications. Never change or stop a medication without first consulting your doctor. Making changes on your own can be harmful.
What You'll Learn
- What each medication is good for, and what research shows
- Risks that older adults should be especially aware of
- What to know about acetaminophen (Tylenol) and chronic back pain
- What over-the-counter options are available and their limitations
- The role of medications in your overall treatment plan
First, the main point: Medications play a supporting role, not the lead. Medications alone are often not enough to ease chronic low back pain. The role of medication is to reduce pain enough so that you can participate in exercise, physical therapy, and other active treatments.
2. Detailed Information on Each Medication
Acetaminophen (Tylenol) — What to Know
Acetaminophen (Tylenol, Panadol) is relatively gentle on the stomach and kidneys, which makes it easier to use for older adults.
At an adequate dose, some people do feel a benefit. On the other hand, some studies overseas found that it did not show the level of benefit for back pain that was expected, and good-quality research on chronic low back pain specifically is still scarce.
The main thing to watch is your liver:
- If you take high doses for a long period, your doctor may check your liver with blood tests
- Many cold remedies and over-the-counter pain relievers contain the same ingredient. To avoid doubling up, show your medication list to the pharmacist when buying OTC products
- If you drink alcohol heavily, tell your doctor
Important: Never stop a medication on your own. Talk to your doctor about whether your current medications are a good match for your type of pain.
NSAIDs (Anti-Inflammatory Medications) — Watch the Load When Taken Long-Term
NSAIDs include both over-the-counter options like ibuprofen (Advil, Motrin) and naproxen (Aleve), and prescription options like celecoxib (Celebrex) and diclofenac.
What they do:
- They ease inflammation-related pain and are often used during sudden flare-ups
- Taken every day for a long time, their burden on the body can add up
Risks, especially for older adults:
| Risk |
Details |
| GI problems |
Stomach ulcers, GI bleeding. Risk increases with blood thinners or steroids |
| Kidney damage |
Reduced kidney function, fluid retention. Extra caution if you already have kidney problems |
| Heart risks |
Slightly increased risk of heart attack and stroke. May worsen heart failure |
| Drug interactions |
If you take multiple medications, NSAIDs may interact with them |
Over-the-counter availability:
Ibuprofen and naproxen are widely available without a prescription, which can create a false sense of safety. Over-the-counter does not mean risk-free. The same GI, kidney, and heart risks apply, especially with regular use.
For older adults: Topical NSAIDs (applied to the skin) carry fewer risks to the stomach, kidneys, and heart compared to pills.
Duloxetine (Cymbalta) — The Only Approved Antidepressant for Chronic Low Back Pain
Duloxetine was originally developed as an antidepressant, but research showed it also helps with chronic pain.
- Approved for chronic low back pain in the US (the only antidepressant with FDA approval for it) and in Japan
- Improves both pain and physical function
- Particularly helpful when chronic low back pain occurs alongside depression or anxiety
What to know:
- It can take 2 to 4 weeks before you notice any benefit
- Common side effects include nausea, dizziness, and drowsiness
- Do not stop suddenly. Your doctor will taper the dose gradually to avoid withdrawal symptoms
Some patients worry when they hear "antidepressant." Duloxetine is used here because it modulates how pain signals are processed in the nervous system, which is a different purpose from treating depression.
Pregabalin (Lyrica) and Gabapentin (Neurontin) — For Nerve Pain
A significant proportion of chronic low back pain cases involve a neuropathic component: pain caused by nerve dysfunction rather than tissue damage. This type of pain often feels like tingling, burning, or electric shocks.
- Pregabalin (Lyrica): Widely prescribed for nerve pain worldwide
- Gabapentin (Neurontin): A related medication that is commonly used in the US and UK. It works through a similar mechanism and is often tried as an alternative to pregabalin
These medications are used for leg tingling and nerve-type pain. For back pain itself or sciatica, however, research has not clearly confirmed a benefit; the evidence is stronger for conditions like diabetic neuropathy and postherpetic neuralgia. Your doctor decides whether to use them based on whether a nerve component is part of your pain. If something bothers you while taking them, don't stop on your own; talk to your doctor.
Key side effects (especially for older adults):
- Dizziness and drowsiness are common
- Unsteadiness that increases fall risk. Be careful at night, especially getting up for the bathroom
- Avoid driving while taking them
- Start at a low dose and increase gradually
Tramadol — When NSAIDs Are Not Enough
Tramadol is classified as a "weak opioid" but also works through a second mechanism, serotonin and norepinephrine reuptake inhibition, similar to duloxetine. This dual action is part of what makes it effective for chronic pain. It is often prescribed as the next step when NSAIDs do not provide sufficient relief.
- Japan's low back pain guideline (2019) lists it as one of the medicines suggested for chronic low back pain
- May be helpful when low back pain occurs with depressive symptoms
- Available as an immediate-release tablet, extended-release formulation, and in some countries as a combination with acetaminophen (e.g., Ultracet in the US). Specific formulations vary by region; ask your doctor or pharmacist about what is available where you live
What to know:
- Nausea is common when starting; your doctor may prescribe anti-nausea medication alongside it
- Constipation and dizziness are also common
- Carries risk of dependence with long-term use. Your body may develop tolerance, meaning you need more for the same effect
- Never stop suddenly. Withdrawal symptoms can occur; your doctor will reduce the dose gradually
- Do not increase the dose on your own. If the medication feels less effective, talk to your doctor first
- For older adults, doctors typically start at a lower dose
- Classified as a controlled substance in many countries (Schedule IV in the US)
Tramadol can be an effective tool when used appropriately, but it is not intended for indefinite long-term use without regular review. Work with your doctor to reassess its role in your treatment plan periodically.
Stronger Opioids — Guidelines Are Cautious
For opioids stronger than tramadol, Japan's low back pain guideline (2019) takes a cautious position: if they are used at all, it should be for selected patients after careful assessment, for the shortest possible time and at the lowest possible dose.
- With long-term use the body can get used to them (tolerance), and there is a risk of dependence
- Constipation, nausea, and drowsiness are common side effects
Key message: Whether to use a stronger opioid is decided with your doctor after other treatments have been considered.
The opioid crisis context:
The US, Canada, and other countries have experienced devastating consequences from widespread opioid prescribing for chronic pain. In response, the CDC's 2022 Clinical Practice Guideline emphasizes:
- Non-opioid therapies (exercise, physical therapy, certain medications) should be tried first
- If opioids are used, they should be at the lowest effective dose for the shortest needed duration
- The risks of long-term opioid therapy for chronic pain frequently outweigh the benefits
Pain medicine has been moving away from opioids as a default treatment for chronic pain.
Topical Treatments — A Safer Choice, Especially for Older Adults
Topical medications are applied directly to the painful area and carry fewer risks of systemic side effects.
Available options:
- Diclofenac gel (Voltaren): An NSAID available over the counter. Provides local anti-inflammatory relief with far less impact on the stomach, kidneys, and heart compared to oral NSAIDs
- Lidocaine patches (Lidoderm): A prescription numbing patch applied to the painful area
- Capsaicin cream: Available over the counter. Derived from chili peppers, it works by desensitizing pain nerve fibers over time. Can cause a burning sensation initially
For older adults, topical treatments have fewer whole-body side effects than tablets.
Muscle Relaxants — Less Benefit Than Expected for Chronic Back Pain
Muscle relaxants, including cyclobenzaprine (Flexeril), tizanidine (Zanaflex), and baclofen, may help with acute muscle spasms, but:
- For chronic low back pain, long-term benefit has not been confirmed
- Common side effects are drowsiness and dry mouth
- In older adults, they increase the risk of falls
Cannabis and CBD — Limited Evidence
As cannabis becomes legal in more jurisdictions (many US states, Canada, Australia, parts of Europe), patients increasingly ask about its role in chronic pain management.
What the research currently shows:
- Evidence for cannabis-based medicines in chronic low back pain specifically is limited and inconclusive
- Some studies suggest modest pain relief for chronic pain in general, but the quality of evidence is low
- CBD (cannabidiol) products vary widely in quality, dosing, and regulation
- Side effects can include dizziness, fatigue, and changes in appetite
Cannabis and CBD are areas of active research, but there is not yet enough high-quality evidence to make clear recommendations for chronic low back pain. If you are considering these products, discuss them with your doctor, especially if you take other medications, as interactions are possible.