Medication Optimisation

It helps to set expectations honestly. For most spinal pain, medication can take the edge off symptoms and help people stay active while their problem settles, but it rarely abolishes pain and does not treat the underlying cause. The common medicines each have their place and their limits: simple painkillers such as paracetamol have surprisingly little effect on back pain; anti-inflammatories can help in the short term but carry risks with prolonged use; and stronger drugs, including opioids, offer only modest benefit for chronic pain at the cost of significant downsides. The goal of "medication optimisation" is to use the least medication necessary to support function, and to avoid drifting into long-term use of drugs that do more harm than good.

I want to be direct about opioids, because this is where the evidence and practice have changed most. For chronic back pain, strong opioids provide only small, short-lived benefits and carry real risks — tolerance, dependence, side effects and, for a minority, serious harm. The evidence shows they are not superior to non-opioid approaches for chronic back and joint pain over the longer term. So the modern, responsible approach is to avoid starting long-term opioids where possible, to keep any use short and purposeful, and, for people already on them, to support careful review and, where appropriate, gradual reduction — always guided by the prescribing clinician, not stopped abruptly.

Because medication for chronic pain involves careful balancing of benefit, risk and individual circumstances, it is best led by the person's GP and, where needed, pain-medicine specialists, who can review the whole picture over time. As a surgeon, my role is to make the diagnosis, treat any surgically correctable problem, and give honest advice that medication is a support rather than a solution. I then defer to and work with prescribing colleagues on the detail. In the specific setting of preparing for surgery, reviewing and optimising medication beforehand is part of good preoperative care, done with the wider team.

The evidence supports a cautious, function-focused approach. A systematic review and meta-analysis found paracetamol ineffective for low back pain; a Cochrane review found only low-quality evidence of small, short-term benefit from anti-inflammatories. For opioids, a meta-analysis found only modest short-term relief with limited long-term evidence, and the SPACE randomised trial found opioids no better than non-opioid medication for chronic back and joint pain. Major guidance, including the Lancet Low Back Pain Series, cautions against routine reliance on these medicines. This is exactly the balanced, honest picture I set out for patients.

Medication, where used, is one supporting part of a broader plan that centres on staying active and, where relevant, physiotherapy and pain management. Decisions about starting, changing or reducing medication should be made with the prescribing clinician — usually the GP or a pain specialist — who can weigh the benefits and risks for the individual over time.

• —Machado GC, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis. BMJ 2015. (PMID 25828856)
• —Enthoven WTM, et al. Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev 2016. (PMID 26863524)
• —Krebs EE, et al. Effect of opioid vs non-opioid medications on pain-related function (SPACE trial). JAMA 2018. (PMID 29509867)
• —Abdel Shaheed C, et al. Efficacy, tolerability and dose-dependent effects of opioid analgesics for low back pain. JAMA Intern Med 2016. (PMID 27213267)
• —Foster NE, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018. (PMID 29573872)