Chronic low back pain: when to stop taking anti-inflammatories and see a doctor

Low back pain is one of the most common reasons people see a doctor — and also one of the least understood by patients themselves. Most acute episodes — the classic "pulled muscle" in the lower back after lifting or overexertion — resolve on their own within 4 to 6 weeks with limited rest, heat and sensible pain management. The problem arises when that pain stays. When the weeks go by and your back still hurts every day. When you start avoiding activities, sleeping poorly, taking more painkillers than you'd like.

In my day-to-day practice, I see that patients with chronic low back pain arrive, on average, much later than they should. Many have been through two or three orthopedic surgeons, several physical therapists and sometimes a neurosurgeon before reaching a pain specialist, after months or years of trying scattered treatments without a clear plan. That delay has a concrete cost: the longer the condition persists, the more changes appear in the central nervous system that make the pain harder to treat. In chronic pain, time works against you.

We speak of chronic low back pain when the pain persists for more than three months. And at that point, the problem stops being "a muscle knot that won't go away" and becomes a condition that requires a different approach.

Why anti-inflammatories stop working

It's a question I hear very often in the office. "Doctor, I took ibuprofen for months and it doesn't do anything anymore." That sentence has a clear clinical explanation.

Nonsteroidal anti-inflammatory drugs — ibuprofen, diclofenac, naproxen, indomethacin — are medications designed to fight the inflammatory component of pain. They are very useful in the first weeks of acute low back pain, when there is tissue swelling and local inflammation is the main pain generator.

But once pain becomes chronic, inflammation is no longer what predominates. Other mechanisms take over: sensitization of the nervous system, changes in how the brain processes pain signals, secondary muscle tightness that perpetuates itself, changes in the facet joints of the spine, and often neuropathic components that anti-inflammatories simply don't touch.

That's why continuing to increase the dose or switching to a different anti-inflammatory rarely solves the problem once the pain has lasted months. What it does do is raise the risks: gastritis and stomach ulcers, kidney failure, high blood pressure, cardiovascular events. Long-term NSAID use is not benign, and the evidence on this is clear.

An important nuance about imaging: most lumbar MRIs in patients over 40 show 'something' — disc bulges, disc dehydration, facet joint osteoarthritis, some small herniation. That's why ordering an MRI without a good clinical history first all but guarantees we'll find something that may or may not explain the pain. My approach is always the same: first the physical exam and the history, then the imaging to confirm or rule out what we already suspect. If imaging overrides the clinical picture, we end up treating MRIs instead of treating patients.

What a Pain Medicine specialist does differently

Pain Medicine is a relatively new medical specialty in Argentina, but one with a solid international track record. A pain specialist — usually with a background in anesthesiology — is trained to approach chronic pain from several angles at once:

• Identifying the pain mechanism: whether it is nociceptive (from damaged tissue), neuropathic (from an injured nerve), or nociplastic (from central sensitization). Each requires a different treatment.
• Locating the pain generator: low back pain often doesn't come from the disc but from the facet joints, the sacroiliac joint, the deep paraspinal muscles or the nerves exiting the spine.
• Offering tailored medication management: there are specific medications for neuropathic pain (gabapentinoids, low-dose antidepressants) that are not anti-inflammatories and tend to work much better for chronic pain.
• Performing image-guided interventional procedures: nerve blocks, joint injections, radiofrequency ablation. These are minimally invasive techniques that deliver medication directly to the site of pain.

The most common causes of chronic low back pain

To understand why it hurts, it helps to know the most common causes. Not all low back pain is the same, and not all of it is treated the same way:

Lumbar facet joint syndrome

The facet joints are small joints on each side of the spine that allow movement. Over time they wear down and produce localized low back pain that worsens with prolonged standing, bending backward or getting up from a chair. It is a very common cause, especially after age 50. It usually responds very well to facet joint blocks and, in some cases, to medial branch radiofrequency ablation.

Lumbar herniated disc

When disc material pushes out of place (herniates) and compresses a nerve root, the pain typically radiates down the leg (sciatica) with numbness or pins-and-needles. Options include medication, physical therapy, epidural injections and surgery depending on severity. Most people do not need surgery.

Sacroiliitis

The sacroiliac joint connects the spine to the pelvis. When it becomes inflamed or wears down, it produces very low back pain, off to one side, which is often mistaken for hip pain or sciatica. Image-guided injections are very effective.

Lumbar spinal stenosis

More common in people over 60. Patients find they can only walk a few blocks before needing to sit down or bend forward to relieve the pain in their legs. There are interventional treatments, such as epidural injections, that may delay or avoid the need for surgery.

Myofascial pain

Deep, persistent muscle tightness that creates trigger points. It is common in people with sedentary jobs or who spend long hours at a computer. Treatment combines physical therapy, trigger-point injections and postural and ergonomic advice.

When it makes sense to see a doctor

There is no single rule, but these are situations where seeing a pain specialist adds value:

• Low back pain that persists for more than three months despite initial treatment.
• Pain that doesn't respond to common painkillers or that requires increasingly stronger medication.
• Pain that limits daily activities: working, walking, sleeping, bending over, lifting light weights.
• Pain radiating down the leg with tingling, numbness or weakness.
• If you have had previous episodes and this one is becoming recurrent.
• Before deciding on surgery: a second opinion from a pain specialist may open up non-surgical alternatives.

My criteria for when low back pain warrants a visit to a pain specialist are clear: more than 6 to 12 weeks without response to initial treatment, recurrent episodes that limit daily life, or any low back pain radiating down the leg that persists beyond a month. The red flags — progressive weakness, loss of bladder or bowel control, fever, a history of cancer, unexplained weight loss — mean immediate consultation, no waiting. Everything else can be managed at first by your primary care physician or internist, but if it isn't improving within that window, there's no point in waiting any longer.

What to expect from a first visit

The first visit combines careful listening, a focused physical exam and a review of any tests you've already had. The goal is not always to recommend a procedure at the first visit. We often start by adjusting medication and setting up physical therapy targeted to your condition, reserving interventional procedures for cases that don't respond or where they are clearly indicated from the start.

The important thing to understand is that being in pain for months is not something you have to "learn to live with". There are many more options than most people realize, and most of them are less invasive than surgery and more effective than continuing to take anti-inflammatories.

When I get a patient with chronic low back pain moving again, back at work and sleeping well, it's almost never thanks to one magic treatment. It's the sum of several well-thought-out interventions: a precise diagnosis of the pain generator, a tailored medication plan, active physical therapy, and sometimes an interventional procedure at the right moment. The goal is not just to lower the pain score: it's to restore function and confidence in one's own body. That difference — between 'a pain score seven points lower' and 'a patient with their life back' — is what defines a successful treatment.

Dr. Mauricio Casarsa

Anesthesiologist, specialist in Pain Medicine and Interventional Pain Management. Postgraduate training at UBA (Fundación Dolor) and UNLP (CAIDBA). Staff physician at Hospital Alemán, Buenos Aires.

MN 137756 · San Isidro · Villa Urquiza