**2. Multimodal and targeted treatment approaches**

There are several important concepts that a clinician must understand before they can ade‐ quately start the treatment of low back pain. The first is that there is more data on the use of medication for acute low back pain than chronic low back pain [1]. This does not mean that specific pharmacologic agents are not effective in the setting of chronic low back pain, but simply that there is less evidence due to constraints in studying the long‐term side effects [1]. When initiating the therapy, the clinician should focus on medications with the most known efficacy for the specific cause of pain and that have the least risk for serious side effects [1]. Specifically, the drug class and sometimes the even the individual drug chosen will be dic‐ tated by side effects (short and long term) and targeted mechanism of pain.

Treatment should include a targeted approach to the individual's cause of low back pain. The majority of low back pain is caused by a mechanical etiology [2]. These causes include degen‐ erative disk or joint disease, vertebral fracture, and deformities and occur in up to 80–90% of patients. Neurogenic (e.g., herniated disks, spinal stenosis) inflammatory (e.g., rheuma‐ toid arthritis, ankylosing spondylitis) and other less common causes (e.g., neoplasm, referred pain) make up the remainder of etiologies. The pharmacologic agents first selected should be completely dependent on the underlying etiology. However, as the pain progresses to a chronic state, a broader approach typically must be taken due to decreased efficacy of the targeted treatment.

The majority of this chapter will focus on the treatment of low back pain with an underlying mechanical etiology since it is by far the most common. However, if the cause of low back pain is inflammatory in nature, targeted therapy should also focus on treatment with anti‐ inflammatory agents. This may mean early use of nonsteroidal anti‐inflammatories (NSAIDs) and treatment with corticosteroids or disease‐modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis or ankylosing spondylitis [3]. Additionally, these disease states have a higher incidence of neuropathic pain and thus may require adjuvant medica‐ tions that target this specific pain type. Some patients with mechanical low back pain also have increased pain due to spasticity and may benefit from treatment with antispasmodics. These agents will be discussed in much greater detail later, but to put it simply treatment should be tailored to the individual.

While the treatment of acute low back pain is normally fairly straight forward, its progression into chronic pain tends to complicate treatment. This is primarily due to the fact that chronic pain can often be associated with not only physical pain, but also deleterious cognitive and behavioral effects [4]. Because of this, a patient's rehabilitation program should emphasize a biopsychosocial model or one that involves a combination of physical, psychological and educational components [4, 5]. This also means that treatment (including medications) should be used to treat any psychological processes that may be worsening the perception of pain such as depression or anxiety.

Lastly, it is important to understand that medication alone will likely not completely allevi‐ ate a patient's pain, and it is even less likely to do so if the pain is chronic. Thus, treatment as a whole should be tailored to the individual and a holistic approach should be taken [4]. In addition to pharmacologic treatments, nonpharmacologic treatments including topical heat for acute pain or cognitive behavioral therapy, exercise therapy, spinal manipulation and interdisciplinary rehabilitation for subacute or chronic pain should be considered [6, 7]. However, for the purpose of this chapter, we will be focusing primarily on pharmacologic treatments and how they should be combined, implemented and optimized.
