New ‘Choosing Wisely’ recommendations for managing pain – including avoiding benzodiazepines for lower back pain – have just been released by trans-Tasman pain specialists.

The recommendations were developed by the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists.  The aim is for the latest evidence-based recommendations to be used as starting points for discussions between clinicians and patients about which pain management options actually make a difference to certain types of pain – including low or lower back pain.

They join a host of other recommendations developed by medical colleges and societies across both sides of the Tasman as part of the global Choosing Wisely initiative to promote conversations about tests, procedures or treatments where evidence shows they provide little to no benefit and, in some cases, can lead to harm.

Dr Mick Vagg, pain medicine physician and Chair of the Faculty’s Professional Affairs Executive Committee said low back pain is one of the most prominent pain conditions experienced by Australasians.

“Up to 80% of people will experience low back pain at some point in their lives, with one in 10 being limited in their day-to-day activities and looking for relief.

“However, a recent review found there was no evidence to support people taking benzodiazepines as ‘muscle relaxants’ to relieve their low back pain, in addition to or instead of anti-inflammatory medicines.

“Like all drugs, there are risks associated with taking benzodiazepine including abuse, addiction, tolerance and overdose resulting in accidental death. We are urging healthcare providers and their patients to discuss the appropriateness of benzodiazepine use.”

The recommendations also include new advice on treating chronic non-cancer pain with opioids.

“Managing chronic pain is complex, but there is little evidence to support the use of opioids as the first or only treatment option,” Dr Vagg said.

“Most trials undertaken into their effectiveness in treating chronic non-cancer pain have been run for under 12 weeks and have shown only modest impact.

“In contrast, some people taking opioids for chronic non-cancer pain have experienced increased distress, poorer self-rated health, inactivity during leisure, unemployment, higher use of healthcare and lower quality of life.”

The five latest recommendations are:

  1. Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic non-cancer pain.
  2. Do not continue opioid prescription for chronic non-cancer pain without ongoing demonstration of functional benefit, periodic attempts at dose reduction and screening for long-term harms.
  3. Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain.
  4. Do not prescribe benzodiazepines for low back pain.
  5. Do not refer axial lower lumbar back pain for spinal fusion surgery.

Choosing Wisely was first launched across the Tasman in April 2015 and later in New Zealand where it the initiative is being facilitated by the Council of Medical Colleges (CMC) in partnership with the Health Quality & Safety Commission and Consumer New Zealand

Since the formal launch of the Choosing Wisely campaign in New Zealand, a total of 20 Australasian and New Zealand colleges and specialist societies have endorsed over a 100 recommendations that healthcare professionals and patients and consumers should question.

More information can be found at: or

Four Choosing Wisely questions for patients to ask:

  1. Do I really need this test or procedure?
  2. What are the risks?
  3. Are there simpler, safer options?
  4. What happens if I don’t do anything?


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