Have you ever had an aching lower back? Most likely, your answer is yes—four out of five Americans have experienced low-back pain.

For some, acute low-back pain—lasting one to three months—turns into chronic low-back pain, a long-term problem that can limit activity and interfere with sleep. Back pain is the number-two symptomatic reason for doctor visits, right behind colds.

Problem: The help that most doctors offer is pills—either over-the-counter painkillers, powerful muscle relaxants such as diazepam (Valium) or even addictive opioid painkillers such as oxycodone (Oxycontin). In fact, guidelines from the American College of Physicians, the main medical society for internists, previously had recommended drugs as the first step in treating low-back pain. But drugs usually are not best!

Surprising development: In February 2017, the American College of Physicians issued new guidelines for treating low-back pain—recommending nondrug treatments as the first choice for acute pain and often for chronic pain, too. Here’s why, plus the nondrug treatments that scientific evidence shows are the most likely to provide real relief…

Many Drugs Don’t Work Well

Research shows that many medications commonly prescribed or recommended by doctors for low-back pain don’t work to relieve the pain—including acetaminophen (Tylenol) and oral steroids. As for opioid medications—they’re dangerously addictive, and more than 16,000 Americans die yearly from overdoses.

That said, some medications can help a bit. Ibuprofen (Advil, Motrin), naproxen (Aleve) or aspirin provide some relief for low-back pain. Muscle relaxants such as cyclobenzaprine (Flexeril) also are moderately effective. In my experience, ibuprofen has the fewest side effects. But the truth is, if you have a classic case of low-back pain, you often don’t need medication.

Misleading Imaging

Getting an imaging test such as an MRI, a CT scan or an X-ray usually is not a good strategy for diagnosing acute low-back pain. Yes, the imaging may detect an abnormality such as a bulging disk in the spine. But such abnormalities are common and rarely are the cause of low-back pain—and treating them may lead to unnecessary tests and invasive procedures, even surgery, that are not needed.

When imaging is essential: There are several serious problems that can cause back pain and are considered medical emergencies that require imaging. A new episode of back pain could be caused by a tumor. If you have unexplained fever or weight loss and back pain, you may have a rare infection of the bones of the spine or the outermost part of the spinal canal. If you have muscle weakness in the foot or the leg and back pain, you may have a disk problem that requires further treatment.

Bottom line: It is not useful to do imaging in most people who don’t have any of the above symptoms or situations. As I tell my patients—if you don’t have imaging now and your pain persists, you can always have imaging later. There usually is no rush.

Best Nondrug Treatments

The American College of Physicians now recommends the following nondrug treatments as among the best for low-back pain, and I agree…

Wait it out. The little-used but effective strategy for most cases of acute back pain is…don’t go to the doctor (and save $150 or more)! That’s because low-back pain almost always improves substantially on its own within a month or so. Instead, try one or more of the following nondrug treatments…

Exercise. There’s good scientific evidence that exercise can help relieve chronic low-back pain—and there’s little evidence that one type of exercise works better than another.

Beneficial types of movement include aerobic exercise, such as brisk walking or bicycling…yoga or stretching…and ­exercises that strengthen your abdominal and spinal muscles, such as Pilates. Best: A physical therapist can tailor and guide an exercise program to get you started. For the long term, find an exercise that you enjoy and that you’ll stick with.

For acute back pain, specific back exercises may not be helpful, but it’s wise to keep walking and maintain normal activities as much as possible. It’s when pain becomes chronic that exercise seems most helpful.

Cognitive behavioral therapy (CBT) or mindfulness-based stress reduction (MBSR). I think the most effective regimen for chronic low-back pain often is a combination of exercise and a mind-body approach such as CBT (a psychological therapy that helps you identify dysfunctional patterns of thinking and behavior that increase your pain) or MBSR (which combines the nonjudgmental acceptance of experience with relaxation techniques). By helping you pace yourself in daily life, these techniques ease muscle tension, relieve depression (common in people with chronic pain) and improve sleep.

Heat. Locally applied heat can soothe acute or chronic back pain. Use a heating pad, a hot-water bottle or an over-the-counter heat wrap such as ThermaCare. Caution: A temperature that’s too hot or an application that’s too prolonged could burn your skin.

Hands-on professionals. Research shows that spinal manipulation (most often performed by chiropractors but sometimes by osteopathic physicians or physical therapists), acupuncture, massage therapy and other hands-on healing techniques can help relieve both acute and chronic back pain.

Optimism. A recent study I coauthored, published in Spine, shows that seniors with low-back pain are more likely to get better if they are confident that their treatment will work. Optimism helps healing!

If Pain Persists

If your back pain persists for more than a month without significant improvement, it’s wise to see a doctor. (Of course, see a doctor immediately if you have any of the serious symptoms mentioned above.) A physician can create a treatment program that is tailored for you.

If your doctor says that you need medication, you should ask, “What are the relative risks and benefits of this choice? What will happen if I don’t take this medication? What are the alternatives?”

And if surgery is recommended, you should probably get a second opinion. The most common surgery for back pain alone is spinal fusion, which is invasive and extensive with a long recovery period. Even worse: Research shows that the surgery is of questionable effectiveness for many back problems. It also shows that a rigorous rehabilitation program—involving physical therapy and training in pain management—works just as well.