A 45-year-old man comes to your office because of low back pain for the past 2 years. The pain is worse with prolonged sitting and bending and improves with rest; there is no radiation, weakness, numbness, fever, weight loss, or bladder or bowel dysfunction. He has been taking acetaminophen and ibuprofen regularly with only partial relief and asks for something stronger, such as morphine or tramadol. He has no history of substance use disorder or psychiatric illness, drinks alcohol occasionally, takes no other medications, and has no known drug allergies. On examination there is paraspinal tenderness with normal neurological findings. Lumbar spine imaging done 6 months ago showed mild degenerative changes only. He has not tried physiotherapy or structured exercise.
| Heart rate | 72/min |
| Respiratory rate | 14/min |
| Temperature | 36.8 °C |
| O2 saturation | 98%, room air |
| Blood pressure | 128/78 mm Hg |
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Which one of the following is the most appropriate medication to add at this time?
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