Experts warn why we need to stop treating back pain with opioids

Opioids are one of the most prescribed pain relievers for people with low back and neck pain. In Australia, around 40 per cent of people with low back and neck pain who present to their GP and 70 per cent of people with low back pain who visit hospital emergency departments are prescribed opioids such as oxycodone.

But our new study, published in July in Lancet medical journal, found opioids do not relieve “acute” low back or neck pain (lasting up to 12 weeks) and can result in more severe pain.

Prescribing opioids for low back and neck pain can also cause harm ranging from common side effects such as nausea, constipation and dizziness to abuse, addiction, poisoning and death.

Our findings suggest that opioids should not recommended for acute lower back pain or neck pain. Change in low back and neck pain prescribing is urgently needed in Australia and around the world to reduce opioid-related harm.

Comparison of opioids with placebo

In our trial, we randomly assigned 347 people with acute low back pain and neck pain to take either an opioid (oxycodone plus naloxone) or a placebo (a pill that looked the same but had no active ingredients).

Oxycodone is an opioid pain reliever that can be taken orally. Naloxone, an opioid reversal drug, reduces the severity of constipation without interfering with the pain-relieving effects of oxycodone.

Participants took opioids or a placebo for a maximum of six weeks.

People in both groups also received education and advice from their doctor. This could be, for example, advice about returning to your normal activities and avoiding bed rest.

We evaluated their results over a period of one year.

What did we find?

After six weeks of treatment, taking opioids did not lead to better pain relief compared to placebo.

Nor were there benefits for other outcomes such as physical function, quality of life, recovery time, or work absenteeism.

More people in the opioid-treated group experienced nausea, constipation, and dizziness than in the placebo group.

The one-year results highlight the potential long-term harm of opioids even with short-term use. Compared to the placebo group, people in the opioid group experienced slightly more pain and reported a higher risk of opioid misuse (problems with their thinking, mood or behavior, or using opioids other than as prescribed ).

More people in the opioid group reported pain at one year: 66 people compared to 50 in the placebo group.

What will this mean for opioid prescribing?

In recent years, international guidelines for low back pain have shifted the focus of treatment from drug treatment to non-drug treatment due to evidence of limited treatment benefits and concerns about drug-induced harm.

For acute low back pain, guidelines recommend patient education and counseling, and if needed, pain relievers such as ibuprofen. Opioids are only recommended when other treatments have not worked or are not appropriate.

Neck pain guidelines similarly discourage the use of opioids.

Our latest research clearly shows that the benefits of opioids do not outweigh the potential harms in people with acute back and neck pain.

Instead of advising on the use of opioids for these conditions in selected circumstances, opioids should be discouraged without qualification.

Change is possible

Complex problems like opioid use require smart solutions, and another study we recently conducted provides compelling data that opioid prescribing can be successfully reduced.

The study included four hospital emergency departments, 269 clinicians, and 4,625 patients with low back pain. The intervention consisted of:

  • educating clinicians on evidence-based management of low back pain
  • patient education using posters and materials to highlight the benefits and harms of opioids
  • providing heat packs and anti-inflammatory pain relievers as alternative treatments for pain relief
  • fast tracking referrals to outpatient clinics to avoid long waiting lists
  • revisions and feedback to clinicians on information on opioid prescribing rates.

This intervention reduced opioid prescribing from 63 percent to 51 percent of low back pain presentations. The reduction lasted 30 months.

The key to this successful approach was that we worked with clinicians to develop appropriate opioid-free pain management treatments that were feasible in their settings.

More work is needed to evaluate this and other interventions aimed at reducing opioid prescribing in other settings, including general practice clinics.

A nuanced approach is often necessary to avoid unintended consequences in reducing opioid use.

If people with back or neck pain are using opioids, especially in higher doses over a long period of time, it is important to seek advice from their doctor or pharmacist before stopping these drugs to avoid side effects when the drugs are stopped abruptly.

Our research provides compelling evidence that opioids have a limited role in the treatment of acute low back and neck pain. The challenge is communicating this new information to clinicians and the general public and implementing this evidence into practice.

Christine Lynn, Professor, University of Sydney; Andrew McLachlan, Head of School and Dean of Pharmacy, University of Sydney; Caitlin Jones, Postdoctoral Research Fellow in Musculoskeletal Health, University of Sydney, and Christopher Maher, Professor, Sydney School of Public Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

An earlier version of this article was published in June 2023.

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