Back and neck pain afflicts millions of American adultsprompting many to seek help from their GP or even the local emergency room.
When these pain episodes are acute and non-specific, meaning there is no clear cause or explanation, it is typically recommended to start with daily remedies such as over-the-counter anti-inflammatories and alternatives such as heat therapy, massage, or exercise.
If that doesn’t work, doctors may prescribe a short course of opioids, with the goal of relieving pain and improving the patient’s function.
But the results of a rigorous clinical study released Wednesday cast doubt on the use of opioids even in this situation.
In a study of more than 340 patients suffering from low back or neck pain, a team of Australian researchers found that there was no difference in pain severity after six weeks between those who received opioids versus a placebo sugar pill.
« It was a real surprise for us, » she says Andrew McLachlanDean of Pharmacy at Sydney Pharmacy School and author of the study, which has been published wednesday at The Lancet. « We thought there would be some pain relief, but overall there was no difference. »
Additionally, the study found that those who received opioids had an elevated risk of abusing the drugs a year later, reinforcing the potential harms of turning to opioids for pain relief, even temporarily.
While previous research has focused on treating chronic pain with opioids, this study is notable because it looks at garden-variety back pain that lasts a shorter period of time, three months at most.
« It’s going to challenge a lot of the main guidelines we have about how to treat people’s back pain, » says Dr. Marco BicketUniversity of Michigan anesthesiologist and director of opioid and pain research.
Some experts already fear the surprising results could be misinterpreted to suggest that opioids don’t work for acute pain more broadly, and caution that the limitations to the study should be considered before generalizing too much.
« My guess is that this will be a landmark study that will be cited a lot, » says Dr. Samer Naruze, the former president of the American Society of Regional Anesthesia and Pain Medicine. “But I am concerned that it will be used or weaponized to deny patients with acute pain much-needed opioids,” such as those experiencing severe post-operative pain and injuries.
No significant difference from placebo
The findings of the new study draw attention to an unexpected gap in our understanding of how well opioids work in the context of acute back pain.
Patients who had new low back or neck pain for 12 weeks or less were recruited from more than 150 primary care clinics and emergency departments in Sydney, Australia, and randomly assigned to either the opioid group or the opioid group. placebo. The study took six years to complete.
Patients were excluded from the study if they had severe spinal pathology, which could be related to injuries such as a fracture, illness or surgery, among other things.
The study focused on acute-onset back pain, which can be caused by anything from awkward twisting or turning to how you sleep, McLachlan says. For this kind of nonspecific pain, he says, « You can’t really take an X-ray and say, ‘That’s the problem.’ «
Participants didn’t know if they were receiving the drug or a placebo. The opioid group received a combination of oxycodone and naloxone, a drug that had the effect of minimizing opioid-related gastrointestinal side effects, particularly constipation, so that participants would not realize they were in the treatment group.
Naloxone, a drug used to treat overdoses, reverses the effects of opioids when given intravenously, under the skin, or as a nasal spray, but not when given orally because it doesn’t reach the blood supply, says McLachlan.
At six weeks, there was no significant difference in pain scores between the two groups. The same was true after 12 weeks.
McLachlan says he focused on pain severity after six weeks because that would give enough time to gradually increase the dosage until patients hit their optimal dose, up to 20 milligrams of oxycodone per day.
Previous research indicates that opioids may have a small but detectable effect in relieving chronic pain, McLachlan says. « This study fills the gap by demonstrating that even though people may have moderate to severe low back pain, opioids don’t appear to be the right choice for them because they provide no benefit » in this shorter time period.
And the study showed that taking opioids appeared to confer an additional risk.
When participants were surveyed a year later to assess whether they had certain risk factors for opioid abuse, 20 percent of those in the opioid group had a score that indicated behaviors a doctor would find problematic when prescribing opioids. This is compared to 10% in the placebo group.
The findings could stir controversy
The findings are sure to spark debate on how to treat patients dealing with bouts of acute back pain.
Medical guidelines In the United States, there are already warnings against the use of opioids as the first choice in treating patients with acute pain, but opioids may be recommended when other forms of treatment fail.
« It’s a well-designed process, » he says Riccardo Deyo, family physician and professor emeritus at Oregon Health and Science University. « He’s going to ruffle feathers and I think there’s going to be a lot of controversy. »
The study points to a significant blind spot in the evidence for opioid prescribing for acute back pain, says Deyo, so much so that it’s somewhat shocking that a study like this hasn’t been done before.
« We thought we knew the answer, » he says, « but as is often the case, when we actually ask some of the most fundamental questions and seek a rigorous answer, we sometimes uncover a surprise. »
The findings shouldn’t be applied to acute pain more broadly and should be replicated before decisions are made about changing guidelines and « changing care for thousands, if not millions of people, » says Dr. Mark Sullivan, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.
« This is just one study, but if its findings are true, then it appears the benefits of opioid treatment for an episode of back pain are smaller and the risks are higher than we’ve assumed, » he says, noting the increase in the risk of opioid misuse among those who received opioids in the study.
A « good » study, but how relevant?
Even with careful study design — considered the gold standard for studying treatment outcomes — the results don’t necessarily reflect the full reality of acute pain treatment in the United States, says Dr. Narouze, president of the Center for Pain Medicine at Western Reserve Hospital in Cuyahoga Falls, Ohio.
He notes that the treatment group received long-acting opioids in the study but were asked to take them twice daily rather than as needed, which « defeats the purpose of acute pain » because the goal is to give pain relief to the patient as soon as possible. possible.
« The regime they used was very unorthodox, at least in the United States, » he says. “We don’t treat acute pain with long-acting opioids. »
It’s unclear whether short-acting opioids would have made a difference, but Narouze says the study design doesn’t make the findings applicable to situations where patients are taking other opioid regimens.
The study also only applies to a very specific patient population — those with recently starting nonspecific back pain — that tends to be related to musculoskeletal issues, he says. « We can’t generalize these data to other pain groups, » she says. « This is just a study, even if it’s a very good study. »
Bicket of the University of Michigan says it’s clear that opioids work very well in relieving pain for short periods of time, such as after severe physical trauma or while recovering from surgery.
« Most of our questions are about the benefit continuing and will it extend for pain that lasts beyond a couple of days? » he says.
This study shouldn’t be taken as the final word, but Bicket says it adds further weight to the idea that treatments other than prescription opioids should be emphasized for low back pain.
« This study is not going to completely rewrite the guidelines, » he says. « I think it will motivate a lot of future studies to be done for both back pain and other conditions where we think prescription opioids may be appropriate. »