Why you should stop treating back pain with opioids, experts warn

Opioids are one of the pain relievers for people with low back and neck pain. In Australia, about 40 per cent of people with low back and neck pain who see 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, Lancet A medical journal found opioids do not relieve “acute” back or neck pain (lasting up to 12 weeks) and may make the pain worse.

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

Our findings suggest that opioids should no recommended for acute low back or neck pain. Change in back pain and neck pain prescribing is urgently needed in Australia and globally to reduce opioid-related harm.

Comparison of opioids with placebo

In our trial, we randomized 347 people with acute back and neck pain to receive either an opioid (oxycodone plus naloxone) or a placebo (a pill that looks the same but has no active ingredients).

Oxycodone is an opioid pain medication that can be given orally. Naloxone, an opioid reversal drug, reduces the severity of constipation while not interfering with the pain-relieving effects of oxycodone.

Participants took the opioid or placebo for a maximum of six weeks.

People in both groups also received education and counseling from their treating physician. This could be, for example, advice to return to their normal activities and avoid bed rest.

We evaluated their results over a 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 absence from work.

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 worse pain and reported a higher risk of opioid misuse (problems with their thinking, mood, or behavior, or using opioids in ways other than prescribed).

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

What will this mean for prescribing opioids?

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

For acute back pain, the guidelines recommend patient education and counseling and, if necessary, anti-inflammatory pain medications such as ibuprofen. Opioids are recommended only when other treatments have failed or are inappropriate.

Neck pain guidelines similarly encourage the use of opioids.

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

Instead of recommending the use of opioids for these conditions under selected circumstances, opioids should be discouraged without qualification.

Change is possible

Complex problems like opioid use need smart solutions, and another recent study of ours provides compelling data that opioid prescribing can be successfully reduced.

Four hospital emergency departments, 269 clinicians, and 4,625 patients with low back pain participated in the study. The intervention consisted of:

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

This intervention reduced opioid prescribing from 63 percent to 51 percent for low back pain episodes. The reduction was maintained for 30 months.

The key to this successful approach is 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 these and other interventions aimed at reducing opioid prescribing in other settings, including GP clinics.

A nuanced approach is often needed to reduce opioid use without causing unintended consequences.

If people with low back or neck pain are using opioids, especially in higher doses for a long time, it is important that they consult a doctor or pharmacist before stopping these drugs to avoid unwanted 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 to get this new information to clinicians and the general public and put this evidence into practice.

Christine Lin, Professor, University of Sydney; Andrew McLachlan, Head of School and Dean of Pharmacology, University of Sydney; Caitlin Jones, Postdoctoral Researcher in Musculoskeletal Health, University of Sydney and Professor Christopher Maher, Sydney School of Public Health, University of Sydney

This article is reprinted 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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