Call to stop opioids for lower back and neck pain

Opioids should be stopped for patients who have lower back or neck pain because they provide no pain-relief benefits, according to a new Australian study.

Researchers completed a randomised controlled trial of 347 participants with lower back or neck pain, comparing opioids with placebo.

They found no significant difference in pain scores between those given opioid pain relievers and those given placebo after six weeks. After one year, patients given the placebo had slightly lower pain scores.

This is the first randomised controlled trial to investigate the safety and efficacy of opioid pain relievers for acute lower back and neck pain with a follow-up period as long as one year. The findings are published in the latest edition of The Lancet.

Senior study author Professor Christine Lin said: “Despite there being no evidence of their efficacy in reducing pain, opioid pain relievers are still widely prescribed for people with lower back and neck pain in many countries.

“Our study now suggests that they could be making patients’ pain levels worse in the medium and long term. As well as not providing patients with the pain relief intended, we also know that being prescribed opioid pain relievers even for a short period of time increases the risk of opioid misuse long term. Considering all the evidence and known risks, we firmly believe doctors should not prescribe opioid pain relievers for new episodes of lower back and neck pain.”

Instead, doctors should be encouraged to focus on patient-centred approaches that could include advice to stay active, and simple pain relievers, she added.

The study took place in 157 sites in Australia between 2016 and 2021 and included 347 participants who had been experiencing lower back pain, neck pain, or both, for up to 12 weeks.

All participants received guideline care and 174 were randomly selected to receive opioid pain relievers and the other 173 were given a placebo for up to six weeks.

After six weeks of treatment, the participants were free to seek other care and their pain severity was assessed. Any adverse events were recorded, after the six weeks of treatment and again after one year.

Their risk of susceptibility to opioid misuse were also measured using the Current Opioid Misuse Measure.

The team found no significant difference in pain scores at six weeks between the opioid and placebo groups: average pain scores out of 10 were 2.8 in the opioid group and 2.3 in the placebo group. At one year, the average pain scores were 2.4 in the opioid group and 1.8 in the placebo group.

After six months 15-20% of 119 participants with ongoing pain reported taking an opioid, and 25% of 106 participants with ongoing pain reported opioid use at week 52.

The authors acknowledge some limitations of their study, particularly in that about 25% of pain score data were missing at the end of the trial because participants dropped out or could not be contacted. However, they add further analysis found the main outcomes were unlikely to be affected by the missing data.

Jones CMP, Day RO, Koes BW et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet 28 June 2023


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