Opioids were no better than placebos in helping back and neck pain
A randomised clinical trial has found that opioids have no particular advantage in the treatment of back and neck pain compared to placebo. As reported in The Lancet, opioid use is associated with a greater risk of abuse after one year.
Back (low back) pain is an increasingly common problem worldwide, and is expected to affect 840 million people worldwide by 2050. Neck pain has the fourth highest number of years of total disability and, in general, these disorders are costly to healthcare systems worldwide.
Clinical guidelines prescribe the use of opioid analgesics for the relief of these pains when other medications are contraindicated or have failed to have a meaningful effect. However, in some countries, such as Australia, up to two thirds of patients receive opioids as first-line treatment when seeking treatment for low back and neck pain.
As there is no direct reliable evidence of the efficacy of opioids for back and neck pain, and their use is always associated with a risk of addiction, Chung-Wei Christine Lin and colleagues at the University of Sydney conducted a randomised trial of the efficacy of opioids for back and neck pain relief.
Participants were recruited as they presented to general practitioners or emergency departments with complaints of back and/or neck pain. Inclusion criteria were low back pain (between the 12th rib and the gluteal crease) or neck pain (below the occiput to the distal cervical spine), or both conditions at once, with or without pain irradiation to a limb. The current moderate painful attack could last up to 12 weeks with a mandatory absence of pain before that for a month.
A total of 347 people were included in the study: 174 in the opioid group and 173 in the placebo group. One participant in the placebo group was found to have bone metastases after randomisation and was excluded from the study. The mean age was 44.7 years and there were no significant differences between the groups, with a slightly higher proportion of women in the opioid group.
In the opioid group, participants took five milligrams of oxycodone and 2.5 milligrams of naloxone twice daily in the form of modified-release tablets. This dose was gradually increased to a maximum dose of ten milligrams twice daily based on the participants' individual progress. Treatment was continued until pain relief, as assessed by a pain scale, or for a maximum of six weeks. The placebo group received seemingly identical pills. All participants were asked not to take additional opioids or non-opioid analgesics.
After six weeks, the researchers found no significant difference in pain scores between the two groups. However, one participant experienced an acute psychiatric disorder, which the researchers labelled as "possibly treatment-related". In addition, after one year, the risk of opioid abuse was significantly higher in the treatment group (p = 0.049).
Many countries are seeking to reduce the use of opioids where they can be dispensed with, as the number of deaths related to their illicit use has been increasing over the past decades. In addition, opioid-related deaths are increasingly affecting younger people.