Opioids failing patients with chronic low back pain

Clinicians should expect treatment failure in half of their patients given an opioid for chronic low back pain – and in the remaining patients they should expect to see only small improvement in their back pain, new research suggests.

A systematic review conducted by the George Institute for Global Health and the University of Sydney, and published in JAMA Internal Medicine has revealed opioids only provide modest short-term pain relief, but many patients cannot tolerate them. Professor Chris Maher, Head of the Musculoskeletal Division at The George Institute, says the review provided unique insights into management of low back pain.

“For people who can tolerate the medicine, taking an opioid analgesic such as oxycodone will reduce pain, but the effect is likely to be small,” he said.

The study also found that even at high doses – above recommended levels – the drugs still provided little clinical benefit.

“People have the mistaken belief that opioids are strong pain killers,” Professor Maher said. “When you look closely at the evidence from the low back pain trials, a completely different picture emerges.”

In Australia, 40% of patients who see a GP for low back pain are prescribed an opioid painkiller. Speaking to the limbic from Oxford, England, Professor Maher told the limbic he believed many rheumatologists would be surprised by the review.

“I was certainly surprised by how small the effect size was,” he said. “The message (for specialists) is that opioids do relieve pain, but not by much, so on their own they are unlikely to be the answer for a patient with chronic low back pain.”

He pointed to the Center for Disease Control’s recent guideline on opioid prescribing for chronic pain, which give preference to non-pharmacologic therapy and non-opioid pharmacologic therapy for chronic pain.

They also advise clinicians to consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

And if opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Professor Maher said the review highlighted the absence of reliable data to guide decision making.

“There are no trials of opioids for acute low back pain, and there are no trials of chronic low back pain which include long term outcomes,” he said.

“Secondly we discovered that many people do not tolerate or respond to opioids. In the trials we located it was typical for half the participants to either not respond or not tolerate the opioid medicine and be excluded from the trial.

Put rather bluntly clinicians should expect treatment failure in half their patients given an opioid and in the remaining patients expect to see only a modest improvement in their back pain.”

Professor Maher said the data did suggest that Australia had a problem with opioid overuse, but pointed out that there were a number of other countries in a similar situation.

“We don’t have as big a problem as countries like Canada and the USA; but prescribing rates are growing in Australia, particularly for spinal pain, so we do need to take action,” he said.

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