Opioids are overrated for some common back pain, study suggests

Severe back and neck pain millions of American adultsAs a result, many turn to their primary care physicians and local emergency rooms for help.

When these episodes of pain are acute and nonspecific—that is, without a clear cause or explanation—they are generally treated with routine therapy, such as over-the-counter anti-inflammatory drugs, or alternative therapies, such as heat therapy, massage, and exercise. Recommended to start.

However, if that doesn’t work, doctors may prescribe a short course of opioids to relieve pain and improve the person’s functioning.

But results from a rigorous clinical trial released Wednesday cast doubt on the use of opioids even in this setting.

In a study of more than 340 patients suffering from back pain and neck pain, a team of Australian researchers found that between those given opioids and those given a placebo sugar tablet, pain after six weeks found no difference in the severity of

“It was quite a surprise for us,” he says. Andrew McLachlanDean of Pharmacy, Sydney College of Pharmacy and author of this study, was published Wednesday lancet. “I expected some pain relief, but overall there was no difference.”

Furthermore, the study found that people who received opioids were at higher risk of misusing the drug after one year, reinforcing the potential harm of relying on opioids for pain relief, even if only temporarily. ing.

While previous studies have focused on treating chronic pain with opioids, this study is notable for examining a range of low back pain that lasts as short as three months.

“It’s going to call into question a lot of the major guidelines we have for treating back pain in people,” he says. Mark Bicketan anesthesiologist at the University of Michigan and director of research in opioids and pain.

Some experts are already concerned that this surprising result could be misinterpreted as suggesting that opioids don’t work for more widespread acute pain, suggesting that research should be done before generalizing too much. It warns that the limits of

“I think this will be a groundbreaking study that will get a lot of citations,” he says. Sameer Narouse Past president of the American Society of Local Anesthesia and Pain Medicine. “However, I am concerned that it will be used or weaponized to deny patients with acute pain from necessary opioids, such as severe injury pain or postoperative pain.”

No significant difference from placebo

Results from a new trial highlight an unexpected gap in our understanding of how well opioids work in the setting of acute low back pain.

Patients from over 150 primary care clinics and emergency departments in Sydney, Australia, within 12 weeks of new-onset back or neck pain, were randomized to opioid or placebo. rice field. This research took six years to complete.

Specifically, patients with severe spinal lesions that could be related to injuries such as fractures, illness, or surgery were excluded from the study.

The study focused on acute onset low back pain, which can be triggered by anything from awkward twisting and rolling to the way you sleep, McLachlan said. With this kind of nonspecific pain, “you can’t just take an x-ray and say, ‘This is the problem,'” he says. ”

Participants did not know whether they were receiving the drug or a placebo. The opioid group received a combination of oxycodone and naloxone. Naloxone, a drug that is effective at minimizing gastrointestinal side effects associated with opioids, particularly constipation, made participants unaware that they were in the treatment group.

Naloxone, which is used to treat overdose, reverses the effects of opioids when given intravenously, subcutaneously, or as a nasal spray, but not when taken orally because it doesn’t reach the blood supply, McLachlan said.

At 6 weeks, there was no significant difference in pain scores between the two groups. The same was true after 12 weeks.

McLachlan said he focused on the severity of pain after six weeks, as this gave patients enough time to gradually increase their doses until they reached their optimal dose of oxycodone (up to 20 milligrams per day).

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Previous research has shown that opioids may have a small but detectable effect in relieving chronic pain, McLachlan said. “This trial bridges the gap by showing in this short time that even if people have moderate to severe back pain, opioids don’t seem to be an option for them because they don’t do anything.” It is something to fill.”

And this study showed that taking opioids appears to pose additional risks.

One year later, when participants were surveyed to assess whether they had specific risk factors for opioid misuse, 20% of the opioid group judged their physicians had problems prescribing opioids. I had a score that showed behavior. 10% in the placebo group.

Findings May Arouse Controversy

The results are sure to spark debate about how to treat patients suffering from acute back pain attacks.

medical guidelines The United States already warns against using opioids as first-line treatment for patients with acute pain, but can also recommend opioids when other treatments are ineffective.

“This is a well-designed test,” he says. –Richard Deyo, is a physician in family medicine and professor emeritus at the Oregon Health and Science University. “It’s going to be confusing and there’s going to be a lot of controversy.”

The study highlights a serious gap in the evidence for opioid prescribing for acute low back pain, says Professor Deyo, and it’s a little shocking that such a study wasn’t done sooner. It has said.

“We thought we knew the answers. But as often happens, when we actually ask some of the most basic questions and pursue the rigorous answers, we find something surprising. There is,” he says.

The results should not be applied to the broader acute pain and should not be replicated before decisions are made regarding revision of the guidelines or “changes in care for thousands, if not millions”. should, says Dr. Mark Sullivan Professor of Psychiatry and Behavioral Sciences at the University of Washington in Seattle.

“This is just one trial, but if the results are true, the benefits of opioid treatment for back pain episodes appear to be small and the risks higher than we thought,” he said. pointed out an increased risk of Opioid misuse in people given opioids in studies.

“Good” research, but how relevant is it?

Despite the careful design of the trial, which is considered the gold standard for studying treatment outcomes, the results do not always fully reflect the realities of acute pain treatment in the United States, Western said. Dr. Narrows, chairman of the Reserve Hospital Pain Medicine Center, said. Cuyahoga Falls, Ohio.

Rather than being provided with short-acting opioids to take as needed, the treatment arm was given long-acting opioids in the trial and was instructed to take them twice daily, although the purpose “defies the purpose of acute pain,” he says. Provides rapid patient pain relief when needed.

“The treatments they used were really unconventional, at least in the United States,” he says. “We do not treat acute pain with long-acting opioids.”. ”

It’s not clear whether short-acting opioids made a difference, but Narouze said the design of the study doesn’t make it applicable to situations where patients are on other opioid therapies. ing.

Also, the study applies only to a very specific patient population with recently-onset, non-specific back pain that tends to be associated with musculoskeletal problems. “This data cannot be generalized to other pain groups,” he says. “Although very good research, this is just one of his studies.”

Professor Bickett of the University of Michigan says it’s clear that opioids are very effective for short-term pain relief, such as after severe physical trauma or when recovering from surgery.

“Most of our questions are whether the effects are long-lasting and extend to pain that lasts beyond just a few days,” he says.

Bickett says the study should not be taken as final word, but it adds weight to the idea that other treatments for back pain should be emphasized beyond prescription opioids.

“This one study will not completely rewrite the guidelines. We believe this study will spark many more studies in the future, not only in back pain, but in other conditions where prescription opioids may be appropriate.” I think,” he says.