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There is no evidence that opioids benefit lower back or neck pain and prescriptions should therefore be stopped for these patients, according to a new study published in The Lancet.
The study found that there was no significant difference in pain scores between those patients given opioid pain relievers and those given placebo after six weeks. Patients given the placebo had slightly lower pain scores after a year.
Clinical guidelines currently recommend opioid pain relievers for patients where other treatments have failed or are contraindicated, but there are concerns around the strength of the evidence to support this recommendation.
A significant concern around prescribing opioids for lower back and neck pain is the risks it carries around future dependence, misuse, and overdose.
Senior author on the study, Prof Christine Lin, University of Sydney, says “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.”
Two-thirds of patients might receive opioids for back and neck pain
The study took place across 157 sites in Australia between 2016 and 2021. It included 347 participants who had already been experiencing lower back pain, neck pain, or both for up to 12 weeks. All participants received guideline care (reassurance and advice to stay active), while 174 were given opioid pain relievers and the other 173 were given a placebo for up to six weeks.
The trial was blinded, so participants did not know whether they were given the opioid pain reliever or placebo. After six weeks of treatment, the participants were free to seek other care if required. Participants’ pain severity was assessed, and 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, which assesses key risk factors such as signs and symptoms of intoxication, emotional volatility, addiction, and problematic medication behaviour.
There was no significant difference in pain scores at six weeks between the opioid and placebo groups – with average pain scores out of 10 being 2.8 in opioid group compared to 2.3 in placebo group. At one year, the average pain scores in the placebo group were slightly lower – 2.4 in opioid group compared to 1.8 in placebo group.
There was no difference in overall number of participants reporting an adverse event between treatment groups, however, there were more reports of nausea, constipation, and dizziness in the opioid group.
Participants in the opioid group had a greater risk of opioid misuse after one year. Risk of misuse was no different between groups after 12 and 26 weeks, but significantly higher in the opioid group after one year – with 20% (24/123) compared to 10% (13/128) scoring at risk on the Current Opioid Misuse Measure Scale.
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.
Writing in a Linked Comment, Prof Mark Sullivan and Prof Jane Ballantyne, University of Washington, who were not involved in this research, said: “The OPAL trial is a single trial, but it raises serious questions about the use of opioid therapy for acute low back and neck pain.
“Current clinical guidelines recommend opioids for patients with acute back and neck pain when other pharmacological treatments are contraindicated or have not worked. As many as two-thirds of patients might receive an opioid when presenting for care of back or neck pain. It is time to re-examine these guidelines and these practices.”