Trial shows no benefit of prescribing opioid to people with acute back or neck pain

Opioid painkillers are no more effective than a placebo in relieving acute back and neck pain and may even cause harm, according to a first global trial conducted by the University of Sydney.

The researchers say this is evidence that treatment guidelines should be updated to advise against the use of opioids for this purpose.

More than 577 million people worldwide suffer from lower back and neck pain at any given time.

Despite a global push to reduce opioid use, in Australia around 40-70% of people who present with neck and back problems are prescribed opioids for their pain.

The OPAL trial recruited nearly 350 participants from 157 primary care and emergency department sites. Participants with sudden and usually short-term back or neck pain were randomly assigned to a six-week course of a commonly prescribed opioid or a placebo.

Both groups also received standard care, including advice to avoid bed rest and stay active. Participants were followed for 52 weeks.

The results of the trial are published in The Lancet Today.

What did the study find?

• At six weeks, those who received opioids had no better pain relief than those who received the placebo.
• Quality of life and pain outcomes at long-term follow-up were better in the placebo group.
• Patients who received opioids had a low but significantly higher risk of opioid abuse 12 months after their short course treatment.

The research team says that under current back and neck pain guidelines, opioids may be considered a last resort if all other pharmacological options have failed, however, this study is proof that opioids should not not at all be recommended.

“We have clearly shown that there is no benefit to prescribing an opioid for pain management in people with acute back or neck pain, and in fact it could cause long-term harm, even with only short-term treatment,” the leader said. Investigator Professor Christine Lin of Sydney Musculoskeletal Health, an initiative of the University of Sydney, Sydney Local Health District and Sydney North Local Health District

“Opioids should not be recommended for acute back and neck pain, period.

“Not even when other drug treatments cannot be prescribed or have not been effective for a patient.”

The study complements previous research on the use of opioids for chronic (long-term) low back pain that found a small benefit from treatment, but an increased risk of harm.

Global push to reduce opioid use

Reducing opioid overuse is a global health priority. Medical authorities around the world have warned that due to the significant risk of harm to individuals and society, opioids should only be used when the benefits are proven to outweigh the harms.

Co-author Professor Chris Maher said in recent years there has been a shift in focus from opioid to non-opioid treatments for low back pain, with an emphasis on physical and psychological therapies and simple painkillers such as anti-inflammatory drugs (called NSAIDs). .

“This study is further evidence that the first-line management of acute low back pain and neck pain should be based on reassurance and advice to stay active, and on simple analgesics such as nonsteroidal anti-inflammatory drugs if necessary,” said said Professor Maher, also from Musculoskeletal Health Sydney.

Harm caused by opioid use

Professor Andrew McLachlan, dean of the Sydney Pharmacy School and co-investigator, said the Lancet study is important and should influence the prescribing and distribution of these drugs as Australia faces rising rates of use of opioids.

According to Australia’s Therapeutic Goods Administration, every day in Australia, nearly 150 hospitalizations and 14 emergency room admissions involve problems related to opioid use, and three people die from prescription opioid use.

The possible harmful effects of opioids are well known. They range from minor harms such as constipation and drowsiness to major harms such as addiction, drug abuse, overdose, and even unintentional death.

The results of the OPAL trial further reinforce the need to reassess the use of opioid analgesic medications, as there is limited evidence of benefit and a known significant risk of harm.”

Professor Andrew McLachlan, Dean of Sydney Pharmacy School

The authors note some study limitations, including data gaps due to participant attrition and medication adherence issues consistent with other back pain medication trials. They suggest that neither is likely to have had an impact on the main results of the study.

The trial is a collaboration between the University of Sydney, the George Institute for Global Health, UNSW, St Vincent’s Hospital Sydney, Sydney Local Health District and Erasmus University Medical Center in the Countries -Down.