Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review

Abstract

BackgroundConsequences of prescription opioid use involve harms, addiction, tolerance and death. Despite routine prescription, opioids are not recommended for initial intervention by any major multidisciplinary low back pain (LBP) guideline.ObjectiveOur primary purpose was to improve overall understanding of the harms and benefits associated with oral opioid interventions prescribed for treatment of acute or chronic back pain. Our second goal was to evaluate pain intensity and to compare and contrast these data with the harms. Our last objective was to evaluate conflicts of interest among the study authors and the findings.Design/data/eligibility criteriaStudies incorporating oral prescription opioid management of non-surgical LBP were evaluated. After systematic assessment, no studies that met inclusion included participants with specifically acute LBP. Therefore, extracted data reflects only populations with subacute and chronic LBP. Data on reported harms, severe harms, pain outcomes and withdrawal rates were extracted and meta-analyses were completed for opioid versus placebo trials and opioids versus non-opioid trials.ResultsFourteen studies met inclusion/exclusion requirements. All trials involved short-term management with limited follow-up. A high percentage of harms were identified across most studies. Opioids were not shown to be superior to other medications, and only showed superiority to placebo comparators (at cost of additional harms).ConclusionThis review identified trends of higher harms rates and higher percentages of severe harms in opioid arms for the management of subacute and chronic LBP. The majority of trials that demonstrated benefits with opioids also had potential conflicts of interest. Lastly, non-opioid medications demonstrated statistically significant pain improvement compared with opioids. We feel that the results of the trial are supportive of current LBP guidelines and do not condone the initial use of opioids in management of subacute or chronic LBP.Trial registration numberCRD42017070914

<p>Predictors of Opioid Prescription Among a Sample of Patients with Acute Musculoskeletal Pain at a Tertiary Care Hospital in Saudi Arabia</p>

“…16 Moreover, the use of opioids in the management of acute and chronic low back pain have not shown to be superior when compared to other non-opioid analgesics. 31 On the other hand, shoulder pain was associated with significantly lower odds of opioid prescription. The reasons behind that can be attributable to the increasing evidence that discourage the use of opioids in the…”

“…34 However, the use of opioids in the management of other types of musculoskeletal pain, such as back pain, is not encouraged either. 31 Therefore, it is unclear why patients with back or lower extremity pain were more likely to be treated with opioid analgesics in comparison to their counterparts with shoulder pain despite the fact that the pain severity, as measured by the NPRS, was controlled for. This can be partly explained by the fact that physicians have different beliefs about the consequences of their prescribing decisions, emotionally charged physician-patient interactions, and patients' and physicians' characteristics, and preferences.…”

Back Pain: Chiropractor’s View

“…During an age of evidence-based medicine, it is difficult to understand how new drugs with so little evidence about their addictive nature or associated adverse effects could be so widely prescribed for a common condition like low back pain (Coulter 2018). Systematic reviews of the literature have shown that opioids are actually not very useful in controlling low back pain and are associated with high rates of adverse events (Tucker et al 2019;Sanger et al 2019).…”

Analgesic medicines for adults with low back pain: protocol for a systematic review and network meta-analysis

“…This requires information about comparative effectivenessthe effect of a medicine compared to other medicinesto be available for clinical decision making. Comparative effectiveness has been insufficiently described in syntheses of the literature to date [25][26][27][28][29][30][31][32][33][34][35]. This is understandable, as most of these systematic reviews [28,29,31,32] investigated a single comparison, usually efficacy, the effect of a medicine compared to sham.…”

“…This is understandable, as most of these systematic reviews [28,29,31,32] investigated a single comparison, usually efficacy, the effect of a medicine compared to sham. Several of these reviews [25,35] additionally examined a limited number of effectiveness comparisons. No quantitative synthesis was made of these data, which was appropriate because methods for single comparisons should not be used across multiple comparisons.…”