Opioids ineffective in medium and long term for lower back pain and neck pain

In the first randomized trial to study the efficacy of opioid pain relievers for the treatment of acute lower back and neck pain for up to one year, researchers report no significant difference in pain relief after six weeks or one year between subjects treated with opioid pain relievers and those given a placebo.

The findings were published on June 28, 2023 in The Lancet.

“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,” said investigator Professor Christine Lin, University of Sydney in Australia and the Sydney Institute for Musculoskeletal Health.

“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,” Lin added.

The OPAL trial was a placebo-controlled randomized trial for which the investigators recruited adults (aged ≥18 years) presenting at primary care or emergency department sites in Sydney, NSW, Australia, within 12 weeks or less of the onset of low back or neck pain (or both) of at least moderate pain severity.

The subjects were randomized to guideline-recommended care plus an opioid (oxycodone– naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks.

The primary outcome was pain severity at 6 weeks; 151 subjects in the opioid group and 159 in the placebo group were included in the primary analysis.

There was no statistically significant difference in the mean pain score at 6 weeks in the opioid group compared to the placebo group (p=0.051).

Subjects given the placebo had slightly, but not significantly, lower pain scores after a year.

Between the cohorts. the risk of opioid misuse was no different at weeks 12 and 26 weeks, but significantly higher in the opioid-treated group after one year, with 20% of the opioid-treated subjects compared to 10% of the placebo-treated subjects scoring “at risk” on the standard Current Opioid Misuse Measure Scale.

The authors concluded, “Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo.”

Writing in a Linked Comment, Mark Sullivan, MD, PhD, Professor of Psychiatry and Behavioral Sciences at the University of Washington in Seattle and Jane Ballantyne, MD, University of Washington, Director of the UW Pain Fellowship. 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.”