Are opioids effective in alleviating pain in adults with acute nonspecific low back or neck pain?
In this rigorously conducted study, from week to week over a 6-week period, adults with acute low back or neck pain treated with opioids had similar pain relief as those treated with placebo. (LOE = 1b)
This POEM aligns with the Canadian Spine Society's Choosing Wisely Canada recommendation (Don’t use an opioid analgesic medication as first-line treatment for acute, uncomplicated, mechanical, back-dominant pain) and with the Opioid Wisely campaign.
Plan de l'etude:
Randomized controlled trial (double-blinded)
These researchers recruited adults with less than 12 weeks of new onset low back or neck pain who sought care from their primary care physician or in an emergency department. The patients could have radicular symptoms, but no alarm symptoms, and they had to have pain of at least moderate severity. The authors randomized the patients to receive an opioid (twice daily 5 mg oxycodone and 2.5 mg naloxone, titratable to 10 mg oxycodone; n = 174) or placebo (n = 172). The patients were treated until their pain score was 0 or 1 out of 10 for 3 consecutive days or for a maximum of 6 weeks. Although the researchers assessed the participants at 2, 4, 6, 12, 26, and 52 weeks after enrollment, the primary outcome was pain on a 10-point visual analog scale at 6 weeks. At baseline, both groups had similar pain ratings (5.7 and 5.6, respectively). After 6 weeks, more participants dropped out of the opioid group (19%) than the placebo group (15%). The remaining participants in both groups improved by a similar degree (2.8 and 2.2, respectively). At no point during the 52-week follow-up did the opioid-treated patients experience more pain relief than the placebo-treated patients. Indeed, at a few points in time, the placebo-treated patients had greater pain relief. The masking of participants worked — roughly half in each group could not guess their treatment assignment. Approximately one-third of participants in each group experienced adverse events, but serious adverse events were infrequent (4% and 2%, respectively). In pain studies, a change of 2 points on a 10-point scale is generally considered to be clinically meaningful. This study only reported average changes and did not report the proportion of participants in each group who achieved this threshold, thereby leaving the question of whether some patients respond better to opioids than others unanswered.
Henry C. Barry, MD, MS
Michigan State University
East Lansing, MI