Opioids = placebo in adults with acute nonspecific low back or neck pain (OPAL)

Clinical Question

Are opioids effective in alleviating pain in adults with acute nonspecific low back or neck pain?

Bottom line

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.

Study design: Randomized controlled trial (double-blinded)

Funding: Government

Setting: Outpatient (any)

Reviewer

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI


Discuss this POEM


Comments

ARUP KUMAR DHARA

Impact assessment

Excellent

Anonymous

I am reassured.

I am reassured.

Anonymous

.

.

Bertus Johannes Reitsma

pain management

it CBD !

Anonymous

opiod didn't cover the proper dosing schedule

Although I would not give an opiod and this supports my prescribing behavior, I do not believe that oxycodone 5 mg lasts 12 hours and so there were nadirs at least 2 times a day which would be a confounder in proving that the drug did not work. Shouldn't the drug in question be given on a q4-6 hour basis?

Anonymous

Opioids = placebo in adults with acute nonspecific low back

The final sentence is the most significant notation on the limitations of this study and reminds us not to throw out the baby with the bathwater..... "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."

Anonymous

Low dose oxycodone. Issues around naloxone.

Oxycodone was used at low dose (5mg Q12H --> 10mg Q12H). Many patients needed 10mg Q6H at least initially.
All opioids are not the same. Some patients do not respond to oxycodone and a trial rotation to another opioid is reasonable.
The oxycodone was provided as a modified release formulation with Naloxone. So 5mg over 12 hours - equivalent to 1/2 of a Percocet every 6 hours. Again - low dose.
Naloxone (2.5mg BID to 5mg BID) can, even at low dose, be absorbed and can cause withdrawal or lack of efficacy. Entirely unclear why naloxone was used in this study.

Pieter Richard Verbeek

Opioids = placebo in adults with acute nonspecific low back

Two comments: 1) I am not familiar with the combination use of oxycodone/naloxone as an analgesic. Presumably the naloxone is meant to protect against apnea in the case of an overdose but why wouldn't naloxone also interfere with the analgesic effect during regular use? 2) The review quotes that this study 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.. Hmmm, I think the study aligns with "don't use opioids for acute back pain". Maybe Choosing wisely needs to strength its opinion on this issue.

Anonymous

No

No